Rw soap

Typhon Encounter: 78070987

Type of Note: Focused

Subjective:

CC: "Cough, runny nose, and sore throat x 7 days."

HPI: 20 y.o. M with PMH: childhood asthma presents to the urgent clinic by himself with complaints of non-productive cough, runny nose, and sore throat x 7 days. Reports runny nose and sore throat developed, then a day later a cough started a week ago which is worsened at night. At times feels like he is coughing and wheezing. He has tried VapoRub, ibuprofen, and OTC cough medication without relief. The cough is disrupting his sleep and causing him to be sleepy during the day. The runny nose and sore throat have improved on its own. Denies headache, fever, chills, sick contacts, or recent travel. Denies exposure to allergens.

Allergies: No known drug allergies. Strawberries fruit/flavoring (rash).

PMH: Seasonal allergies, asthma until high school, and varicella at age 2.

Surgical: Tonsillectomy (1998), Coronectomy (2005)

Medications: Vicks VapoRub, ibuprofen, and OTC cough medication (he is unsure of doses but follows box directions and only uses as needed for recent symptoms)

Health Maintenance/Promotion: Received all scheduled childhood vaccines, Last influenza immunization (Oct 2019). Dental exam 4 mos. ago. USPSTF (2021): Recommendations Hepatitis B Virus screening, HIV screening, HTN screening, screening for depression, STI counseling, skin cancer prevention, syphilis screening; CDC (2022) immunization: influenza yearly, Tdap/Td (PRN wound or Q10yers); Healthy People 2030 SDOH (2022): Shared decision making, communication, understanding of care, access to medical record, exposure to environmental air and water toxin, injury prevention, physical activity.

Social History: Lives alone. Denies illicit drug use, tobacco/e-cigarette use. Admits to occasional once every 2-3 months alcohol use – last drink 2 months ago, works in IT remotely from home in an urban apartment. Health insurance through work.

Family History: Denies recent illnesses, hx of COPD, or lung disorders.

ROS:

General: No weakness, fatigue, fevers, or chill. Eyes: Denies visual changes, itchy eyes, pain, redness, and excessive tearing. Ears: No hearing change, tinnitus, earaches, itch, or discharge. Nose: No sinus pain or epistaxis. Nasal congestion improved. Throat: Sore throat resolved. No sore tongue or dry mouth. C/V: Denies chest pain, palpitations. Pulmonary: Reports NON-PRODUCTIVE COUGH with wheezing at times worst at night, Denies hemoptysis, dyspnea, and pleuritic pain. Neuro: Denies headache or dizziness. GI: Denies nausea and vomiting. Lymph: Denies swollen lymph nodes in the neck. Allergy/immunology: Denies frequent illness.

Objective:

Physical Exam:

VS: T – 98.6, P – 80, R – 16, BP – 128/72, O2 sat – 99% RA, - 1/10 pain in the throat. Wt.: 205 lbs., Ht.: 72 in, BMI: 27.8

General: Alert, oriented x 4, in no acute distress. Able to speak in full complete sentences. Skin: Natural in color, warm, and dry with good skin turgor. Nails without clubbing or cyanosis. HEENT: Ears: TM intact and pearly gray with the cone of light bilateral. Nose: Nasal mucosa pink and moist. Inferior turbinates mild erythema bilaterally. Nares patent bilaterally. No sinus pain upon palpation. Septum midline. Throat: Oral mucosa pink and moist, tongue mobile without lesions, tonsils absent. Posterior pharynx with mild erythema but no cobblestone appearance. Neck: non-tender and no lymph nodes palpable. Trachea midline. Cardio: RRR. Crisp S1 S2 without clicks, rubs, or murmurs. Thorax and lungs: Thorax is symmetric with good expansion. Respirations are even and unlabored. No use of accessory muscles, stridor, grunting, or nasal flaring. Lungs CTA bilaterally.

Rapid strep negative

Assessment:

20 y.o. M PMH: childhood asthma presents to the urgent clinic with complaints of non-productive cough, runny nose, and sore throat for 7 days without improvement with OTC medications and no fever or chills. Reporting congestion and sore throat are improving, but cough with wheezing sometimes disrupts his sleep. Physical examination was unremarkable except for improving erythema to the oropharynx and turbinates, and the strep test was negative. Based on the presentation, viral URI is likely due to sore throat, congestion, and cough and unlikely allergic etiology due to lack of exposure. However, a component of mild asthma exacerbation is a concern with a history of symptoms worse at night and wheezing. Will treat for resolving viral URI with post-viral cough and possible mild asthma exacerbation.

1. Viral upper respiratory infection resolving with post-viral cough (J06.9)

2. Possible mild asthma flare-up (J45.2)

Plan:

Viral upper respiratory infection resolving with post-viral cough (J06.9)

Diagnostic: SARS-CoV-2 RT-PCR. Influenza Viral Panel PCR.

Therapeutics: Nasal saline irrigation per manufacturer instructions as needed for congestion. Menthol rub per manufacturer instructions daily as needed for cough. Honey 1 tsp. by mouth daily as needed for sore throat/irritation and cough. Acetaminophen 500 mg PO Q4H as needed for pain and/or fever (> 101).

Education: Diagnosis of a common cold with expected symptoms and treatment. Avoid OTC cold medication. Use hand sanitizer/washing for at least 15 seconds frequently throughout the day for prevention. Antibiotics are not an effective treatment for the common cold. On return precautions. Stop taking ibuprofen and replace it with acetaminophen.

Consultation: If you develop a fever (higher than 101), productive cough, shortness of breath, headaches, or facial pain. Reach out to your PCP via call or EMR message for a follow-up appt.

(DeGeorge, Ring, & Dalrymple, 2019).

2. Possible mild intermittent asthma flare-up (J45.2)

Diagnostic: Office spirometry.

Therapeutics: Ventolin HFA 180 mcg (2 puffs) MDI inhaled with spacer Q4H as needed for cough and wheezing. No refills.

Education: Educated on possible asthma flare-ups. The educated will trial the Ventolin inhaler during episodes at night when symptoms worsen, which does not follow GINA guidelines. Educated on MDI technique and return precautions. Educated on modifiable risk factors like self-monitoring symptoms, avoiding tobacco and allergens exposure, regular- physical activity, explore if aspirin-induced respiratory disease.

Consultation: Follow-up in the office in 3-4 days for re-evaluation. If you continue to have symptoms, will prescribe low-dose ICS-formoterol like budesonide-formoterol. Will create an action plan. If they continue to have 1-2 exacerbations per year despite escalating care to steps 4-5 will refer to a specialist.

(GINA, 2020).

CPT: 99203

References:

Centers for Disease Control and Prevention (CDC). (2022, February). Adult immunization schedule. Centers for Disease Control and Prevention. https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html#table-age

DeGeorge, K.C., Ring, D.J., & Dalrymple, S.N. (2019, September). Treatment of the common cold. American Family Physician (AF). https://www.aafp.org/pubs/afp/issues/2019/0901/p281.html

Global Initiative for Asthma (GINA). (2020). Pocket guide for asthma management and prevention. Global Initiative for Asthma. https://ginasthma.org/wp content/uploads/2020/04/Main-pocket-guide_2020_04_03-final-wms.pdf

Healthy People 2023. (2022). Social determinates of health. U.S. Department of Health and Human Services. https://health.gov/healthypeople/priority-areas/social-determinants health

U.S. Preventive Service Task Force (USPSTF). (2021). A & B recommendations. U.S. Preventive Service Task Force. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf a-and-b-recommendations