How to Answer Year Female Have Questions (Complete Guide)

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Original Question

15-year-old Female CC: “I have a terrible cold” HPI: 15-year-old female has had 2-3 weeks of cold symptoms. She had had nasal congestion and runny nose with green discharge. Her cough is productive, persistent and produces green sputum. The cough is worse when lying down or when patient is active. She has tried cough drops and chloraseptic spray with little relief. She has had an intermittent headache that is generalized, is not associated with any precipitating events, is dull in nature and is relieved with Tylenol. She denies fever, vomiting, rash, decreased oral intake, shortness of breath. She has had difficulty sleeping due to nasal congestions and presence of cough. Her sister was diagnosed with pneumonia 2 weeks previously and mother is concerned that patient has the same. She presents during this visit with her mother. PMH: Seasonal allergies Immunizations: Up to date on immunizations though has not yet received seasonal influenza vaccine. Medications: Cetirizine HCl 10mg po qhs prn Fluticasone Propionate 50mcg- 2 sprays daily per nostril- moderate compliance Tylenol prn for headache- last dose in morning Allergies: No known drug or food allergies. Has seasonal allergies. Family History: No significant childhood illness in family including asthma or other respiratory illness. Social History: Lives with mother and older sister. Performs well in school. Has friends and gets along with other students. She denies smoking. She denies drug use, marijuana and denies alcohol No recent travel Sexual Hx: LMP was 2 weeks ago and denies being sexually active (ever) or chance of pregnancy. REVIEW OF SYSTEMS: Growth and Development – Patient has been developing well and appropriate grades in school. Constitutional – Mild fatigue x 2-3 weeks. No fever. Skin – No rash or excessive dryness. Has had cold sores to lip previous week that self-resolved. HEENT – Sore throat and cough. Nasal congestion with runny nose producing green discharge. Pain to face with sensation of pressure. No irritation to eyes nor discharge. No ear pain or discharge. Respiratory – Productive strong cough with green phlegm. No difficulty breathing. Cough worsened when lying flat or with exertion. Gastrointestinal – Appetite mildly decreased though continues to have adequate oral intake. No nausea, vomiting, diarrhea. What is the primary diagnosis? Is it Upper respiratory infection or Acute bacterial sinusitis (Rhinosinusitis) what could be three more diagnosis after the primary diagnosis? DD #1: Findings & Citation DD #2: Findings & Citation DD #3: Findings & Citation

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