Patient’s Details
Initials: J.R. Age: 36 years Race: Hispanic Gender: Male
SUBJECTIVE:
Chief Complaint (CC): “I have a sore throat, a stuffy nose that is preventing me from breathing through the nose, a runny nose, and a headache with facial pain. The facial pain worsens when I bend forward.”
History of Present Illness (HPI): J.R. is a 36-year-old Hispanic male who has visited the clinic today unaccompanied complaining of a sore throat, a stuffy and runny nose, and a headache with facial pain. J.R. indicates that the facial pain worsens when he bends forward. These symptoms have lasted for about 2 weeks. Although the symptoms are getting better, J.R. reports that they are resolving slowly and he is concerned that they might recur when he fails to get treatment. J.R. cannot breath through the nose due to nasal congestion. He also feels some slight pressure on his forehead. The pressure together with a headache even prevent him for rising up comfortably whenever he is lying down. His current symptoms do not radiate to other parts of the body. J.R. further states that he took two tablets of paracetamol three times a day 3 days ago to help relieve the headache and the facial pain. However, the facial pain and the headache reoccurred a day later. As indicated by J.R., his work is quite involving and sometimes he has to work long hours before going home. The symptoms have affected his ability to work but he is optimistic that he will be fine when he finally gets treatment.
III. Past medical history (PHx)
J.R. reports that he can recall having asthma during his early adolescent years but he was treated without hospitalization. He however denies being diagnosed with any serious medical condition apart from that except for the occasional fevers.
Medical records indicate that J.R. received all immunizations according to schedule. He received hepatitis B vaccine 1st and 2nd doses, rotavirus vaccine 1st and 2nd doses, measles, mumps, rubella (MMR) vaccine, and diphtheria, pertussis, and tetanus (DPT) vaccine. Other vaccines that he has received include polio vaccine, varicella, hepatitis A, and pneumonia vaccines. His last influenza vaccine was on 17/11/2022.
J.R. denies having any serious illness during adulthood. He occasionally experiences headaches when he has a lot of work to do but these usually resolve when he uses painkillers.
Denies a history of surgery.
No known drug or food allergies reported.
J.R. is not using any medications at the moment. He took paracetamol two days ago to relieved the facial pain and he headache.
He denies use of complementary treatments.
J.R. is the second born in a family of three children. His father and mother are both alive. The mother is 62 years old and the father is 68 years old. The mother was diagnosed with hyperlipidemia two years ago while the father is healthy. Maternal grandmother has diabetes whereas grandfather is deceased. His paternal grandparents are both deceased.
J.R. is a mechanical engineer at a nearby construction company. He is married with one kid and stay with his family in the city. His wife is a nurse and she is employed at a nearby hospital. J.R. denies consuming cigarettes, alcohol, or illicit substances like heroin and cocaine. The family’s typical diet comprises of the five major food groups including carbohydrates, proteins, minerals, fruits, and vegetables. J.R. rarely engages on physical activities but he occasionally walks to work when he leaves home early. He works hard every day to ensure that his family gets basic needs such as food, clothing, shelter, and healthcare. They have a family health insurance that caters for medical bills whenever a family member falls sick.
General: Denies abnormal weight gain or significant weight loss in the recent months. Reports chills, fever, and fatigue. Reports discomfort due to the nasal congestion, headache, and facial pain. His la
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