DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR REFERRAL: Persistent cough and hoarseness.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female who for the past two years has been complaining of seasonal allergies and hoarseness. She has a dry, nonproductive cough. Over the past year, she has not been able to sing due to the hoarseness. She just did not feel like she can trust her voice. She does have a lot of allergies, and she took Alavert the other day and that seemed to help her. She has also been diagnosed with GERD and has been on Aciphex for a year, recently increased the dose to twice a day. She always feels like there is something in the back of her throat and that she has to clear it constantly. She was recently diagnosed with a thyroid nodule and has seen Dr. Jane Doe for this; although, she does not recall having a direct laryngoscopy. She has no dyspnea, wheeze or cold symptoms. She is also seeing Dr. X. She has no headache. She has no effect with changes in position or food with these symptoms.
PAST MEDICAL HISTORY: Hypertension, CAD, nephroma, spontaneous pneumothorax, mother had TB with a negative PPD, thyroid nodule, meningioma and GERD.
PAST SURGICAL HISTORY: Right nephrectomy, angioplasty of the left leg and right leg, and appendectomy.
MEDICATIONS: Aciphex 20 mg twice a day, Univasc 7.5 mg daily, Norvasc 10 mg daily, aspirin, Fosamax, Alavert p.r.n., multivitamin and calcium.
ALLERGIES: NKDA.
SOCIAL HISTORY: She never smoked. She does not drink.
FAMILY HISTORY: Father deceased at 86, hypertension. Mother deceased at 76 with ALS.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Negative.
HEENT: She has little hoarseness, postnasal drip, otherwise negative.
GASTROINTESTINAL: Reflux.
GENITOURINARY: Negative.
CARDIOPULMONARY: As in the HPI.
MUSCULOSKELETAL: Negative.
HEMATOLOGIC: Negative.
ENDOCRINE: Negative.
PSYCHIATRIC: Negative.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: This is a pleasant female in no distress.
VITAL SIGNS: Weight 132, pulse 74, blood pressure 162/84, respiratory rate 18, and saturations on room air 97%.
HEENT: NC/AT. EOMI. PERRL. Conjunctivae are pink. Nares are slightly congested bilaterally with no sinus tenderness. Oral cavity has good dentition with no lesions or exudates. She has a stage II oropharynx.
NECK: She has a bounding right carotid, left has a bruit. There is no adenopathy or increased JVP.
HEART: PMI is nondisplaced. It is regular, S1/S2, with a 2/6 systolic ejection murmur in the right upper sternal border and left lower sternal border.
LUNGS: Symmetrical excursion, equal diaphragmatic descent. Clear to auscultation and percussion.
ABDOMEN: Soft, nontender with no appreciable HSM.
EXTREMITIES: No C/C/E. The patient has mild DJD.
DIAGNOSTIC DATA: Chest x-ray shows mild cardiomegaly.
IMPRESSION: The patient has hoarseness, which could be related to a lot of symptoms including but not limited to structural abnormality or chronic irritative state. She does have gastroesophageal reflux disease, which may be contributing to this. Although, we do not believe she has had what sounds like a vocal cord visualization, certainly vocal cord paralysis or structural abnormality needs to be evaluated. She has a cough, which is likely related to gastroesophageal reflux disease and/or postnasal drip with constant throat clearing. Other concerns include her thyroid nodule, valvular heart disease with her cardiac murmur, the known gastroesophageal reflux disease and her left carotid bruit.
PLAN: We recommended that she elevate the head of her bed and showed her how to do that. We will continue the Aciphex twice a day. We started her on Flonase one puff in each nostril twice a day and Zyrtec and reviewed the side effects of those medications. She needs a spirometry to evaluate her flow volume loop. She needs to have Dr. Jane Doe reevaluate her for a direct laryngoscopy, and she is seeing her in the near future. In the future, we will consider doing a 2D echocardiogram to evaluate her valvular heart disease and mild cardiomegaly and/or CT scan of her neck and/or thorax. She understands this plan and agrees, and we will see her back in about six weeks after she has tried these medications and had a spirometry.
