Chief complaint: Sore throat, cough
History of present illness: The patient is a 18 year old male presenting with sore throat and cough. Three weeks ago the sore throat started and has not improved. He also has a cough productive of colorless sputum. The cough started 2 weeks ago. Denies fever, chills, night sweats, headaches, dizziness, chest pain, palpitations, shortness of breath, hemoptysis, nausea, vomiting, abdominal pain, numbness, tingling or weakness. MDM: The patient is a 18 year old male who presented to the emergency department with a sore throat and cough. Airway is patent, tolerating oral secretions, tolerating p.o. Liquids, not tachycardic or febrile, oxygen saturation is adequate on room air, and no other physical exam/history findings to suggest acute airway or respiratory compromise. On examination the patient had exudative discharge and enlarged tonsils. Much of this discharge was removed with warm normal saline gargles in the ED. I was able to manually express a small amount of discharge and both tonsils which the patient tolerated without difficulty and told me he was feeling better after treatment. He had a negative streptococcal antigen test. Up to date on immunizations. Clinically, there was no evidence for peritonsillar abscess, Ludwig’s angina, retropharyngeal abscess, epiglottitis or other serious throat disease. I was able to manually expressed a small amount of discharge from bilateral tonsils which patient tolerated without difficulty. Patient is comfortable with plan to treat with amoxicillin, OTC analgesics, and primary care follow-up. Regarding the patient’s cough I think this is most likely due to postnasal drip. Chest x-ray was unremarkable for pneumonia, pulmonary edema, pleural effusion, pneumothorax, rib fracture. Abdominal examination was benign and I doubt mono or splenic rupture at this time. Counseled and educated patient on treatment plan and risks and benefits of treatment. Close follow-up advised. Patient understands that we are not able to diagnose all conditions in the emergency department, and that although at this time there are no worrisome symptoms and patient appears to be stable, patient will need to return at once if any recurrent, worsening, or new symptoms.
Medical history: No diabetes, hypertension or peripheral artery disease.
SOCIAL: Denies alcohol, tobacco, or recreational drug use.
ROS: Constitutional: No fevers, chills, night sweats.
Head: No headaches, head injury.
Ears: No ear aches. No ear discharge, new auditory deficits.
Nose: No epistaxis, rhinorrhea, sinus congestion.
Throat: Positive sore throats. No trouble swallowing, muffled voice.
Cardiovascular: No chest pain, palpitations, chest wall injuries.
Respiratory: Positive coughs. Positive productive coughs. No shortness of breath. No hemoptysis.
Abdominal: No abdominal pain, nausea, vomiting.
Skin: No rashes.
PE: Vitals: Reviewed by me.
Constitutional: Well developed, well nourished. No acute distress.
Head: Atraumatic, normocephalic.
Eyes: Extraocular movements in tact. Pupils are 5mm, ERRLA.
Nose: Patent nares bilaterally. Nasal mucosae is pink, moist.
Mouth/Throat: Moist membranes. Uvula midline.Oropharynx is pink, moist. Bilaterally enlarged tonsils with exudate discharge. Floor of the mouth is soft.
Neck: Supple.No JVD.
Cardiovascular: Normal heart rate and regular rhythm. CTA.
Respiratory: Non-labored breathing. No accessory muscle use. Lungs CTA.
Gastrointestinal: Soft, non-tender. Bowel sounds audible in all four quadrants and epigastrium. No masses or bruits.
Musculoskeletal: Full range of motion with passive and active testing. No obvious deformity.
Neurologic: Awake, alert, and oriented to time, place, and person. CNII-XII grossly in tact. Motor strength is 5/5. Sensation intact to fine touch.Gait and coordination are grossly normal.
Peripheral Vascular: Radial pulses 2+ and equal bilaterally. Capillary refill less than 3 seconds.
Skin: Warm, dry. No erythema or lacerations.
Vital Signs
Most Recent Set of Vitals:
BP: 118/61 09/01/ 10:10
Pulse: 81 09/01/ 10:10
Temp: 36.7 C 09/01/ 10:10
Resp: 16 09/01/ 10:10
02 Sat: 98%(Room Air) 09/01/ 10:10
Calculated BMI: 32.4 09/01/ 10:10
Vitals: Pulse Ox [This section may be copied as needed]
02 Source : Room Air 02 Delivery : 02 L/min FiO2 %
Pulse Ox Reading: 98 % Interpretation: Normal Date/Time:
CXR was: Interpreted by radiologist
Interpretation:
FINDINGS: The cardiomediastinal silhouette is within normal limits for age. There is no evidence of consolidation, pulmonary edema, pleural effusion, or pneumothorax. No acute rib fractures visualized.
IMPRESSION:
1.No radiographic evidence of acute cardiopulmonary disease.
Assessment and Planning:
Cough R05 – COUGH Active
Disposition
Disposition Decision Date/Time:
D/C from ED to: Home
Condition at D/C: Improved
CPT code :
99283 -25 Emergency department visit for the E/M of pt, requires these 3 key components: Expanded problem focused hx; Expanded problem focused exam; & Medical decision making of moderate complexity. Counseling &/or coordination of care with other physicians, other QHCPs, or agencies consistent with the nature of the problem(s) & the patient’s &/or family’s needs. Usually, the presenting problem(s) are of moderate severity
71046 Radiologic examination, chest; 2 views
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