SUBJECTIVE DATA (S):

IDENTIFYING DATA:
Initials:G.B.
Age:61years
Race:Caucasian
Gender:Female
Marital Status:Married

CHIEF COMPLAINT (CC):

Patient complains of “cough and congestion for 2 weeks.”
HISTORY OF PRESENT ILLNESS (HPI): Patient c/o dry cough x 2 weeks. Patient states she just got
back from a cruise and was in the casinos on the ship a lot. She thought the cigarette smoke
could have been making her cough but it is not any better. She now feels congestion in her chest and
c/o hoarseness and expiratory wheezing.
location: congestion in chest
quality: patient describes a feeling of tightness in her chest
severity: patient rates pain a “3” on a scale from 1-10. She states her cough is constant and is continuing
to worsen
timing: symptoms started 2 weeks ago
setting: patient states her symptoms started while she was on a cruise in the
ship’s casinos
alleviating and aggravating factors: cough is worse at night, with any physical exertion, or when she gets
hot. She states she still coughs at rest but it is somewhat better.
associated signs and symptoms: hoarseness and expiratory wheezing

PAST MEDICAL HISTORY (PMH):

Allergies: NKDA
 Current medications: citalopram 40 mg tablet, levothyroxine 50 mcg tablet, pantoprazole 40 mg
tablet, delayed release
 Age/health status:61 years
Appropriate immunization status: Up to date on all vaccines; Flu vaccine given November2013. She
states she will be getting the flu and pneumonia vaccines at her primary physician’s office this fall.
Previous screening tests result: Patient states she had a
pap smear and mammogram in March2014 and both were reported normal.
Dates of illnesses during childhood: N/A

Major adult illnesses: Patient states she has a history of depression,

hypothyroidism, and GERD
Injuries: N/A
Hospitalizations: No hospitalizations other than when she had a tonsillectomy as a child
Surgeries: Tonsillectomy at age 10

FAMILY HISTORY (FH):

Father has a history of HTN and Type II Diabetes; Mother has a history of COPD. Patient has 1 sister
who has HTN. She does not have any children.
SOCIAL HISTORY (SH):
She is married and works as a social worker for DHR. She is independent with her ADLs and lives with
her husband. She states she currently exercises about 3 times per week which includes brisk walking for
about 1 mile. She is a former smoker-½ pack/day but she states she quit 5 years ago. She does drink
alcohol occasionally if she is at a social event. She drinks caffeine (coffee or soda) 1-3 times daily. No
illicit drug use.

REVIEW OF SYSTEMS (ROS):

