History

Name: H.S.

Sex: Female

Age: 40 years

Date: March 22, 2024

Location: Dr. Devicka Persaud

Source of Information: Self

Reliability: Reliable

Source of referral: Self

Mode of transportation: Public transportation

CC:

“My eyes are red and I have a cough” x 7 days.

HPI:

40 year old female presents today complaining of a cough x7 days. The cough is mainly a dry cough which sometimes produces green phlegm with occasional streaks of small amounts of bright red blood. She has an associated sore throat. Pt also has nasal congestion and says that sometimes she notices blood after blowing her nose. Since yesterday pt notices that she has redness in her eyes. Her eyes are also very watery. She says that this morning she woke up with dried green mucus crusting by both of her eyes. She says that once she wiped it away, the crusting did not return. Pt had fever and body aches for 2 days last week but that is no longer present. Pt has tried mucinex, but that did not provide any relief.  Pt does not use public transport but admits that many people at work are also sick. Pt has no known history of allergies. 

Denies shortness of breath, headache, chest pain, blurry vision, eye pain, wheezing and ear pain.

PMHx:

• Type 2 diabetes x unknown time
• GERD x unknown time
• No known hospitalizations
• UTD on all vaccines

Medications:

• Famotidine 20 mg BID for GERD
• Omeprazole 20 mg BID a half hour before food for GERD
• Metformin HCl 1,000 mg BID for diabetes
• Denies herbal supplement use.

Past surgical history:

• No past surgical history.

Allergies:

• No known drug/food/environmental allergies

Family history:

• Mother: Alive age 60, good health
• Father: Alive age 68, DM
• No children

Social history:

• Smoking: Denies
• Alcohol: Socially
• Illicit drug use: Denies past or current use
• Marital History: Single
• Language: English
• Occupational History: Manager of a store
• Travel: No recent travel
• Home situation: Lives at home with family
• Sleep: Endorses adequate sleep
• Exercise: Does not exercise
• Diet: Reports balanced diet with lean protein and vegetables. Carbs minimally.
• Caffeine: Denies caffeine use

Review of Systems:

• General– Denies fever, fatigue, chills, night sweats, weight loss/gain, changes in appetite.
• Skin, hair, nails– Denies discolorations, moles, rashes, changes in hair distribution or texture, pruritus.
• HEENT– Admits to epistaxis, nasal congestion and sore throat. Denies head trauma, vertigo, visual disturbances, ear pain, hearing loss, tinnitus, discharge, bleeding gums.
• Neck– Denies localized swelling/lumps, stiffness/decreased ROM
• Breast– Denies lumps, nipple discharge, or pain.
• Pulmonary– Admits to cough and hemoptysis. Denies dyspnea, wheezing, cyanosis.
• Cardiovascular– Denies chest pain, edema/swelling of ankles or feet, palpitations.
• Gastrointestinal- Denies abdominal pain, nausea, vomiting, jaundice, diarrhea, constipation, dysphagia, pyrosis, flatulence, eructation, rectal bleeding, hemorrhoids or blood in stool.
• Genitourinary– Denies urinary frequency, nocturia, urgency, flank pain, oliguria, polyuria and incontinence, vaginal discharge, dysuria and malodorous urine.
• Menstrual/Obstetrical– G0P0000, LMP 03/15/2024; sexually active with one male partner
• Musculoskeletal– Denies back pain, muscle pain, joint pain, arthritis and joint swelling.
• Nervous system- Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory.
• Peripheral vascular– Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes.
• Hematologic– Denies anemia, easy bruising or bleeding, lymph node enlargement, history of DVT/PE.
• Endocrine– Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, excessive sweating, or hirsutism.
• Psychiatric– Denies feelings of helplessness, hopelessness, lack of interest in usual activities, or suicidal ideations, anxiety, obsessive/compulsive disorder, or ever seeing a mental health professional.

Physical

General:

• Well developed, obese female in no apparent discomfort. Appears stated age of 40. Neatly groomed, alert and oriented x3.

Vitals:

• BP: 130/80 mm Hg
• R: 18/min, regular rate and rhythm, unlabored
• P: 98 beats per minute, regular rate, rhythm and amplitude 
• T: 97.9 degrees F (temporal)
• Height: 62 inches Weight: 178 lbs BMI: 32.55

Skin/Head:

• Skin: Warm and moist, good turgor. Nonicteric, no lesions, scars, or tattoos noted.
• Hair: No balding with average texture. No alopecia, seborrhea, or lice on exam.
• Nails: No clubbing, cyanosis, or lesions. Capillary refill < 2 seconds in upper and lower extremities.
• Head: Normocephalic, atraumatic with no evidence of contusions, ecchymoses, hematomas, or lacerations, and nontender to palpation throughout.
• Eyes: Symmetrical OU. No strabismus, exophthalmos, or ptosis. PERRLA. EOMS intact. Bilateral conjunctival injection. Watery discharge bilaterally. No sign of FB or trauma. Visual acuity intact. Fundoscopic exam deferred. 
• Ears: Symmetrical and appropriate in size. No lesions, masses, or trauma on external ears. No discharge/foreign bodies in external auditory canals AU. TMs pearly gray/intact with light reflex in good position AU.

Nose/Sinuses:

• Nose: Symmetrical. No masses, lesions, deformities, trauma. No discharge visualized. Nares patent bilaterally. Nasal mucosa is pink and well hydrated. Septum midline without lesions, deformities, injection, or perforation. No foreign bodies.
• Sinuses: Nontender to palpation and percussion over bilateral frontal, ethmoid, and maxillary sinuses. 

