FM H&P #3

Chief Complaint: “Sore throat and cough” x 8 days

42 y/o male with a past medical history of HTN came in today due to sore throat and persistent cough for the past 8 days. Patient states symptoms started suddenly and have worsened these last 2 days reporting a fever of 101.2 this morning. Patient states having a cough associated with the sore throat, reporting a yellow phlegm associated with cough. Patient denies taking anything to help with his symptoms. Patient denies recent travel or any recent sick contacts. Patient states he is in no pain for states the cough persists throughout the whole day causing him discomfort. Patient denies any myalgias, SOB or wheezing associated with his symptoms.

Past Medical History:

  • Diabetes x 3 years
  • HTN x 10 years 

Past Surgical History:

  • No past surgical history

Medications:

  • Amlodipine 5 mg orally once daily 

Allergies:

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

Family History:

  • Mother: Alive63 , hx of diabetes and htn
  • Father: Age 66, hx of HTN
  • Spouse: 39, alive

Review of Systems:

  • General: Admits to fever/chills, generalized weakness for 5 days,Denies  night sweats, weight loss or gain, changes in appetite.
  • Skin, hair, nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution.
  • Head: Denies head trauma, vertigo.
  • Eyes: Denies ear pain, deafness, discharge, tinnitus.
  • Ears: Denies deafness, ear pain, discharge, tinnitus.
  • Nose: Denies epistaxis, discharge, congestion
  • Mouth/throat: Admits to  sore throat, Denies voice changes, bleeding gums.
  • Neck: Denies localized swelling/lumps, stiffness/decreased ROM
  • Breast: Denies lumps, nipple discharge, pain.
  • Pulmonary: Admits to cough with yellow sputum, states he at times has difficulty breathing , Denies orthopnea, paroxysmal nocturnal dyspnea, wheezing, cyanosis, hemoptysis.
  • Cardiovascular: Denies chest pain ,edema/swelling of ankles or feet, hx of HTN, palpitations, irregular heartbeat, syncope, known heart murmur.
  • Gastrointestinal: Denies change in appetite, intolerance to specific foods, abdominal pain nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructations, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.
  • Genitourinary: Denies urinary frequency, urinary urgency, nocturia, oliguria, polyuria, dysuria, incontinence, flank pain, hematuria, history of hernias.
  • Sexual History: Admits to currently being sexually active with his wife. Admits to condom use. Denies history of STIs.
  • Musculoskeletal: Denies arthritis, muscle pain, deformity or swelling, redness.
  • Nervous system: Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory.
  • Peripheral vascular: Denies intermittent claudication, varicose veins, coldness or trophic changes, color changes, peripheral edema.
  • Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, history of DVT/PE.
  • Endocrine: Denies polydipsia, polyphagia, heat or cold intolerance, excessive sweating, goiter, hirsutism.
  • Psychiatric: Denies depression/sadness, anxiety, OCD, or ever seeing a mental health professional.

  Physical Exam: 

Vitals:

  • BP: 132/84(seated,left arm)  Right 134/86(seated, right arm)
  • HR: 86 BPM (regular)
  • RR: 17/min (unlabored)
  • T: 99.8 F (oral)
  • O2: 98% (room air)
  • Height: 70 in Weight: 165 lbs BMI: 23.7

General: AAO x 3, appears in no acute distress, well groomed, appears stated age

Skin: Warm & moist; good turgor; non-icteric; no rashes or lesions noted

Head: Normocephalic, atraumatic, non-tender to palpation throughout

Eyes: Symmetrical OU. No strabismus, exophthalmos, or ptosis. Sclera white, cornea clear, conjunctiva pink.

Ears: Symmetrical and appropriate in size. No lesions, masses or trauma on external ears. No discharge or foreign bodies on external auditory canals.TM pearly grey and intact with light reflect in good position 

Nose: Symmetrical. No masses, lesions, deformities, trauma or discharge. Nares patent bilaterally, nasal mucosa pink & well hydrated

Sinus: Non-tender to palpation.

Mouth/pharynx: Mucosa pink and well hydrated. Pharynx non-erythematous. No exudates or lesions visualized. Uvula midline.

Neck: Trachea midline. Supple and nontender to palpation. No cervical adenopathy noted.

Cardiac: Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmur.

Chest: Symmetrical, no deformities. Respirations unlabored, no accessory muscle use.

Lungs: Clear to auscultation 

Abdomen: . Abdomen round and symmetric, no scars, striae or pulsations noted. Bowel sounds normoactive in all four quadrants. Tympanic throughout, no guarding or rebound noted. Negative CVA tenderness.

Nervous system: Cranial nerves I-XII intact.

Peripheral vascular: Pulses 2+ bilaterally in upper and lower extremities. No clubbing, cyanosis or edema noted.

Musculoskeletal: FROM (full range of motion) of all upper and lower extremities bilaterally. Non tender to palpation.

Rectal: exam not performed. 

Differential Diagnosis:

Acute Bronchitis: The hallmark finding in acute bronchitis is a cough with or without sputum production. It must be present for at least 8 days and may present with associative symptoms such as runny nose, sore throat, low grade fever, malaise. My patient’s temperature today was 99.8 and the clinical description of  a persistent cough with phlegm and sore throat making acute bronchitis more likely. 

Influenza: Patient abrupt onset of symptoms that are worsening since onset, would make us consider Flu as a possible ddx. Some of the symptoms that overlap with influenza from my patients presentation would be the sore throat, fever and cough. But since my patient presented with a cough with sputum production this helps us narrow down to acute bronchitis over the flu. Along with the lack of other symptoms such as myalgias,headache and recent contact with someone sick.

Covid-19: Covid is also a possibility is the symptoms my patient presented with and should be ruled out as a possible cause. My patient’s lack of other symptoms such as SOB, myalgias, any smell or taste abnormalities does point us in a direction that this would be a mild case if even it was COVID. My patient also stated he did not come across any sick contacts which is something you would see if you suspected COVID.

Assessment: 42 y/o male with a medical history of HTN comes in with cough(yellow sputum) and sore throat  x 5 days. Patient today has a temperature of 99.8 and is pulse ox is 98% in room air.  Patient states he did not recently come into contact with any sick contacts.From the patients symptoms we can assume the patient has acute bronchitis which is mostly caused by viral infections and the patient will be managed symptomatically.  

Plan:

Acute Bronchitis:

  1. Take Tylenol 500mg as needed.
  2. Encourage adequate fluid intake
  3. If symptoms drastically worsen(SOB) or last longer than 3 weeks, follow up with the office.