1.Constitutional symptoms-Patient reports fatigue, fever, and difficulty sleeping due to coughing. Patient
denies chills, malaise, night sweats, unexplained weight loss or weight gain, loss of appetite.
2. Eyes- Patient denies blurred vision, difficulty focusing, ocular pain, diplopia, scotoma, peripheral visual
changes, and dry
eyes. Patient states she does wear reading glasses. Date of last eye exam was in 2013.
3.Ears, nose, mouth, and throat- Patient reports headaches and hoarseness. Patient denies vertigo, sinus
problems, epistaxis, dental problems, oral lesions, hearing loss or changes, nasal congestion, sore throat.
Date of last dental visit was about 6months ago.
4.Cardiovascular- Patient states she exercises about 3 times a week
for about 30 minutes to an hour. Patient denies any history of heart murmur, chest pain,
palpitations, dyspnea, activity intolerance, varicose veins, edema. Date of last EKG and cholesterol level
was in March 2014 at her yearly physical and was reported normal.
5.Respiratory - Patient reports cough, SOB on exertion, difficulty breathing at times, expiratory wheezing,
chest tightness/pain on inspiration, exposure to secondary smoke. Patient denies history of respiratory
infections, exposure to TB, hemoptysis. Patient states she has never had a chest x-ray. Her last
TB skin test was done in March 2014 for work and it was negative. Patient states she is a former smoker
but quit 5 years ago.
6. Gastrointestinal - Patient reports a history of GERD. She states she was diagnosed about 1 year ago
and it is managed well with protonix. Patient denies dysphagia, reflux, pyrosis, loss of appetite, bloating,
nausea, vomiting, diarrhea, constipation, hematemesis, abdominal
or epigastric pain, hematochezia, change in bowel habits, food intolerance, flatulence, hemorrhoids.
Patient states she tries to eat healthy, well-balanced meals.
7. Genitourinary -Patient denies urgency, frequency, dysuria, suprapubic pain, nocturia, incontinence,
hematuria, history of stones, vaginal discharge. Patient states her LMP was about 9 years ago.
She does not take any hormone replacements. Her last pap smear was in March 2014 and was reported
normal. Her last mammogram was in March 2014 and was reported normal.
8.Musculoskeletal -Patient denies back pain, joint pain, swelling, muscle pain or cramps, neck pain or
stiffness, changes in ROM. She states she exercises about 3 times a week. She does wear her seatbelt.
9.Integumentary - Patient denies itching, uritcaria, hives, nail deformities, hair loss, moles, open areas,
bruising. Patient denies breast tenderness, masses, skin changes. She states she uses sunscreen while
outside and inspects her skin regularly for any changes.
10.Neurologic - Patient reports a headache. Patient denies weakness, numbness, muscular weakness,
tingling, memory difficulties, involuntary movements or tremors, syncope, stroke, seizures, paresthesias.
11.Psychiatric - Patient reports a history of depression. She was diagnosed in her late 30s but states it is
well controlled with celexa. Patient denies nightmares, mood changes, anxiety, nervousness, insomnia,
suicidal thoughts, exposure to violence, or excessive anger.
12. Endocrine - Patient reports hypothyroidism. She was diagnosed about 10 years ago and has been
taking levothyroxine to manage it. Patient denies cold or heat intolerance, polydipsia, polyphagia,
polyuria, changes in skin, hair or nail texture, unexplained change in weight, changes in facial or body
hair, changes in hat or glove size, use of hormonal therapy.
13.Hematologic/lymphatic - Patient denies unusual bleeding or bruising, lymph node enlargement or
tenderness, fatigue, history of anemia, blood transfusions. Patient is unsure of last HCT result but states
all lab work was done at her last physical in March 2014 and everything was reported to her as “normal”.
14. Allergic/immunologic - Patient denies seasonal allergies, allergy testing, exposure to blood or body
fluids, use of steroids, or immunosuppression in self or family. She is unsure of her last Hep B vaccine
but states she has had one for work.
OBJECTIVE DATA (O):
1.Constitutional - VS: Temp- 96.8, BP- 124/74, HR-74,RR-18, O2 sat-97%,Height-5’5”, Weight-170 lbs,
BMI-28.29; General Appearance: healthy-appearing, well-nourished, and well-developed. Level of
Distress: NAD. Ambulation: ambulating normally.
2.Eyes-sclerae white. Conjunctivae pink. Pupils are PERRL, 3 mm bilaterally. Extraocular movements
intact.
3. Ear, Nose, Throat- Ears: external appearance normal- no lesions, redness, or swelling;on otoscopic
exam tympanic membranes clear. Hearing is intact.
Nose:appearance of nose normal with no mucous, inflammation, or lesions present. Nares patent.
Septum is midline. Mouth:pink, moist mucous membranes.No missing or decayed teeth.
Throat: no inflammation or lesions present. Tonsils WNL-
no erythema, ulcers, masses, exudate, inflammation.
4.Cardiovascular- S1, S2. Regular rate and rhythm, no murmurs, gallops, or rubs Carotid Arteries: normal
pulses bilaterally, no bruits present Pedal Pulses: 2+ bilaterally
Extremities: no cyanosis, clubbing
,
or edema, less than 2 second
refill
noted
5.
Respiratory
-
Even and unlabored
.
Bilateral expiratory wheezes
and fine crackles
in upper lobes on auscultation. Non
-
productive, hacking cough frequently.
Patient is unable to take a deep breath without coughing.
Fremitus is equal and
there is no egophony.
6.
Gastrointestinal
-
abdomen soft and nontender to palpation, nondistended. No
rigidity or guarding, no masses present, BS present in all 4 quadrants
7.
Genitourinary
-
N
o bladder distention, s
uprapu
bic pain, or
CVA tenderness.
Pelvic exam was not performed.
8.
Musculoskeletal
-
join
t stability normal in all extremities, no tenderness to
palpation
9.
Integument/lymphatic
-
Inspection
:
No scaling or breaks on skin, face, neck, or arms.
General palpation:
no skin or subc
utaneous tissue masses present,
no
tenderness, skin turgor normal
Face:
no rash, lesion
,
or discoloration present
Lower Extremities:
no rash, lesion
,
or discoloration present
Upper Extremities:
no rash, lesion, or discoloration present
10.
Neurologic
-
Grossly oriented x3, communication ability within normal limits,
attention
and concentration normal. Sensation intact to light touch, gait within
normal limits
11.
Psychiatric
-
Judgment and insight intact, rate of thoughts normal and logical
.
Pleasant, calm, and cooperative
.
Patient appears to be happy/content.
12.
Hematologic/immunologic
-
Lymph nodes not palpable, no tenderness or masses
present, no bruising
DIAGNOSTIC TESTS:
-
X
-
RAY, CHEST
-
08/26/14
Results:
no acute findings that suggest pneumonia

