Reference no: EM133796600
Question
BC is a 45 year old female with c/o sinus pain and congestion for over 1 week, She has a headache hat is frontal and throbbing especially in the AM. She has greenish nasal discharge. Unable to smell or taste. Bending over makes the headache worse. She has been using ibuprofen and Tylenol sinus with some relief. Denies ear pain, throat pain, unusual vision changes, loss of balance, fever. PSY/Social- She is a house wife, does not drink, smokes 1 PPD x 20 years PMHX- HTN, had all vaccinations as a child, no childhood illness, Surgical hx- neg, Obstetrical hx- Para 2, gravida 2, Medications: Hydrochlorothiazide 25 mg 1 qd. and Altace 1 qd. (doesn't remember dose) Fmhx -Mom has HTN ROS- General- no fever or fatigue, or weight loss EENT: See HPI Skin- flakes a lot, dry, has to use Vaseline to keep it lubricated, has patchy rash on elbows and knees Head/Neck- see above Resp- admits to congested non productive cough, mild SOB with exertion, no PND, no dyspnea Cardio/PV- denies tachycardia, palpitations, chest pain, claudication, neck or arm pain GI- denies constipation, diarrhea, nausea, vomiting. GU-sexually active, 1 partner with vasectomy, LMP 1/15/20 Hematopoietic- no easy bruising.