Initials: K.M. Age: 17 years Sex: F Race: Caucasian
S.
We can deliver within hours.
CC (chief complaint): “I have had a sensation of irritation and itching in my eyes since last Sunday. I have also had pain in my right ear since yesterday and a cough accompanied by throat pain for a week. Lastly, I had a nose bleed today as well as several episodes of headaches.”
HPI: The patient is a 17-year-old Caucasian adolescent presenting with the above symptoms. She has a past history of the same as she suffers from allergy to strong smells, dust, and the cold. The onset of the symptoms started a week ago and they are located in the respiratory system, the eyes, and in the cranial sinuses. The total duration of these symptoms has been about seven days. The symptoms include rhinorrhea, nasal and chest congestion, headaches, sinus pain, malaise, and epistaxis. They are characteristically sudden, unrelenting, and recalcitrant. The symptoms are aggravated by strong smells like that of perfumes, cold wind currents (such as those coming in from open windows), and dust particles. Symptomatic relief occurs when she takes medications such as Zyrtec and albuterol. The timing of the symptoms is anytime day or night. The patient gives the symptoms a severity rating of 7/10.
Current Medications: She is currently taking the following medications.
She has used albuterol (Salbutamol) for years to combat acute shortness of breath and wheezing as a rescue inhaler (Papi et al., 2020; Ramsahai et al., 2019). The cetirizine is used to combat allergy symptoms and has been used for six months. Lastly, she is also on over-the-counter (OTC) APAP for the sporadic headaches.
Allergies: She is allergic to dust, strong smells, and cold breezes or weather.
PMHx: She has received all her immunization doses from childhood up to the present time without missing. She has no history of any past major illness or surgeries; although she was born allergic to dust, strong smells, and cold. Because of her allergies, she has in the past suffered colds, coughs, and headaches.
Soc & Substance Hx: The patient is a student in high school in grade 11 currently. She lives with her father and mother as well as her two other siblings. Her hobbies include reading, riding the bicycle, cooking, watching movies on Netflix, and traveling. She denies ever using any drugs or substances such as alcohol and tobacco. She states that she also does not have any friends that use drugs or substances at present. Their flat has smoke detectors and all amenities are available in the neighborhood. She does not yet have a driving license but always makes sure she has a seatbelt on when being driven. She is the middle child and states the family is very closely knit and she has a strong social support system around her.
Fam Hx: She has a strong family history of allergies from her father’s side. Both of her two siblings also have allergies. There is no history of any chronic illnesses in the family. Both sets of grandparents on both sides are still alive and healthy. No first-degree relative has died of any suspected disease causes.
Surgical Hx: She denies any past surgical history.
Mental Hx: There is no history of mental illness such as depression or anxiety. There is also no history of self-harm tendencies or suicidality as well as homicidal ideation. However, she has a history of attention-deficit/ hyperactivity disorder (ADHD) since her childhood. She has been treated for this by psychotherapy but not medications as the symptoms were mild.
Violence Hx: She presents no violence history whatsoever. There are therefore no concerns or issues about her personal, home, community, sexual safety.
Reproductive Hx: She got her menarche at the age of 12 years. She states that she is not yet sexually active and is therefore consequently not pregnant. She is not on any contraceptive method as at now. Her last menstrual period (LMP) was on 05/12/2024.
ROS:
GENERAL: She denies fever, chills, and weight loss; but admits to malaise.
HEENT: She is positive for headaches. She also admits t
Struggling with online classes or exams? Get expert help to ace your coursework, assignments, and tests stress-free!