CC: “I have been experiencing a severe headache and sore throat the past four days. I started to cough.”
The patient had been well up until four days ago when he experienced a persistent, severe pharyngeal headache and dry cough. The patient had a fever but denied feeling any discomforts like chest tightness, nausea, shortness and breathlessness, chest discomfort or chest tightness. It is nonproductive and intermittent. Sometimes, it disrupts breathing patterns. It is described by the doctor as “the most severe headache” and has a pain rating 9/10. It is described as intense pressure on the entire brain that’s exacerbated with light and sound. There are no relief elements. He can’t swallow any food due to this “cutting” discomfort. This has caused him to lose his appetite.
The average age is 45
Histories for filing complaints: The aforementioned symptoms appeared four days after the mother returned from Sweden with her daughter.
Analyse of Systems
Constitutional: Mr. X suffers from a dry cough and a persistent headache. He also has a sore throat.
Respiratory Problem: The patient has a persistent cough, and is feeling tired. Denies difficulty breathing even though they are coughing.
•Surgical History: denial of any history of surgical procedure •Family History: strong family history for prostate cancer and diabetes
•Social History: Denies smoking, alcohol use, or recreational drug use in the past
•Allergies: No known food, environmental, or drug allergies
History of vaccinations. The current yearly shot is taken. A yearly flu shot has been taken.
One week ago she went to Sweden to visit her child.
The heart beat is 108 beats/minute
The rate of respiration is 32 beats/minute
Blood Pressure: 128/73mmHg
90% oxygen saturation