CC
Cough.

S
The patient is a 43-year-old female with a history of asthma for which she takes Singulair as well as albuterol on a p.r.n. basis. Generally, she does not need her albuterol on a regular basis. Three weeks ago however, both of her daughters, as well as herself had a typical cold. She states that all of the symptoms of the cold got better except she is left with a cough, which is productive of yellow to greenish sputum. She does state the cough is fairly consistent throughout the day although she does have episodes of feeling like she has a "coughing fit". At those times, it is hard to get her breath and she does use her albuterol inhaler and it does seem to help. She denies any post tussive vomiting. She generally is feeling well, good energy, she did not have any fevers throughout these symptoms. The patient does have allergies and does use Zyrtec, as well as a decongestant for this. She states that if she does not take her decongestant, her allergies cause her to have some sinus pressure, but generally this is not an issue. She has needed Medrol Dosepak in the past. She did have a tetanus pertussis shot in 2009.

Objective …show more content…
Pulse is 102. O2 saturation is 96% on room air. Peak flow is 360, 400, 400. Other vital signs per flow sheet.

General
Patient is alert, oriented, no acute distress.

HEENT
Sclera white. TMs are normal. Oropharynx with no erythema, no exudate, no swelling. Of note, her left tonsil is slightly larger than her right.

Neck
Supple, no lymphadenopathy.

Lungs
Clear to auscultation bilaterally with good air movement throughout.