H&P #3

Identifying data:

  • Date & Time: 1/24/23 6:00 pm
  • Full name: Ms. K. G.
  • Address: Queens, NY
  • Date of birth: 11/11/90
  • Location: Centers Urgent Care, Middle Village
  • Religion: Unknown
  • Marital status: Single
  • Source of information: Self
  • Reliability: Reliable
  • Source of referral: Self

 

Chief Complaint: “Cough and congestion” x 7 days

History of Present Illness:

32 y/o F with no significant PMHx c/o productive cough, sinus congestion and sore throat x 7 days. Patient states symptoms began with dry cough and congestion and symptoms were improving at first, but worsened 2 days ago. States she developed a sore throat, 3/10 pain, is able to tolerate foods/liquids normally. Reports cough with yellow sputum that worsens at night and “feels mucus dripping down” the back of her throat. Admits to sinus pressure, pt has noticed thick green drainage from nose. States she has felt similar symptoms in the past and was diagnosed with a sinus infection. Has tried OTC Sudafed, felt mild relief of symptoms. Denies fever, chills, chest pain, SOB, dizziness, headache, ear pain, N/V/D.

 

Past Medical History:

  • No past medical history

Past Surgical History:

  • No past surgical history

Medications:

  • No medications
  • No herbal supplement use

Allergies:

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

Family History:

  • Mother: alive and well, no significant PMHx
  • Father: alive and well, no significant PMHx
  • Maternal grandparents: unknown
  • Paternal grandparents: unknown

Social History:

  • Smoking: non-smoker
  • Substance use: denies alcohol or drug use
  • Caffeine: denies caffeine use
  • Occupational history: unemployed
  • Home situation: lives at home with boyfriend

 

Review of Systems:

  • General: Denies generalized weakness/fatigue, fever, chills, 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.
  • Ears: Denies deafness, ear pain, discharge, tinnitus.
  • Nose: Admits to discharge, congestion. Denies epistaxis.
  • 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. Denies dyspnea, dyspnea on exertion, 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.
  • Menstrual/Obstetrical: G0, P(T0 P0 A0 L0), menarche age 16, LMP 1/11/23, regular menstrual cycles every 30 days. Denies hot flashes, vaginal discharge.
  • Sexual History: Admits to currently being sexually active with 1 male partner. 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: 113/72 (seated, right arm)
  • HR: 74 BPM (regular)
  • RR: 18/min (unlabored)
  • T: 99.4 F (oral)
  • O2: 99% (room air)
  • Height: 65 in Weight: 140lbs     BMI: 23.3

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: Conjunctiva pink. PERRLA. Visual fields full OU.

Ears: TM pearly grey and intact with light reflect in good position AU. No tenderness, discharge or foreign bodies.

Nose: Symmetrical, no deformities. Swelling and erythema noted in B/L turbinates. Mucopurulent discharge noted.

Sinus: Tenderness to palpation over bilateral maxillary and ethmoid sinuses. No tenderness over frontal sinuses.

Mouth: Mucosa pink and well hydrated.

Pharynx: Mild Pharyngeal erythema. Postnasal drip noted in oropharrynx. No exudates or lesions visualized. Uvula midline.

Neck: Trachea midline. Supple and non-tender 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 bilaterally.

Abdomen: Abdomen flat and symmetric, no scars, striae or pulsations noted. Bowel sounds normoactive in all four quadrants. Tympanic throughout, nontender, no guarding or rebound noted.

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.

 

Differential Diagnosis:

  1. Acute sinusitis
  2. Pharyngitis – strep or viral
  3. COVID-19
  4. Influenza
  5. Upper respiratory infection
  6. Acute bronchitis

 

Workup:

  • Rapid Strep – negative
  • Rapid COVID – negative
  • Rapid Influenza A/B – negative

 

Diagnosis: Acute Sinusitis

 

Assessment: 31 y/o F with a 7-day complaint of worsening productive cough, sinus congestion with green drainage, and sore throat. Rapid strep, rapid covid and rapid influenza are all negative. On exam, there is tenderness over B/L maxillary and ethmoid sinuses. Lungs are clear to auscultation bilaterally. Pharynx is mildly erythematous, no exudates noted, uvula midline.

 

Plan:

  • Amoxicillin – Clavulanate 875-125 mg 1 tab BID x 10 days
  • OTC Tylenol/ibuprofen as needed for pain
  • Use humidifier at home to help break up mucus
  • Go to ER if worsening symptoms (fever, intractable facial pain, unable to tolerate foods/liquids) or follow up with PCP if symptoms are not improving with treatment