History:

Date & time: 10/16/23 10:00 am

Full Name: KA

DOB: 01/23/2000

Address: Jamaica, NY 

Age: 23 y/o

Sex: male 

Race: African American

Religion: Christian 

Source: Pt himself

Transportation: Pt himself  

Reliability: Reliable 

Location: Middle Village, NY 

Chief Complaint: “I have had a cough” x 2 days 

History of Present Illness:

     23 y/o male with PMH of asthma presents c/o cough for 2 days. Pt states that his cough has gotten gradually worse over the past 2 days and has a productive sputum with a clear color. He denies taking any medications to try and alleviate his cough and but does admit that his cough worsens when he works out. Pt states that he has never been hospitalized for his asthma and has never been intubated. He admits to accompanying symptoms of nasal congestion, headache, and subjective fever. Pt denies any h/o of smoking, sick contacts, and recent travel as well as any symptoms of SOB, chest pain, palpitations, chills, sore throat, rash, abdominal pain, nausea, vomiting, diarrhea, and constipation. 

Past Medical History:

• Immunizations up to date; flu vaccine yearly (unknown date); Covid vaccines and booster up to date (unknown dates).

Past Surgical History:

• Pt denies any previous surgeries for pt.  
• Pt. denies past blood transfusions for pt. 

Medications:

• Ventolin HFA (Albuterol) 90 mcg/actuation INH Q4-6h PRN
• Denies use of herbal supplements.

Allergies:

• NKDA
• Denies seasonal, food, and animal allergies. 

Family History:

• Mother – age 43 alive and well 
• Father – age 45 alive and well
• Maternal/paternal grandparents – deceased at unknown age & unknown reasons

Social History:

• Habits- Pt. denies h/o of smoking or tobacco use along with illicit drug use. Pt. also denies alcohol and caffeine use.  
• Travel- Pt. denies any recent travel.
• Marital history- Pt denies ever being married
• Occupational history- Pt attends college
• Home situation- Lives with mother and father.
• Diet- Pt. states that his diet consists mainly of vegetables, protein, and rice. 
• Safety measures– Admits to seat belt use.

Review of Systems:

General – Reports subjective fever. Denies night sweats, weight loss or gain, generalized fatigue, chills, changes in appetite. 

Skin, hair, nails –Denies rash, excessive dryness, pigmentations, moles, pruritus, excessive sweating, or changes in hair distribution, 

Head – Denies vertigo, or head trauma, dizziness

Eyes – Denies glasses or contact usage, Last eye exam 2021 visual acuity unknown. Denies glasses or contact usage, visual disturbances, photophobia, lacrimation, or pruritus.

Ears – Denies deafness, pain, discharge, tinnitus.

Nose/sinuses –Denies discharge obstruction, or epistaxis.

Mouth/throat –Last dental exam February 2022. Denies sore throat, bleeding gums, sore tongue, mouth ulcers, or voice changes. 

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion 

Breast – Denies lumps, nipple discharge, or pain. 

Pulmonary system –  See HPI

Cardiovascular system – See HPI

Gastrointestinal system – Has regular bowel movements daily. Denies intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructation, abdominal pain, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool. 

Genitourinary system – Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, incontinence, awakening at night to urinate or flank pain.

Nervous – Reports headache. Denies seizures, loss of consciousness, sensory disturbances, ataxia, loss of strength, changes in cognition / mental status / memory, or weakness.

Musculoskeletal system –Denies muscle/joint pain, deformity or swelling, or redness.

Peripheral vascular system – Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes.

Hematological system –Denies anemia, lymph node enlargement, blood transfusions, or history of DVT/PE.

Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter

Psychiatric – Denies depression/sadness, anxiety, OCD or ever seeing a mental health professional.

Physical: 

General: Thin male, neatly groomed, looks his stated age of 23 years.

Vital Signs: BP:                             R                                                       L

                  Seated                        124/74                                               126/75

                  R: 15/min, unlabored                                               P: 79 beats/min, regular

                  T: 102.0 degrees F (oral)                                         O2 Sat: 98% Room air

                  Height: 74-inches              Weight: 180 lbs                  BMI: 22.5

Skin: No rashes appreciated skin is warm & moist, good turgor, no scars.

Nose: Symmetrical / no masses / lesions / deformities / trauma / discharge. Nares patent bilaterally / Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions / deformities / injection / perforation. No foreign bodies.

Sinuses: Non tender to palpation and percussion over bilateral frontal, ethmoid, and maxillary sinuses.

Ears: Symmetrical and appropriate in size. No lesions/masses / trauma on external ears. No discharge / foreign bodies in external auditory canals AU. TM pearly grey / intact with light reflex in good position AU. 

Lips – Pink, moist; no cyanosis or lesions.

Mucosa – Pink; well hydrated. No masses: lesions noted. No leukoplakia. 

Palate – Pink; well hydrated. Palate intact with no lesions; masses; scars.  

Teeth – Good dentition / no obvious dental caries noted. 

Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge. 

Tongue – = no masses, lesions, or deviation. 

Oropharynx – Tonsils appear swollen and erythematous with exudates present. Well hydrated; no injection, masses, lesions, or foreign bodies. Uvula pink, no edema, or lesions.

Neck – Trachea midline. No cervical lymphadenopathy, masses; lesions; scars; pulsations noted.   Supple; non-tender to palpation. FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally.

Thyroid – Non-tender; no palpable masses; no thyromegaly; no bruits noted.

Chest: Symmetrical, no deformities, no trauma. Respirations unlabored / no paradoxical respirations or use of accessory muscles noted. 

Lungs: Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. No adventitious sounds.

Heart: PMI in 5^th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.

Abdomen: Abdomen flat and symmetric with no scars, striae or pulsations noted. Bowel sounds normoactive in all four quadrants. Non-tender to palpation and tympanic throughout, no guarding or rebound noted. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness appreciated. 

Differential diagnosis: 

• COVID-19
• Upper respiratory infection
• Viral sinusitis
• Pneumonia
• Asthma exacerbation 
• Acute bronchitis

Assessment: 23 y/o male presents to urgent care c/o cough, headache, and nasal congestion for 2 days.  

Work up

• Rapid Covid test- positive 
• Chest x-ray- negative 
• Viral respiratory panel- pending 

Plan: 

• OTC Tylenol/ibuprofen as needed for fever.
• OTC decongestant such as Mucinex as needed.
• Use humidifier at home to help break up mucus.
• Go to ER if worsening symptoms (persistent fever, SOB, CP) or follow up with PCP if symptoms are not improving with treatment.