Cough With Phlegm Case Study

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Chief Complaint: “I have a bad cough with phlegm”
History of Present Illness: The patient is an 84-year-old Pacific Islander woman who presented to the clinic with complaints of a “bad” cough with phlegm which she notes to have started two weeks ago. She describes the cough as productive and the phlegm as rusty-colored. She states that the cough has been constant. Patient does not know what brought on the cough. She has been taking cough drops with no relief. She came to the clinic today because the cough has gotten worse. She reports that the cough is usually worse at night and sometimes prevents her from falling asleep. She has not tried any over the counter medication. She complains that her symptoms interfere with her daily activities. …show more content…

She uses a hypoallergenic pillow cover and her mattress is less than one year old
• Screening tests: Women over age 65
1. Blood pressure screening: Has blood pressure checked every year at annual physical, no high blood pressure readings reported
2. Cervical cancer screening: Last pap-smear was 15-20 years ago with no abnormal result
3. Cholesterol screening: Patient has hyperlipidemia that is controlled with medicine. Lipid panel check every three months at the clinic
4. STDs: Denies ever having STDs
5. HIV: Denies any history of HIV or receiving any blood transfusion
6. Diabetic screening: Admits to diabetes. A1c check every 3months
7. Dental exam: Last dental visit 2017
8. Eye exam: Last eye exam about a years ago
9. Physical exam: Last annually physical exam 2017
10. Breast Exam: Denies any breast problem
11. Last mammogram: 10 years ago
12. Bone density test: 2013
• Safety measures: Patient always use her seatbelt while driving. Patient has smoke detector and a fire extinguisher in her home
• Immunizations:
o Patient states that her immunization record is up to date.
o Had chicken pox in 3rd grade
o Influenza vaccination received in October

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