John Corlet- 35-year-old male who presents to the outpatient department with 5 days of cough.

History of Present Illness: A 35-year-old male with history of seasonal allergies and mild asthma
presents to the outpatient department with 5 days of productive cough of yellow sputum. He were
well until 7 days ago when noted a sore throat, sinus congestion, runny nose, mild frontal
headache, and subjective fever to 100.2 (37.8 C) degrees. The symptoms persisted and then
developed a worsening cough that is keeping awake at night. He is coughing up a teaspoonful of
sputum each time.

He is also still having a mild frontal headache that is slightly worse with lying down. There is no
blood in the sputum, chills, night sweats, chest pain, shortness of breath, wheezing, or abdominal
pain. There was some slight relief with Tylenol and Robitussin DM. His 8-year-old son was also
recently sick.

Past medical history: Asthma - had it since childhood with mild intermittent symptoms. Seasonal
allergies- mainly in the Fall and Spring.
Past surgical history: None
Medications: Albuterol inhaler, 1-2 puffs as needed
Allergies: No medications, but you are allergic to cats.

Family history:
Father is 60 years old and has asthma
Mother is 59 and is healthy
You have no other siblings

Social history: Live with your wife and son. He currently work as a paramedic.Has smoked 1 PPD
for the past 10 years and drink occasionally. Has never used illegal drugs and also have not had any
blood transfusions.

Physical Exam findings:

The following are your temperature (T), blood pressure (BP), heart rate (HR), and respiratory rate
(RR).
Vital signs: T 101.0 F (38.3 C ) , BP 120/75, HR 98/min, RR 20/min

Head and Neck: No redness or exudates in the mouth, no sinus tenderness to percussion, no
enlarged lymph nodes

Chest/Lungs: Clear to auscultation bilaterally

Heart: Regular rate and rhythm

Prompts and Special Instructions:

 Questions the patient MUST ask/ Statements patient must make (optional)

Ch/Q: What additional warning signs should I be aware of with a cough?

Cough with hemoptysis- Lung cancer; tuberculosis

Cough, fever, purulent sputum- Pneumonia, Lung abscess
Cough with chest pain- Pulmonary embolism; Acute coronary syndrome
Cough with excessive chronic sputum production- Lung abscess; Lung cancer;
Cough and unintentional weight loss- Lung abscess; Lung cancer; tuberculosis
Cough, dyspnea and lower extremity edema- Congestive heart failer; Pulmonary embolism

Diagnosis #1
History finding(s) Physical Exam finding(s)

Diagnosis #2
History finding(s) Physical Exam finding(s)

Diagnosis #3
History finding(s) Physical Exam finding(s)

Diagnostic Studies