Pharmacology Case Studies
CC: "Stuffy nose and watery eyes for the past one week"
59 year old male present to office Nasal congestion, clear rhinorrhea, and frequent sneezing that started about one week ago. Two days ago started experiencing itchy and watery eyes. Denied any fever and cough.
. He stated treated with Benadryl but no improvement. He denies any known sick contacts recently. He denies any recent travel. He currently is a non-smoker but did smoke a pack a day for approximately 10 years prior to quitting 10 years ago.
PMH: High blood pressure, HTN, High cholesterol, Back pain, prostate enlarged, Anxiety
Past Surgical history: Back surgery 6 year ago, shoulder surgery 15 year because of Gunshot
Hospitalizations: no recent Hospitalization,
Medication: …show more content…
Musculoskeletal: Patients Reports neck pain or back pain but stated medication help his pain
Integumentary: Patient Denies changes in skin, rash, itching, nail deformity, hair loss,
Neurologic: Pt. denies numbness and tingling; denies any prosthesis
Endocrine: Patient denies thyroid problems, cold or heat intolerance,
Hematologic: Denies bruising, abnormal bleeding, and fatigue.
Psych: Anxiety some …show more content…
General Appearance
General Appearance: mild distress. Alert and oriented time 3 Cooperative with fluent speech.
HEENT: normocephalic, a traumatic. External ocular muscles intact. Pupils equal round and reactive to light. TM’s intact c clear fluid. No erythema or exudates noted. Nasal mucosa swollen and erythematous with watery discharge. No polyps noted. There is right no maxillary and frontal tenderness to palpation. Posterior oropharynx without exudates. Mild erythema noted.
Respiratory: clear to auscultation bilaterally without crackles, rhonchi, or wheeze,No use of accessory muscles
Gastrointestinal: Normal bowel sounds; soft; no tenderness
Genitourinary: No bladder tenderness upon palpation, no distention noted.
Musculoskeletal: Generally normal and intact; extremities exhibit full range of motion ,Normal gait.
Integumentary: Skin intact; no draining wounds; skin color is within the patient's norm; good turgor.
Lower Extremity: NO edema. Skin is warm; skin is dry
Neurological: Alert and oriented times 3.Cranial nerves grossly intact. No focal, motor, or sensory deficit. Reflexes
59 year old male present to office Nasal congestion, clear rhinorrhea, and frequent sneezing that started about one week ago. Two days ago started experiencing itchy and watery eyes. Denied any fever and cough.
. He stated treated with Benadryl but no improvement. He denies any known sick contacts recently. He denies any recent travel. He currently is a non-smoker but did smoke a pack a day for approximately 10 years prior to quitting 10 years ago.
PMH: High blood pressure, HTN, High cholesterol, Back pain, prostate enlarged, Anxiety
Past Surgical history: Back surgery 6 year ago, shoulder surgery 15 year because of Gunshot
Hospitalizations: no recent Hospitalization,
Medication: …show more content…
Musculoskeletal: Patients Reports neck pain or back pain but stated medication help his pain
Integumentary: Patient Denies changes in skin, rash, itching, nail deformity, hair loss,
Neurologic: Pt. denies numbness and tingling; denies any prosthesis
Endocrine: Patient denies thyroid problems, cold or heat intolerance,
Hematologic: Denies bruising, abnormal bleeding, and fatigue.
Psych: Anxiety some …show more content…
General Appearance
General Appearance: mild distress. Alert and oriented time 3 Cooperative with fluent speech.
HEENT: normocephalic, a traumatic. External ocular muscles intact. Pupils equal round and reactive to light. TM’s intact c clear fluid. No erythema or exudates noted. Nasal mucosa swollen and erythematous with watery discharge. No polyps noted. There is right no maxillary and frontal tenderness to palpation. Posterior oropharynx without exudates. Mild erythema noted.
Respiratory: clear to auscultation bilaterally without crackles, rhonchi, or wheeze,No use of accessory muscles
Gastrointestinal: Normal bowel sounds; soft; no tenderness
Genitourinary: No bladder tenderness upon palpation, no distention noted.
Musculoskeletal: Generally normal and intact; extremities exhibit full range of motion ,Normal gait.
Integumentary: Skin intact; no draining wounds; skin color is within the patient's norm; good turgor.
Lower Extremity: NO edema. Skin is warm; skin is dry
Neurological: Alert and oriented times 3.Cranial nerves grossly intact. No focal, motor, or sensory deficit. Reflexes