Mouth/Pharynx:

• Teeth: Good dentition. No obvious dental caries noted.
• Tongue: Pink and well papillated. No masses, lesions or deviation. Mild fasciculation on exam. 
• Oropharynx: Well hydrated. No injection, exudate, masses, lesions or foreign bodies. Mildly enlarged tonsils present with no injection or exudate. Uvula midline, pink with no edema or lesions.

Neck/Trachea/Thyroid:

• Neck: Trachea midline. No masses, lesions, scars, pulsations. Supple and non-tender to palpation. FROM, no stridor noted. 2+ carotid pulses, no bruits or thrills noted bilaterally. No cervical adenopathy.
• Thyroid: Non-tender to palpation. No masses, thyromegaly, or bruits noted.  

Thorax/Lungs:

• Chest: Symmetrical, no deformities, no trauma. Respirations unlabored/ no paradoxical respirations or use of accessory muscles noted. Non-tender to palpation throughout. 
• Lungs: Clear to auscultation and percussion bilaterally. No adventitious sounds.

Cardiac:

• Heart: Regular rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. 

Abdominal:

• Abdomen flat and symmetric with no scars, striae or pulsations noted. Bowel sounds normoactive in all 4 quadrants with no aortic/renal/iliac or femoral bruits. Nontender to palpation and tympanic throughout, no guarding or rebound noted. No hepatosplenomegaly to palpation. No CVA tenderness noted.

Pelvic:

• Genitalia: external genitalia without erythema or lesions. Vaginal mucosa Pink without inflammation, erythema or discharge. Cervix multiparous, pink and without lesions or discharge. No cervical motion tenderness. Uterus anterior, midline, smooth, non-tender and not enlarged. No adnexal tenderness or masses noted. No inguinal adenopathy.

Neurologic:

• Cranial Nerves: CN I- XII are intact
• Mental status exam: Patient is well appearing, has good hygiene and is neatly groomed. Patient is alert and oriented to name, date, time and location. Speech and language ability intact, with normal quantity, fluency, and articulation. Patient denies changes to mood. Conversation progresses logically. Insight, judgment, cognition, memory and attention intact.
• Reflexes: Biceps, brachioradialis, triceps, patellar, and Achilles are 2/4 bilaterally. No clonus. Plantar reflex is downward bilaterally.
• Sensation: Sensation is intact bilaterally to pain and light touch. Two-point discrimination is intact. 
• Motor: Good muscle tone. Strength is 5/5 bilaterally at the deltoid, biceps, triceps, quadriceps, and hamstrings. 
• Cerebellar: Finger-to-nose and heel-to-shin test normal bilaterally. Balances with eyes closed (Romberg). Rapid alternating movements are normal. Gait is steady with a normal base. Coordination is intact as measured by heel walk and toe walk.

Peripheral vascular system:

• Extremities are warm and without edema. No varicosities or stasis changes. Calves are supple and nontender. No femoral or abdominal bruits. Brachial, radial, ulnar, femoral, popliteal, dorsalis pedis and posterior tibial pulses are 2+ and symmetric.

Musculoskeletal:

• No erythema, warmth or crepitus noted. Non-tender to palpation. Full range of motion of all upper and lower extremities bilaterally. 

Differential diagnosis:

• URI
  • A URI is an infection of the upper respiratory tract and presents like the common cold. A URI commonly presents with nasal congestion, a sore throat due to a post nasal drip and a dry cough. All of these are symptoms that this pt is experiencing. A URI may also cause watery eyes as this pt has. This is a clinical diagnosis. 
• Viral conjunctivitis
  • Viral conjunctivitis presents with red, watery eyes. The symptoms are generally in bilateral eyes due to its contagious nature. Additionally, the symptoms are often secondary to a URI, which this pt also has symptoms of. This is a clinical diagnosis.
• Acute Bronchitis
  • Acute bronchitis is an infection which also affects the lower respiratory tract. The symptoms are very similar to a common URI but some things differentiate it. Acute bronchitis presents with a productive cough and typically has additional symptoms such as chest pain, shortness of breath and wheezing, Acute bronchitis will also not have any ocular symptoms. For these reasons, this diagnosis is less likely in this pt.
• Allergic rhinitis
  • Allergic rhinitis typically presents with similar symptoms to what this pt is experiencing- cough, stuffy nose, watery eyes etc. However, being that this pt does not have a history of allergies and because it is not yet peak allergy season this is a less likely diagnosis. Pt also has none of the other diseases that fall under the atopy triad (asthma, atopic dermatitis).

Assessment:

• 40 year old female with PMHx of GERD and type 2 diabetes presents with complaints of a cough and sore throat x7 days. Pt also developed redness in her eyes yesterday. On exam, pt has bilateral conjunctival injections and watery discharge along with mildly enlarged tonsils. All other parts of the exam are within normal limits. There are no labs or imaging available at this point. This is most consistent with a diagnosis of URI and viral conjunctivitis.

Diagnosis:

• URI
• Viral conjunctivitis

Plan:

• URI
  • Acetaminophen or NSAIDs PRN pain or fever
  • Dextromethorphan 20 mg Q4H x5-7 days
  • Saline nasal spray
  • Pt education
  • Tea and honey
  • Pt education:
    • Return if symptoms worsen or don’t get better in 10 days. Will consider chest x-ray at that point.
• Viral conjunctivitis
  • Olopatadine 0.2%: Instill 1 drop into each affected eye once daily 
  • Warm or cool compresses
  • Non antibiotic lubricating eye drops (artificial tears)
  • Pt education
    • Wash hands frequently because this is very contagious
    • Do not share handkerchiefs, tissues, towels, cosmetics, linens, or eating utensils.
    • Symptoms will get worse for three to five days before getting better
    • Symptoms can persist for two to three weeks
• Diabetes
  • Continue metformin 1,000 mf BID
• GERD
  • Continue famotidine 20 mg BID and omeprazole 20 mg BID