Describes cough as productive-with yellow-green mucus

Reference no: EM133727864

Question

Care plan for Robert Smith, a 72-year-old man, presents to the clinic with complaints of cough and nasal congestion for the past two weeks. He describes the cough as productive, with yellow-green mucus. He denies any chest pain, shortness of breath, fever, or chills. However, he mentions feeling fatigued and having a mild headache. He reports a history of seasonal allergies but denies any recent travel, sick contacts, or exposure to environmental irritants. Medical History: -Seasonal allergies (no known triggers) -Well-controlled hypertension -Hyperlipidemia -Former smoker (quit 10 years ago, 20 pack-years) -Occasional alcohol consumption, no illicit drug use -Family history of hypertension and type 2 diabetes Current Medications: -Lisinopril 10 mg once daily for hypertension -Atorvastatin 20 mg once daily for hyperlipidemia -Over-the-counter loratadine as needed for allergies Clinical Presentation: Vital Signs: -Blood pressure: 130/80 mmHg -Heart rate: 72 beats per minute -Respiratory rate: 24 breaths per minute -Temperature: 100.1°F (37°C) Physical Examination: General: Alert and oriented, in no acute distress HEENT: Nasal congestion with thick green rhinorrhea, facial tenderness over the maxillary and frontal sinuses, no nasal polyps Lungs: Clear to auscultation bilaterally, no wheezing or crackles Cardiovascular: Regular rate and rhythm, no murmurs or extra heart sounds Abdomen:

Reference no: EM133727864

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