Practice History

ID:
-John Doe
-White Male
-Student
-Healthy
CC
Complains of a cold
Hx
Cough, sinus headache, congestion, sore throat, no fever, diarrhea
Dull headache in frontal and maxillary sinuses
Leaning forward or holding breath makes sinus pain/headache feel
worse
Cough syrup, ibuprofen, sleeping, vitamin C made symptoms feel
better
Symptoms started 1-2 weeks ago
Slow onset
Upon waking, no congestion, but gets worse throughout the day
Last cold like this was a year ago during the same time of year
Environment does not affect symptoms
Hasnt been eating as much because he was sad
Feeling sad because broke up with girlfriend
Severity of cough ranges from 3 to 7, congestion was 4-5
Daily life was not significantly affected
PMH
No medication
No chronic illness
Seizure related to EtOH last spring
No major surgeries
Up to date immunizations
Family History
P. Grandfather has Parkinsons
M. Grandfather had Type II Diabetes but is now under control
M. Grandfather also had prostate cancer but had a prostatectomy
SH
High school student from upper middle class family
Has health insurance
Good family/friends support

Habits
Occasional EtOH use
Doesnt smoke
No drugs
Not sexually active
Plays on school lacrosse team