CC
Mrs. Hoffman is a 57-year-old female here today complaining of a persistent cough.
HPI
The patient tells me she actually saw Katy Lilly, MD for the same cough back on September 25, 2015. At that point, she had had a cough for about three weeks. She is now going on approximately five weeks with the cough. She describes it has an annoying type of dry cough. She says that the symptoms initially that she had were cold symptoms with a runny nose, stuffy nose, and the cough. The rest of them seem to have resolved, but the cough is persistent. She describes feeling a tightness in her chest. When she takes a deep breath, it makes her feel as though she wants to cough. She would not describe herself as feeling short of breath. She is not …show more content…
There is no wheezing or rhonchorous breath sounds. She does cough with deep inspiration at times.
She did receive an albuterol nebulizer treatment here in the office, which she tolerated well. Following that, her pulse ox improved to 99%. She felt she was able to take a deeper breath without coughing. On exam, there was perhaps more air excursion. Still no wheezing or rhonchorous breath sounds, and otherwise normal.
A/P
Dorothy Hoffman is 57-year-old female here today with a persistent cough and chest tightness. I did discuss with her at this point, that I do not feel antibiotics are necessary. She was in agreement of that, but we did talk about what to be monitoring for. I did give her an order for a PA and lateral chest x-ray, particularly if she is not feeling better in the next couple of days with the therapies recommended. That is something she can do. She knows she should hear from me within 24 hours of the testing and if she does not, she will contact me. She felt comfortable with that. We will have her use the spacer device with the inhaler. I did write her for that. She will do two puffs every four hours and then taper, as she is able. In addition, she was written for prednisone 20 mg tablets three p.o. for five days #15 with no refills. I did review the use and side effects of the prednisone with her. Consideration for the x-ray and follow
Mrs. Hoffman is a 57-year-old female here today complaining of a persistent cough.
HPI
The patient tells me she actually saw Katy Lilly, MD for the same cough back on September 25, 2015. At that point, she had had a cough for about three weeks. She is now going on approximately five weeks with the cough. She describes it has an annoying type of dry cough. She says that the symptoms initially that she had were cold symptoms with a runny nose, stuffy nose, and the cough. The rest of them seem to have resolved, but the cough is persistent. She describes feeling a tightness in her chest. When she takes a deep breath, it makes her feel as though she wants to cough. She would not describe herself as feeling short of breath. She is not …show more content…
There is no wheezing or rhonchorous breath sounds. She does cough with deep inspiration at times.
She did receive an albuterol nebulizer treatment here in the office, which she tolerated well. Following that, her pulse ox improved to 99%. She felt she was able to take a deeper breath without coughing. On exam, there was perhaps more air excursion. Still no wheezing or rhonchorous breath sounds, and otherwise normal.
A/P
Dorothy Hoffman is 57-year-old female here today with a persistent cough and chest tightness. I did discuss with her at this point, that I do not feel antibiotics are necessary. She was in agreement of that, but we did talk about what to be monitoring for. I did give her an order for a PA and lateral chest x-ray, particularly if she is not feeling better in the next couple of days with the therapies recommended. That is something she can do. She knows she should hear from me within 24 hours of the testing and if she does not, she will contact me. She felt comfortable with that. We will have her use the spacer device with the inhaler. I did write her for that. She will do two puffs every four hours and then taper, as she is able. In addition, she was written for prednisone 20 mg tablets three p.o. for five days #15 with no refills. I did review the use and side effects of the prednisone with her. Consideration for the x-ray and follow