Demographic data: Katie, Caucasian female, 65 years old S: Subjective: CC: Cough HPI: O: A week ago—Have you had any recent respiratory infections? Any exposure to noxious agents? What are your typical symptoms of hay fever? How bad are your allergies? L:

Demographic data: Katie, Caucasian female, 65 years old S: Subjective: CC: Cough HPI: O: A week ago—Have you had any recent respiratory infections? Any exposure to noxious agents? What are your typical symptoms of hay fever? How bad are your allergies? L: Throat, chest D: Intermittent for one week; Cough is worse at night. C: Her chest is starting to hurt from all the coughing. She has noticed that she has been more tired and gets easily winded when she takes her daily walks.—Is the cough dry and hacking, wet, raspy, deep? A: No information given—Is there anything that makes the cough worse? Do you notice you cough more when lying flat? Is the cough worsened by cool air or exercise? R: No information given—Is there anything that makes the pain better? Have you tried sleeping in a chair to help with the coughing? T: No information given—Have you taken anything for your cough S: The cough wakes her up. She has not gone to Curves this week like she usually does because she doesn’t have the energy. PMH: History of chicken pox, measles and rubella as a child; history of osteopenia, HTN and hyperlipidemia. Takes a daily multivitamin, Evista 60 mg daily and HCTZ 25 mg daily. No reports of past injuries. Previous surgeries include a tonsillectomy and cholecystectomy. Hospitalized for surgeries and childbirth. Has seasonal allergies to pollen and reports hay fever. She is allergic to Demerol, it makes her vomit. No alcohol or tobacco use. Family History: No information given Social History: Married to John, they live with their married daughter and her family. Takes care of the kids and home as Mary and her husband work. Her husband and son-in-law both smoke, but not in the house. ROS: General/Constitutional: Patient is unsure of temperature. Denies feeling feverish.—Have you felt more fatigued? Any recent weight gain/loss? Eyes: Have you noticed any visual changes? Do you feel a tickling or trickling sensation in the back of your throat? Ears, Nose, Mouth, Throat: Are you having any ear pain, difficulty hearing or ringing in the ears? Have you noticed changes in smell or increased nasal drainage? Do you have a dry mouth, sores, or lesions on the mucosal membrane? Have you had a sore throat? Cardiovascular: Have you had any chest pain? Palpitations? Dizziness? Respiratory: Admits cough. Admits dyspnea on exertion.—Is your cough productive? Have you had any blood in your sputum? Musculoskeletal: Any joint pain or stiffness? Hematologic/Lymphatic: Have you noticed any swelling or tenderness of your lymph nodes? Allergies: Demerol (nausea/vomiting)