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2 months ago

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Visit Date: 1/14/2019

 

Patient: Ms. S

Age: 57

Race: Asian

Informant: Pt herself, reliable.

 

CC: “cold symptoms” x2 weeks

 

HPI: 57 y/o female /c PMH hyperlipidemia, diabetes presents to clinic c/o sore throat, nasal congestion, and runny nose with discharge for x2 weeks. Her cough is productive, producing greenish white sputum. Her cough is worse when lying dying o when active. She admits to sinus pressure and intermittent headaches with no precipitating factors. Pt takes Tylenol and Nyquil with minimal relief but this time last two nights did not alleviate symptoms. Pt denies fever, chills, body aches, fatigue, weight changes, epistaxis, chest pain, shortness of breath, hemoptysis, n/v/d, and abdominal pain.

 

PMH: hyperlipidemia; diabetes

PSH: Cholecystectomy 2016 w/ no complications

PH: None

Medications

  • Metformin HCL 500 mg 1 Tab with meals PO x2 a day
  • Atorvastatin 40 mg Tab PO x1 a day

Allergies:

  • Penicillin Allergy-Rash
  • NKDA

Immunizations

  • Up to date
  • Flu shot 2018

Family Hx:

  • Mother: Deceased at age 70. PMH diabetes, HTN
  • Father: Deceased at age 65. PMH diabetes
  • Children: None

Social Hx:

  • Caffeine/coffee x2 a day
  • Denies alcohol, drugs, smoking/tobacco use
  • Marital Status: Lives alone
  • Exercise/Diet: Goes on walks every night, eats x2 meals
  • Occupation: High school teacher

Sexual Hx

  • Not active

ROS

 

General: Denies fever, night sweats, chills fatigue, weakness

Skin, hair, nails: Denies lesions, rashes, sores, pruritus

Head: Denies h/a, vertigo, lightheadedness

Eyes: Denies glasses, blurring or recent visual disturbances

Ears: Denies hearing loss, pain, discharge and tinnitus,

Noses/sinuses: SEE HPI

Mouth/throat: Admits sore throat. Denies bleeding gums, sore tongue, mouth ulcers

Neck: Denies localized swelling/lumps, stiffness or decreased ROM

Breast: Denies lumps, nipple discharge, pain

Cardiac: Denies murmurs, palpitations, DOE, orthopnea, CP

Respiratory: Denies dyspnea, SOB, cough, wheezing, hemoptysis, cyanosis, PND

GI: No appetite changes. Regular BMs. No blood in stool .

GU: Denies urgency, dysuria, changes in frequency, hesitancy, dribbling

MSK: Denies arthralgias, swelling, joint pain or back pain

Peripheral Vascular: Denies claudication, trophic changes, peripheral edema

Heme: Denies anemia, easy bruising or bleeding, lymph node enlargement

Endo: Denies polyuria, polydipsia, polyphagia, heat/cold intolerance, goiter, hirsutism

Nervous: Denies seizures, tingling/numbness, sensation changes.

Psych: Denies little interest or pleasure in doings things. No feelings of depression or hopelessness

 

PE

General Appearance: Alert and oriented. Appears older than documented age. Average build. Good hygiene and grooming. Posture, gait not assessed. Patient in no acute distress.

 

Vitals

Temp: 98.4 F

HR: 81 bpm, RRR

BP: sitting 122/84 Right arm

Ht:  60”

Wt:  135#

BMI: 26.36 kg/m^2

RR: 17 breaths per min, unlabored

O2 Sat: 98

Pain Scale: 2

 

Skin: Warm and moist, good turgor, nonicteric, no lesions, scars or tattoos

Hair: Average quantity and distribution

Nails: cap refill <2 secs. No clubbing present

Head: normocephalic, atraumatic, Non-tender to palpation

Eyes: Not assessed

Ears: Symmetrical. No evidence of trauma, lesions, discharge bilaterally. TM pearly white intact /c cone of light normal position bilaterally.

Nose: Mild erythema in nasal mucosa. Symmetrical nares, patent, no nasal obstruction noted bilaterally.

Sinuses: Bilateral frontal and maxillary tender to palpation

Throat:  +PND, Mild erythema. No exudates, uvula midline.

Neck: Tender cervical lymphadenopathy on palpation, no thyromegaly

Heart: RRR, Normal S1, S2. No murmurs heard. PMI in 5th ICS midclavicular No heaves, thrills noted

Lungs: Clear to percussion and auscultation bilaterally. No crackles, rhonchi, rales. No use of accessory muscles noted. Non-tender to palpation bilaterally. Negative increase in tactile fremitus throughout.

Breasts: Not assessed

Abdomen: Symmetrical, ND/NT. BS present in all 4 quadrants. No bruits. Tympany to percussion throughout. Nontender to palpation. Neg CVAT bilaterally

GU: Not assessed

Rectal: Not assessed

Peripheral Vascular: Pulses normal, no cyanosis no edema.

MSK: Not assessed

Neuro: Not assessed

 

DDx

 

  1. Acute Sinusitis
    1. + Nasal congestion and cough
    2. + Mild HA and head pressure. Sinus tender to palpate
  2. Viral URI/pharyngitis
    1. +sneezing, itchy throat, watery eyes
    2. +Cold symptoms make this likely
    3. +Congestion could be viral; cough be post viral
  3. Streptococcal tonsillopharyngitis
    1. +tender cervical adenopathy (could be from coughing_
    2. -Fever
    3. However, usually sudden onset sore throat, presence of tonsillar exudates and lack of cold symptoms so less likely
  4. Infectious mononucleosis
    1. +Sore throat, lymphadenopathy
    2. However, common in young adults. Does not have generalized lymphadenopathy or grayish white deposits on tonsils typically seen in IM, so less likely.

Labs/Testing

  1. Rapid Strep- neg
  2. Rapid Flu- neg

 

Assessment/Plan

 

57 y/o F presenting to clinic c/o of sore throat, cough with sputum, nasal congestion for x2 weeks. Pt has tender cervical adenopathy, and frontal and maxillary sinuses are tender to palpation bilaterally. Throat is mild erythematous with PND. Pt admits to mild h/a and sinus/head pressure.  Pt denies fever, chills, night sweats, exudates. Findings most consistent with acute sinusitis.

  1. Acute Sinusitis
    1. Start Zithromax Z-Pack 250mg TAB PO, 2 tabs on day 1, then 1 tab x4day, 1 pack
    2. Start Mucinex ER 600mg TAB PO q12hr PRN cough x7d, 14
    3. Flonase 2 sprays in the nostril x1 a day
  2. Diabetes
    1. Continue current management
    2. F/u as needed
  3. Hyperlipidemia
    1. Continue current management
    2. F/u as needed

 

Patient Education

Get rest and drink plenty of fluids to thin the mucus. Antibiotics may be prescribed however, if it’s a true viral illness, it will not fight infection. Patient should avoid irritants and allergy triggers to prevent future sinusitis. Stay up to date on vaccines, ie flu.

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