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 …show more content…
Maternal grandmother and aunt positive for diabetes mellitus type 2. Maternal grandfather decreased of natural causes. Paternal grandfather noted with hypertension. Paternal grandmother noted with hyperlipidemia. One brother positive for pyloric stenosis during infancy and second brother with negative medical history.
ROS:
CONSTITUTIONAL: Denies any weight loss or gain. He denies any complaints of fever, chills, fatigue or weakness. He states “generally I am in good health and do not have any medical issues”.
HEENT: Eyes: Denies any complaints of blurred vision, double vision or discharge from eyes. He notes being positive for myopia. He wears contact lens and eyeglasses to correct this impairment. Ears: Denies any pain or discomfort. He denies any sensitivity to sounds, hearing loss or drainage in ears. Nose: He complains for having clear colored nasal drainage. He is also noted with some nasal congestion. This drainage has been occurring for 2 weeks. Throat: Complains of having throat irritation and soreness. He denies any noted hoarseness or dysphagia.
SKIN: Denies any complaints of itching, rash, lesions, pruritus or skin sensitivity.
CARDIOVASCULAR: Denies any complaints of chest pain, chest pressure or chest discomforts. He denies any feelings of palpitations or edema. No noted dizziness, syncope or complaints of
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 …show more content…
Maternal grandmother and aunt positive for diabetes mellitus type 2. Maternal grandfather decreased of natural causes. Paternal grandfather noted with hypertension. Paternal grandmother noted with hyperlipidemia. One brother positive for pyloric stenosis during infancy and second brother with negative medical history.
ROS:
CONSTITUTIONAL: Denies any weight loss or gain. He denies any complaints of fever, chills, fatigue or weakness. He states “generally I am in good health and do not have any medical issues”.
HEENT: Eyes: Denies any complaints of blurred vision, double vision or discharge from eyes. He notes being positive for myopia. He wears contact lens and eyeglasses to correct this impairment. Ears: Denies any pain or discomfort. He denies any sensitivity to sounds, hearing loss or drainage in ears. Nose: He complains for having clear colored nasal drainage. He is also noted with some nasal congestion. This drainage has been occurring for 2 weeks. Throat: Complains of having throat irritation and soreness. He denies any noted hoarseness or dysphagia.
SKIN: Denies any complaints of itching, rash, lesions, pruritus or skin sensitivity.
CARDIOVASCULAR: Denies any complaints of chest pain, chest pressure or chest discomforts. He denies any feelings of palpitations or edema. No noted dizziness, syncope or complaints of