Identifying Data: 

Full Name: Ms. SL

Address: Jamaica, NY

Date of Birth: XX/XX/1960

Date & Time: 05/06/2024 12PM

Location: Jamaica, Queens

Religion: Christian 

Source of Information: Self

Reliability: Reliable 

Source of Referral: Self 

Mode of Transportation: Self 

 

Chief Complaint: “cough and hoarseness” x 2 weeks 

History of Present Illness: 

A 63 year old female with a history of hypertension and diabetes presents to the clinic accompanied by her niece, complaining of a productive cough and hoarseness that began last Friday (4/26). She describes the mucus as yellow and nonbloody. Reports a subjective fever, non-bloody vomiting, and dizziness shortly after standing up. Patient is experiencing rib pain due to repetitive coughing. Patient had two episodes of vomiting 3 days ago and then 1 episode of vomiting yesterday. Noted decreased appetite. Denies constipation/diarrhea, sick contacts. Reports recent travel to CT to visit grandchildren. States she has used Flu HBP, Vicks and hot water to help alleviate her symptoms with no relief. Denies chest pain, shortness of breath. 

Past Medical History: 

Present Illnesses – Hypertension and Diabetes

Immunizations: Fully up to date

Childhood illnesses: None 

 

Past Hospitalizations: 

Weakness and dehydration, LIJ Oct 2012

 

Past Surgical History:  

None

 

Medications: 

NovoLOG Flexpen 100 unit/mL Solution Pen-injector, 33 units as directed, SC

Gabapentin 300 mg capsule, orally, three times a day

Ramipril 10 mg capsule, orally, once a day

 

Allergies: 

Pravastatin – side effect: dizzy

 

Family History: 

Mother – alive, DM

Father – alive, DM

7 siblings – 2 brothers, 5 sisters: alive and well 

3 sons – alive and well 

 

Social History: 

Ms. MA is a female living at home with her spouse and son. She is retired.

Habits: Denies smoking. Denies smoking marijuana recreationally. Denies alcohol intake. Denies illicit drug use. Denies coffee consumption.

Travel: Reports recent travel to Connecticut

Diet: Admits to a poorly balanced diet, mainly consisting of fried, fast foods. 

Exercise: Denies regular exercise daily.

Safety measures: Admits to using seatbelt in moving vehicles. 

Sexual history: Denies being currently sexually active. Denies history of STIs.

 

Review of Systems:

General – +Fever. Denies weight loss, weight change, or night sweats.

Skin, hair, nails – Denies pain, pruritus, discoloration, excessive sweating, skin changes, and hair changes.

Head – +Dizziness. Denies headache, trauma, fainting, and Hx of vertigo.

Eyes – Denies discharge, diplopia, eye pain, visual changes, and photophobia. Last eye exam: 3 months ago.

Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids. 

Nose/Sinuses – +Nasal congestion. Denies sinus pressure, epistaxis, swelling.  

Mouth/Throat – +Hoarseness, +cough. Denies dysphagia. Last dental exam: 3 months ago.

Neck – Denies pain with movement, stiffness, swollen glands and trouble swallowing.  

Breasts – Denies skin changes, lumps, nipple discharge. 

Pulmonary System – Denies SOB, DOE, wheezing, hemoptysis or cyanosis. 

Cardiovascular System – Denies chest pain, palpitations, edema. Last EKG: 1 year ago.

Gastrointestinal System – +Vomiting, +loss of appetite. Denies  heartburn/regurgitation, abdominal pain, diarrhea, hemorrhoids, constipation, rectal bleeding. 

Genitourinary System – Denies flank pain, frequency, oliguria, urgency, nocturia, incontinence.

Sexual History – Denies being currently sexually active. Denies history of STIs. 

Nervous – Denies sensory disturbances, paresthesia, or changes in cognition/mental status. 

Musculoskeletal system – +Rib pain with coughing. Denies swelling/stiffness, joint pain, muscle soreness, reduced mobility. Denies tenderness to palpation and erythema. 

Peripheral vascular system – Denies pins and needles, edema, calf pain, varicosities, cyanosis. 

Hematological System – Denies Hx of DVT/PE, lymph node enlargement, blood transfusions, anemia, clotting.