ASSESSMENT (A):
1.
Bronchitis
490: Bronchitis, not specified acute
or chronic
Patient reports
frequent
cough
that is worse at night
, congestion, chest
tightness, hoarseness, expiratory wheezing,
headache,
and fever.
Bilateral
expiratory wheezes and fine crackles in upper lobes on auscultation. Non
-
productive, hacking coug
h frequently. Patient is unable to take a deep breath
without coughing. Fremitus is equal and there is no egophony.
2.
311:
Depression
Currently controlled. Patient is taking
citalopram 40 mg tablet
daily
3.
244.9:
Hypothyroidism
Currently controlled. Patient
is taking
levothyroxine 50 mcg tablet
daily
4.
530.81:
GERD
Currently controlled. Patient is taking pantoprazole 40 mg tablet, delayed release
daily
Differential Diagnoses:
1.
Pneumonia
Patient c/o cough, fever, chest discomfort, crackles and expiratory wheezes
on
exam.
Refuting data: ruled out with chest x
-
ray
. No shaking chills, rigors, tachycardia,
tachypnea, uneven fremitus, or egophony.
2.
Sinusitis
Patient c/o
cough, fever, headache, and difficulty breathing at times.
Refuting data:
Patient c/o congestion in
chest and not sinuses. No sore throat,
purulent nasal drainage, or ear pain.
3.
Asthma
Patient c/o chest tightness/congestion,
non
-
productive cough, SOB with
exertion, and wheezing.
Refuting data:
Patient’s complaint is acute. PFTs are needed to completely r
ule
out.
4.
Tuberculosis
Patient c/o fatigue and fever, non
-
productive cough.
Refuting data:
No progressive dyspnea, night sweats, weight loss, or hemoptysis.
CXR did not show TB.
5.
GERD
Patient c/o cough. Patient has a history of GERD.
Refuting data:
No hea
rtburn or other GI symptoms noted.
6.
Malignancy
History of smoking. Patient c/o dyspnea at times, cough, fatigue, wheezing, and
chest discomfort/tightness.
Refuting data:
No hemoptysis, recurrent respiratory infections, unexplained
weight loss.
PLAN (P):
1.
Cefdinir
300mg capsule; Take 1 capsule by mouth every 12 hours for 10
days
Albuerol sulfate HFA 90mcg/actuation aerosol inhaler; Inhale 2 puffs every 4
hours
Depo
-
medrol 40mg/ml suspension for injection
-
IM injection in office
Dexamethasone 4mg/ml
injection solution
-
IM injection in office
-
Take cefidinir 300mg twice a day for 10 days for the infection. Importance of
finishing antibiotic even if symptoms improve or go away.
-
Albuterol sulfate inhaler will help with the wheezing.
-
Steroid shot in offic
e will help control the symptoms and reduce
inflammation so it will be
easier for you to breathe.
-
Continue with smoking cessation and avoid secondary smoke inhalation and
other environmental irritants.
-
Return to the urgent care clinic or follow
-
up with you
r primary physician if
symptoms persist longer than 21 days or if condition worsens.
-
Health promotion: flu and pneumonia vaccines at next primary physician
appointment this month.
2.
Continue taking citalopram 40 mg PO daily to manage depression.
Continue follow
-
up with primary physician every 3 to 6 months.
3.
Continue taking levothyroxine 50 mcg PO daily to manage hypothyroidism.
Continue follow
-
up with primary physician for lab work to check thyroid levels.
TSH levels should be monitored every 6 t
o 12 months.
Take levothyroxine with water consistently 30
-
60 min before breakfast or at
bedtime 4 hours after last meal.
4.
Continue taking pantoprazole 40 mg PO daily to manage GERD.
Lifestyle modifications such as avoiding foods that may precipitate ref
lux and
cause heartburn. Adopt behaviors that may decrease acid exposure such as
weight loss, elevating HOB, a
nd avoiding l
ying down 3
-
4 hours after a meal.
Continue follow
-
up with primary physician.