unit 7 journal

Name:  Vernon Hawthorne

 Pt. Encounter Number: 1

Date: 10/3/23

Age: 55

Sex: Male

SUBJECTIVE

CC: 

“runny nose, sore throat and cough”

HPI: 

55 yo male presents to the office today with c/o runny nose, sore/scratchy throat and cough for 3 days. He reports the symptoms presented suddenly upon awakening 3 days ago. He denies any sick contacts or known exposure to COVID 19. Pt states the symptoms have been constant and are worsening with time. Denies aggravating factors. States he has tried Nyquil to treat the symptoms however, but it makes him groggy which he does not like. Reports he was treated at a clinic about 1 year ago for similar symptoms with a Zpack. Rates the severity of his symptoms 7/10 and states they are interfering with his work. He is requesting a Zpack for treatment but is agreeable to history and physical exam. 

Medications:

No prescription medications.

Advil PRN .

Allergies: NKDA

Past Medical History: Denies

Chronic Illnesses/Major traumas: Denies

Hospitalizations/Surgeries: Denies

Preventive: Vaccinations UTD

Family History

Denies significant family history. Both parents alive and well.

Social History

Pt has a Juris Doctor degree and practices law in his own firm which handles estate planning. He has been divorced twice, is not currently in a relationship and lives alone. He feels safe in his home. Reports alcohol use of one drink daily at night. Denies problem drinking. Denies tobacco use and drug use.

ROS Student to ask each of these questions to the patient: “Have you had any…..”

General

Denies fever or fatigue.

Denies recent weight change.

Cardiovascular

Denies chest pain or palpitations.

Skin

Denies complaints

Respiratory

+nonproductive cough

Denies SOB. Denies wheezing

Eyes

Denies complaints 

Gastrointestinal

Denies abdominal pain, denies nausea.

Ears

Denies complaints.

Genitourinary/Gynecological

Denies complaints

Not sexually active

Head/Nose/Mouth/Throat

+rhinorrhea, +sore, scratchy throat

Denies post nasal drip. Denies sinus pain or hoarseness.

Denies difficulty swallowing

Musculoskeletal

Denies complaints

Breast

Denies mass.

Neurological

Denies weakness. Denies syncope

Heme/Lymph/Endo

Denies swollen glands

Denies heat/cold intolerance.

Psychiatric

Denies depression + anxiety related to current presentation

Denies SI

OBJECTIVE

Weight      BMI

Temp

BP

Height

Pulse

Resp

General Appearance

Generally healthy appearing in no acute distress. Mood slightly irritated, requesting antibiotic prescription, easily redirected.

Skin

Skin is warm and dry, no rashes noted.

HEENT

PERLA. EOM intact. Conjunctiva normal.

Nasal mucosa with mild erythema and swelling. +rhinorrhea. Frontal and maxillary sinuses nontender.

Posterior pharynx erythematous. No exudate.

Bilateral tympanic membranes normal.

Cardiovascular

Heart with regular rate and rhythm, S1, S2 normal with no murmur, rub or gallop 3+ pulses, no edema

Respiratory

Lung sounds clear bilaterally. Normal effort. Frequent cough present during assessment.

Gastrointestinal

Abdomen is soft, nontender. Active bowel sounds all quadrants. No organomegaly .

Breast

Not examined

Genitourinary

Not examined

Musculoskeletal

Observed normal ROM.

Neurological

Awake, alert and oriented x 4. Speech clear. Normal gait observed.

Psychiatric

Dressed appropriately. Interacting and answering questions appropriately.

Lab Tests

POC COVID 19 Antigen testing negative.

Assessment

· Include at least three differential diagnoses

· Provide rationale for each differential diagnosis

· Final diagnosis

· Pathophysiology of primary and rationale for choosing as final

Plan

· Medications *****include Tessalon and any others***

· Non-pharmacological recommendations

· Diagnostic tests

· Patient education

· Culture considerations

· Health promotion

· Referrals

· Follow up