REASON FOR VISIT: Cough and chest congestion, also body aches and chills.
SUBJECTIVE: The patient is a (XX)-year-old male who presents this afternoon with the above chief complaint. He tells me that he has had a cough for the past several weeks as well as some body aches, headache, and some sinus congestion. His cough has been worsening, and for the past 24 hours, he has been coughing with such force, it has caused him to vomit. He notes that his cough is productive of thick brown-greenish phlegm. He also describes having sinus congestion and a runny nose, which has led him to have a decreased appetite and also a headache. He also reports some generalized body aches and chills, though he denies any measured fever. He tells me that several years ago, he was hospitalized with pneumonia.
He also describes having sinus congestion and a runny nose, which has led him to have a decreased appetite and also a headache. He also reports some generalized body aches and chills, though he denies any measured fever. He tells me that several years ago, he was hospitalized with pneumonia and therefore was concerned and wanted to be checked. He is not currently taking any medications on a regular basis. No known allergies.
OBJECTIVE: Blood pressure 132/72, pulse 82, temperature 98.8, oxygen saturation 98% on room air. General: The patient is alert and oriented, pleasant and conversive. He is in no acute physical distress, though he appears pale and fatigued. HEENT: Maxillary sinus tenderness. TMs gray, nonbulging. Oropharynx injected but without tonsillar swelling or exudate. Neck: Supple without lymphadenopathy. Chest: Lung sounds are coarse and congested with a question of crackles in the left base and mid section. Abdomen: Soft and nontender.
ASSESSMENT AND PLAN: Cough and congestion in a (XX)-year-old male patient. Given his history of pneumonia, we will send him for a chest x-ray to rule that out. Additionally, we will cover him, at least to start with, with a Z-Pak and then if his chest x-ray does indicate pneumonia, consider increasing this up to 500 mg for about 7 days. The patient is agreeable with this plan. He was advised to stay out of work for the next few days and really try to rest, also pushing fluids. We will communicate with him regarding the results of the chest x-ray and send a prescription for Z-Pak, at least to get things started, to his pharmacy.
