History of present illness
You go in to see Kathy. She tells you that she started feeling sick approximately 5 days ago. It started with a dry cough; however, over the past couple days she has expectorated some clear, and more recently, thicker rust-colored, mucous. She denies frank blood in her sputum. She notices some wheezing after coughing spells. This morning, Kathy woke up in a "coughing fit" and she said she felt some sharp pain in her chest. She rates the pain a 5/10 when it occurs. Kathy has felt feverish over the past few days; she sometimes gets the "chills." Her highest temperature was 102 degrees. She has taken Tylenol 650mg prn for fever with some relief. The last time she took Tylenol was last night before bed. She has been increasingly fatigued over the past several days; she states she feels like she was "hit by a bus." She denies headache, nausea, vomiting, and diarrhea. Her appetite has been decreased ever since she started feeling sick.
Review of systems:
Patient complains of increasing fatigue and malaise. Denies recent weight loss/ gain. Denies headache, sinus pressure, changes in vision/ hearing, eye/ear pain, dizziness, vertigo, and neck tenderness. States throat feels scratchy from coughing. Denies palpitations, syncope, each bruising and bleeding, and edema. Feels short of breath at rest after coughing and with activity. Denies history of lung disease including asthma and COPD. Denies abdominal discomfort. Denies history of mental illness, including anxiety and depression.
Additional history:
Past medical and surgical history: osteopenia (2011), hypertension (2004); had hysterectomy at age 41 for uterine fibroids. Denies recent hospitalizations. No known exposure to illnesses.
Allergies: denies allergies to food and medications; states she might have mild seasonal allergies, but this has never been diagnosed
Medications:
|
Medication/Dose/Route |
Time/duration |
|
Tylenol 650mg PO |
Q4-6 hours prn |
|
Lisinopril 10mg PO |
Q day |
|
Calcium 1000mg and Vitamin D 800 units PO |
Q day |
Social history: Patient works as a bank teller at Chase full-time. Lives at home alone; husband died from MI approximately 10 years ago. Not currently sexually active. Has 2 children that live out of state. Tries to walk for 15-30 minutes 3-5 days a week; however, has not been walking recently related to being sick. States she drinks wine occasionally on the weekends. Denies use of tobacco products and recreational drugs. States she is a never-smoker.
