Biology And Physical Examination : Symptoms And Treatment Essay

754 Words Jan 6th, 2016 4 Pages
CC (chief compliant): JID is a 27 year-old African American male who presents for a history and physical examination. He presents with complaints of nasal drainage and a nonproductive cough. He states “I have had a runny nose and cough for the last past 2 weeks”.
HPI:
Onset: Runny nose and non productive cough that began 2 weeks.
Location: Nose: nasal drainage chest: nonproductive cough
Duration: Nasal drainage continuous throughout the day. Coughing throughout the day and increases during the night.
Characteristics: Clear nasal drainage and cough with no sputum production.
Aggravating Factors: Nasal drainage increases in different environments.
Relieving Factors: Breathing in cool air.
Treatment: over the counter medication.
Current Medications: He notes taking 1 multivitamin and 1 vitamin C tablet orally daily. Currently taking over the counter pseudoephedrine 30 mg 1 tablet twice a day and a cough suppressant He denies any use of herbal or homeopathic products.
Allergies: Medication allergy to Biotin. He notes developing angioedema and dyspnea when taking this medication. Allergy to bee stings is also identified. He develops hives, dyspnea and angioedema with bee stings. He carries an epinephrine injectable pen.
PMHx: He is current with all immunizations including his tetanus. Last tetanus was administered nine years ago at the age of 18. He denies receiving any immunization or having a titer drawn for varicella. He notes having contracted chickenpox during…

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