Endocrine system – Denies diabetes, heat or cold intolerance, excessive hunger/thirst.

Psychiatric – Denies changes in mood, suicidal ideations, irritability, and changes in eating habits.

 

Physical 

General: Well groomed female, appearing as her stated age of 63 years, with medium build. She appears awake, alert, oriented to person, place, time and situation. She is cooperative and appears to be a reliable source of information. She appears uncomfortable in the chair due to hoarseness. 

Vital Signs: 

BP: Seated – (R) 131/78

R: 16 breaths/min, unlabored 

P: 100 beats/min, regular rhythm

T: 97 F (Tympanic)

O2 Sat: 94%, room air 

Height: 5’7 inches     Weight: 190 lbs      BMI:  29.32

 

Skin, Hair, Nails, Head:

Skin: Warm and moist. No discoloration. Good turgor. No tattoos, no masses, no bruises, no ulcerations on upper/lower extremities. No visible scarring. 

Hair: Regular quantity, even distribution. Color is dark brown, and the texture is normal. No visible dandruff or lice.

Nails: No clubbing, pitting, signs of infection. Presence of lunula on all nails. Capillary refill < 2 seconds in upper extremities.

Head: Normocephalic, atraumatic, non-tender to palpation. 

 

Eyes:

Eyes appear symmetrical. Eye lashes are well distributed. No strabismus, lid lag, or ptosis noted. Sclera white with no jaundice, cornea clear with no signs of abrasion or nodules. Conjunctiva is clear with no foreign bodies. 

 

Mouth/Neck/Pharynx

Lips: Pink, moist, no cyanosis or edema. 

Buccal Mucosa: Pink, well hydrated, no masses, ulcerations, or leukoplakia.

Palate: Pink, well hydrated, no scars or ulcerations present.

Teeth: Normal dentition, no dental caries present, no plaque buildup.

Gingivae: Moist, with no bleeding, ulcerations, hyperplasia, or discoloration. 

Tongue: Pink, well papillated. Symmetrical with normal texture. 

Oropharynx: Well hydrated, no exudates, masses, or foreign bodies. Uvula pink, midline elevation, no ulcerations. 

Neck: Trachea midline. No masses, scars or pulsations noted. Non-tender to palpation.

 

Thorax/Lungs

Bilateral crackles appreciated in lower lung fields. Chest was symmetrical with no signs of deformities or trauma. Respirations were unlabored and no accessory muscle use was noted. No tenderness to palpation.

 

Heart

Regular rate and rhythm. Distinct S1/S2 with no murmurs, splitting, friction rubs, or S3/S4 appreciated. Carotid pulses are 2+ bilaterally, no bruits present. 

 

Abdomen

Normoactive bowel sounds in all four quadrants with no bruits or pulsations appreciated. Abdomen is soft, symmetrical, and nondistended. No ecchymosis, rebound, or guarding. 

Neuro Exam 

Mental Status: A&O x3, cooperative, thoughts & speech coherent.

 

Differential Diagnosis

• Pneumonia

• Laryngitis

• COVID-19

• Strep Pharyngitis

Assessment

A 58 year old female with PMHx of HTN and diabetes complains of cough and hoarseness for 2 weeks. This is accompanied with GI symptoms such as loss of appetite and few episodes of non-bloody, nonbilious vomiting. Patient is currently afebrile and non-toxic. Physical exam reveals crackles in bilateral lower lung fields, suggestive of pneumonia. 

 

Plan

• Viral PCR for influenza and COVID-19
• Azithromycin Tablet 250 mg, for 5 days
• Augmentin 875-125 mg, 1 tablet every 12 hrs, 7 days
• Benzonatate Capsule 100 mg, 1 capsule as needed orally, 3 times per day, 7 days

 

Results

COVID-19 positive

 

Diagnosis

Likely pneumonia secondary to COVID-19 infection.

 

Patient Education

• Pneumonia is an infection that inflames the air sacs in one or both lungs, leading to symptoms like coughing, fever, and difficulty breathing. It can be caused by bacteria, viruses, or fungi, and can range from mild to severe. Treatment often involves antibiotics, rest, and staying hydrated, while prevention through vaccination and good hygiene practices is crucial.
• Instructed to go to ER if worsening shortness of breath, high fever, intractable vomiting, hypoxia.