SUBJECTIVE: The patient is a very pleasant (XX)-year-old gentleman who is coming in for a persistent cough. The patient has not had a physical in over 5 years and that is why he has been scheduled for a physical. Apart from the cough, the patient states he has been feeling well and has not had any issues since last being seen by a physician.
He states that he feels quite healthy and that is why has never sought any medical care. However, a month ago, he started developing a dry cough, which 1 week later turned into a productive cough of purulent sputum.
He was seen in a walk-in clinic last week, where they did a chest x-ray; however, at that time, they said there was no need for antibiotics. Despite over-the-counter remedies, the patient’s symptoms have persisted and have not improved at all. This is in the setting of having recurrent measured temperatures, most recently at 101.4.
He denies any shortness of breath or wheezing with this. He does have associated rhinitis and has had some sick contacts also. His kids have been ill with similar symptoms over the last couple of weeks. He denies any recent travel and did not get his flu shot this year.
He denies any pleuritic chest pain and has not had any diarrhea, muscle aches, neck pain or photophobia. He has had intermittent headaches but none for a couple of days.
PAST MEDICAL HISTORY: Not significant; however, the patient did have a positive PPD on arrival to the US but a negative chest x-ray. He denies any exposure to tuberculosis in the past.
SOCIAL HISTORY: The patient is a nonsmoker. Occasionally drinks. He is married and has children. He exercises infrequently; however, he states that his diet is quite balanced.
ALLERGIES: NKDA.
FAMILY HISTORY: The patient’s father had diabetes.
OBJECTIVE: General: The patient is a well-appearing male in no distress. Vitals: Heart rate is 72, blood pressure is 122/82, and temperature is 98.4. Examination of his hands reveals that he has got no clubbing, no pallor. His pulse is regular with a good volume and no abnormal character. Examination of the head and neck reveals he has no jugular venous distention, no adenopathy. His pharynx is mildly erythematous but has no exudate or tonsillar enlargement. Pupils are equal, round and reactive to light. He has no thyromegaly. Chest is clear to auscultation bilaterally. Heart: Sounds S1 and S2 are present. No added sounds, no murmurs. Abdomen: Soft, nontender, nondistended, with bowel sounds auscultated diffusely. He has no organomegaly. Peripherally, he has got no edema. Good pedal pulses.
ASSESSMENT AND PLAN: The patient is a (XX)-year-old gentleman coming in with cough and also for general health maintenance with no significant past medical history.
Cough: Given the fact that his symptoms have persisted and he has been recurrently febrile despite over-the-counter remedies, we feel it is likely that he has a bacterial bronchitis. For now, we will give him a 5-day course of azithromycin. Chest x-ray was done, which the patient states was normal. We will obtain a report of that in the interim.
Health maintenance: As mentioned, the patient has no past medical history of note. At this time, we will check total cholesterol and direct LDL. We will also get a baseline CBC and metabolic profile given the history of diabetes in the family.
