REASON FOR REFERRAL: Cough.
HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old gentleman who was referred to the office for evaluation of what appears to be a chronic cough, which has been present for approximately one year.
This gentleman states that this cough has been present for about a year, quite annoying to him, sometimes reproduced just with simple talking. It does not truly have a time predilection; it can come day or night. He occasionally makes some phlegm; it could be thick, but now, for the most part, his cough is dry.
There is no hemoptysis, no pleurisy, no epistaxis, no orthopnea, though there used to be some in the past. He denies any significant wheezing. He has no dysphagia. Appetite is well preserved. Weight is stable. He does admit to postnasal drip. Occasional changes in his voice.
PAST MEDICAL HISTORY: Positive for coronary artery disease status post MI nine years ago. He has had angioplasties and stents in the past. He denies any known history of underlying COPD. He has some DJD of his spine. He has had lung cancer surgically excised, the left lower lobe, 10 years ago. We do not have a path report. He also had colon cancer 12 years ago with a partial resection of his colon. He has had coronary artery bypass surgery 10 years ago as well, back surgery, appendectomy, and bilateral cataract surgery.
FAMILY HISTORY: Father died aged 84, had a heart attack. Otherwise noncontributory.
SOCIAL HISTORY: He has never smoked. Alcohol only on a social basis. No work-related industrial exposures.
REVIEW OF SYSTEMS: As per history of present illness.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: This is a well-developed gentleman in no distress. He answers questions appropriately.
VITAL SIGNS: WT: 236 pounds. H: 6 feet 2-1/2 inches. P: 84 per minute RR: 20 per minute. BP: 130/70. Saturations on room air 96%.
HEAD AND NECK EXAM: No JVD, adenopathy or tracheal deviations.
CARDIAC: Regular.
LUNGS: Actually quite clear on exam.
ABDOMEN: Benign.
EXTREMITIES: No cyanosis, clubbing or edema.
NEUROLOGIC: Exam is grossly nonfocal.
IMPRESSION:
1. Chronic cough. At the present time, we will treat his sinus disease with nasal inhaled steroids and obtain a CT scan of the sinus.
2. Intermittent snoring for which an overnight oximetry will be performed to make sure he does not have a sleep disturbance.
3. We do not rule out the need for fiberoptic bronchoscopy, as the patient at present continues to cough, and no significant airflow obstruction is noted.
PLAN: The patient will be set up for all these studies, and we will comment further. With regard to the CT scan of the chest, which was performed 4 months ago, we have reviewed it carefully. We see no obvious evidence of acute abnormal findings.
