Chief Complaint
Sinus congestion, cough, sore throat
History of Present Illness
A pleasant 55-year-old male presents to the clinic with complains of six days of sinus congestion
and pressure, sore throat, headache, a
...
Chief Complaint
Sinus congestion, cough, sore throat
History of Present Illness
A pleasant 55-year-old male presents to the clinic with complains of six days of sinus congestion
and pressure, sore throat, headache, and a productive cough that is worse at night. Patient states
he had been fighting a cold two weeks ago which improved and then relapsed. Patient reports a
productive cough with clear sputum. Patient reports 7/10 achy headache; and 8/10 dull pain to
his throat – “hurts when I swallow.” Patient has been taking Tylenol for pain and Sudafed for the
nasal congestion. Denies any nausea, vomiting, chills, fever or night sweats. He is currently
taking care of his wife who is undergoing chemotherapy for advanced breast cancer.
Past Medical History
Past medical history: NKDA, Seasonal Allergies
Past surgical history: Left inguinal hernia repair 2014
Patient is up to date on his influenza and tetanus vaccines. Patient does not qualify at this time
for a pneumonia vaccine. Patient received all of his childhood immunizations. Patient does not
have any known drug allergies. Has seasonal allergies.
Patient currently takes: Simvastatin 10 mg daily at night; Metoprolol 25mg daily; Zyrtec 10mg
PRN
Family History
Mother: 72 years old; hyperlipidemia, hypothyroidism.
Father: 82 years old; HTN, HDL, Parkinson’s disease
Sister: 39 years old; IBS
Personal/Social History
Patient is a Senior Systems Administrator and works at L3 Harris. Patient is active with his
family and at church. Patient is currently taking care of his wife who has advanced breast cancer.
Patient states he has a strong support system that help care for his wife. Non-smoker. Denies
exposure to second-hand smoke. Denies the use of recreational drugs.
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