AC H&P 3

History & Physical (H&P) #1

Chief Complaint:
“Cough and sore throat” x 4 days

History of Present Illness:
A 34-year-old male with no significant past medical history presents with a 4-day history of cough and sore throat. The patient reports the onset of a dry cough, which he describes as intermittent but worse at night. He also complains of a scratchy throat that has worsened over the past 2 days, making it uncomfortable to swallow. He denies shortness of breath, chest pain, or wheezing.

The patient also reports nasal congestion, mild runny nose, and postnasal drip. He took over-the-counter acetaminophen and cough drops, which provided mild relief. No fever, chills, or body aches are noted. He denies any recent travel, known sick contacts, or exposure to environmental irritants. No history of seasonal allergies or asthma.

Past Medical History:

  • No significant past medical history

Past Surgical History:

  • None

Medications:

  • Acetaminophen 500 mg as needed for pain and fever
  • Cough drops as needed

Allergies:

  • No known drug allergies
  • No known food or environmental allergies

Family History:

  • Mother: Alive, history of hypertension
  • Father: Alive, history of type 2 diabetes
  • Siblings: One brother with asthma

Social History:

  • Smoking: Non-smoker
  • Alcohol: Occasional drinker, 1-2 drinks per week
  • Drug use: Denies recreational drug use
  • Caffeine: 1 cup of coffee daily
  • Occupation: Office worker
  • Living situation: Lives with roommates

Review of Systems:

  • General: Denies fever, chills, or night sweats.
  • Skin: Denies rashes, itching, or lesions.
  • Head: Denies headache or facial pain.
  • Eyes: Denies vision changes, redness, or discharge.
  • Ears: Denies ear pain or discharge.
  • Nose: Admits to nasal congestion and runny nose. Denies nosebleeds.
  • Mouth/Throat: Admits to sore throat and postnasal drip. Denies oral lesions or difficulty swallowing solids.
  • Neck: Denies neck stiffness or swelling.
  • Cardiovascular: Denies chest pain, palpitations, or swelling in the extremities.
  • Pulmonary: Admits to dry cough. Denies shortness of breath or wheezing.
  • Gastrointestinal: Denies nausea, vomiting, diarrhea, or abdominal pain.
  • Genitourinary: Denies dysuria, hematuria, or urinary frequency.
  • Musculoskeletal: Denies joint pain or muscle aches.
  • Neurological: Denies dizziness, weakness, or numbness.
  • Hematologic: Denies easy bruising or prolonged bleeding.
  • Endocrine: Denies heat/cold intolerance or excessive thirst/urination.
  • Psychiatric: Denies depression or anxiety.

Physical Exam:

  • Vitals:
    • BP: 120/78 (seated, right arm)
    • HR: 76 BPM (regular)
    • RR: 16/min (unlabored)
    • T: 98.4 F (oral)
    • O2: 98% (room air)
    • Height: 5’9” Weight: 170 lbs BMI: 25.1
  • General:
    • Alert and oriented x 3, appears in no acute distress.
  • Head:
    • Normocephalic, atraumatic.
  • Eyes:
    • Conjunctiva clear, no discharge. PERRLA, visual fields full bilaterally.
  • Ears:
    • TMs intact bilaterally, no erythema or bulging.
  • Nose:
    • Nasal mucosa slightly erythematous with clear rhinorrhea. No septal deviation or lesions noted.
  • Mouth/Throat:
    • Pharyngeal mucosa erythematous, no tonsillar enlargement or exudates. Posterior pharynx shows mild postnasal drip. Oral mucosa pink and moist.
  • Neck:
    • Supple, no lymphadenopathy or thyromegaly.
  • Cardiovascular:
    • Regular rate and rhythm, S1/S2 normal, no murmurs, rubs, or gallops.
  • Pulmonary:
    • Clear to auscultation bilaterally, no wheezes, rales, or rhonchi.
  • Abdomen:
    • Soft, non-tender, no guarding or rebound. Bowel sounds normoactive in all four quadrants.
  • Musculoskeletal:
    • Full range of motion in all extremities, no deformities or tenderness.
  • Neurological:
    • No focal deficits.
  • Peripheral Vascular:
    • No edema or cyanosis.

Assessment:
34-year-old male with 4 days of cough, sore throat, and nasal congestion, consistent with upper respiratory infection (URI). No signs of bacterial infection or serious complications 

Differential Diagnosis:

  1. Viral upper respiratory infection (URI) 
  2. Allergic rhinitis
  3. Pharyngitis (viral)

Plan:

  1. Diagnostics:
    • No labs or imaging indicated at this time. Diagnosis based on clinical presentation.
  2. Treatment:
    • Supportive care:
      • Increase fluid intake, rest, and maintain a well-balanced diet.
    • Symptomatic relief:
      • Acetaminophen 500 mg PO as needed for sore throat and discomfort.
      • Saline nasal spray for congestion.
      • Cough drops or throat lozenges for sore throat.
  3. Patient Education:
    • Educate patient on the viral nature of URIs and the typical course (5-10 days).
    • Advise against antibiotics as no bacterial infection is suspected.
    • Discuss signs of worsening illness (fever > 100.4°F, persistent symptoms beyond 10 days, or difficulty breathing), and to return if these develop.
  4. Follow-Up:
    • Return to the clinic in 1 week if symptoms persist or worsen. Seek care earlier if new or severe symptoms (e.g., high fever, worsening cough, or chest pain) arise.