SUBJECTIVE DATA (S):
IDENTIFYING DATA:
Initials:
G.B
.
Age: 61 years
Race:
Caucasian
Gender:
Female
Marital Status: Married
CHIEF COMPLAINT (CC): Patient complains of “cough and
congestion for 2 weeks”
HISTORY OF PRESENT ILLNESS (HPI): Patient c/o dry cough x 2
weeks.
Patient states she just got back from a cruise and was in the
casinos
on the ship a lot. She thought the cigarette smoke could have
been making her cough, but it is not any better. She now feels
congestion in her chest and c/o hoarseness and expiratory
wheezing.
• location: congestion in chest
• quality: patient describes a feeling of tightness in her chest
• severity: patient rates pain a “3” on a scale from 1-10
. She states her cough is constant and is continuing to worsen
• timing: symptoms started 2 weeks ago
• setting: patient states her symptoms started while she was on
a cruise in the ship’s casinos
• alleviating and aggravating factors: cough is worse at night,
with any physical exertion, or when she gets hot. She states she
still coughs at rest but it is somewhat better.
• associated signs and symptoms: hoarseness and expiratory
wheezing
PAST MEDICAL HISTORY (PMH):
• Allergies: NKDA
• Current medications: citalopram 40 mg tablet,
levothyroxine 50 mcg tablet, pantoprazole 40 mg tablet,
delayed release
• Age/health status: 61 years
• Appropriate immunization status: Up to date on all vaccines;
Flu vaccine given November 2020. She states she will be getting
the flu and
,pneumonia vaccines at her primary physician’s office this fall.
• Previous screening tests result: Patient states she had a pap
smear and mammogram in March 2020 and both were reported
normal.
• Dates of illnesses during childhood: N/A
, • Major adult illnesses: Patient states she has a history of
depression, hypothyroidism, and GERD
• Injuries: N/A
• Hospitalizations: No hospitalizations other than when
she had a tonsillectomy as a child
• Surgeries: Tonsillectomy at age 10
FAMILY HISTORY (FH): Father has a history of HTN and Type II
Diabetes; Mother has a history of COPD. Patient has 1 sister who
has HTN
. She does not have any children.
SOCIAL HISTORY (SH): She is married
and works as a social worker for DHR. She is independent with
her ADLs and lives with her husband. She states she currently
exercises about 3 times per week which includes brisk walking
for about 1 mile. She is a former smoker - ½ pack/day but she
states she quit 5 years ago. She does drink alcohol occasionally if
she is at a social event. She drinks caffeine (coffee or soda)1 - 3
times daily. No illicit drug uses.
REVIEW OF SYSTEMS (ROS):
1. Constitutional symptoms - Patient reports fatigue, fever,
and difficulty sleeping due to coughing. Patient denies chills,
malaise, night sweats, unexplained weight loss or weight gain,
loss of appetite.
2. Eyes - Patient denies blurred vision, difficulty focusing,
ocular pain, diplopia, scotoma, peripheral visual changes,
and dry eyes.
Patient states she does wear reading glasses. Date of last eye
exam was in 2019.
3. Ears, nose, mouth, and throat - Patient reports headaches
and hoarseness. Patient denies vertigo, sinus problems,
epistaxis, dental problems, oral lesions, hearing loss or
changes, nasal congestion, sore throat. Date of last dental
visit was about 6 months ago.
4. Cardiovascular- Patient states she exercises about 3 times a
week for about 30 minutes to an hour. Patient denies any
history of heart murmur, chest pain, palpitations, dyspnea,
IDENTIFYING DATA:
Initials:
G.B
.
Age: 61 years
Race:
Caucasian
Gender:
Female
Marital Status: Married
CHIEF COMPLAINT (CC): Patient complains of “cough and
congestion for 2 weeks”
HISTORY OF PRESENT ILLNESS (HPI): Patient c/o dry cough x 2
weeks.
Patient states she just got back from a cruise and was in the
casinos
on the ship a lot. She thought the cigarette smoke could have
been making her cough, but it is not any better. She now feels
congestion in her chest and c/o hoarseness and expiratory
wheezing.
• location: congestion in chest
• quality: patient describes a feeling of tightness in her chest
• severity: patient rates pain a “3” on a scale from 1-10
. She states her cough is constant and is continuing to worsen
• timing: symptoms started 2 weeks ago
• setting: patient states her symptoms started while she was on
a cruise in the ship’s casinos
• alleviating and aggravating factors: cough is worse at night,
with any physical exertion, or when she gets hot. She states she
still coughs at rest but it is somewhat better.
• associated signs and symptoms: hoarseness and expiratory
wheezing
PAST MEDICAL HISTORY (PMH):
• Allergies: NKDA
• Current medications: citalopram 40 mg tablet,
levothyroxine 50 mcg tablet, pantoprazole 40 mg tablet,
delayed release
• Age/health status: 61 years
• Appropriate immunization status: Up to date on all vaccines;
Flu vaccine given November 2020. She states she will be getting
the flu and
,pneumonia vaccines at her primary physician’s office this fall.
• Previous screening tests result: Patient states she had a pap
smear and mammogram in March 2020 and both were reported
normal.
• Dates of illnesses during childhood: N/A
, • Major adult illnesses: Patient states she has a history of
depression, hypothyroidism, and GERD
• Injuries: N/A
• Hospitalizations: No hospitalizations other than when
she had a tonsillectomy as a child
• Surgeries: Tonsillectomy at age 10
FAMILY HISTORY (FH): Father has a history of HTN and Type II
Diabetes; Mother has a history of COPD. Patient has 1 sister who
has HTN
. She does not have any children.
SOCIAL HISTORY (SH): She is married
and works as a social worker for DHR. She is independent with
her ADLs and lives with her husband. She states she currently
exercises about 3 times per week which includes brisk walking
for about 1 mile. She is a former smoker - ½ pack/day but she
states she quit 5 years ago. She does drink alcohol occasionally if
she is at a social event. She drinks caffeine (coffee or soda)1 - 3
times daily. No illicit drug uses.
REVIEW OF SYSTEMS (ROS):
1. Constitutional symptoms - Patient reports fatigue, fever,
and difficulty sleeping due to coughing. Patient denies chills,
malaise, night sweats, unexplained weight loss or weight gain,
loss of appetite.
2. Eyes - Patient denies blurred vision, difficulty focusing,
ocular pain, diplopia, scotoma, peripheral visual changes,
and dry eyes.
Patient states she does wear reading glasses. Date of last eye
exam was in 2019.
3. Ears, nose, mouth, and throat - Patient reports headaches
and hoarseness. Patient denies vertigo, sinus problems,
epistaxis, dental problems, oral lesions, hearing loss or
changes, nasal congestion, sore throat. Date of last dental
visit was about 6 months ago.
4. Cardiovascular- Patient states she exercises about 3 times a
week for about 30 minutes to an hour. Patient denies any
history of heart murmur, chest pain, palpitations, dyspnea,
