CHIEF COMPLAINT: Swollen gland.
HISTORY OF PRESENT ILLNESS: The patient was added acutely to my schedule today for swollen gland. It has been ongoing for several weeks now. He had actually called our office on MM/DD/YYYY complaining of swollen gland under his right chin. It was not associated with any other symptoms, including fevers, chills, night sweats or weight loss.
He notes no shortness of breath or chest pain. He does have chronic cough, however, related to chronic obstructive pulmonary disease. He notes it is nonpainful and it is not associated with dental pain. He does have poor dentition. He knows he has some teeth he needed fixed but has had no pain in his teeth or jaw.
REVIEW OF SYSTEMS: Review of systems for 11 systems reviewed otherwise negative at this time.
PAST MEDICAL HISTORY/MEDICATIONS/ALLERGIES/SOCIAL HISTORY/FAMILY HISTORY: All reviewed, in the chart.
PHYSICAL EXAMINATION: VITAL SIGNS: Afebrile, 97.8, pulse 66, respirations unlabored at 14, blood pressure 122/76, and weight 200 pounds. That weight is down 5 pounds since last visit for cough and congestion. HEENT: Normocephalic and atraumatic. His extraocular muscles are intact. His oropharynx is clear. His dentition is poor. He has no evidence of dental abscess. No buccal mucosa lesions. Turbinates are dry without evidence of erythema. Conjunctivae are pink. NECK: Supple without anterior cervical adenopathy. No supraclavicular adenopathy. No JVD, bruits or thyromegaly. He does have a 1.5 cm right submandibular lymph node that is somewhat firm, nontender, difficult to move. I would not exactly call it matted however. HEART: Irregularly irregular with a soft systolic murmur at the second intercostal space in the right sternal border. PMI minimally displaced. LUNGS: Increased inspiratory-expiratory ratio throughout with noted wheeze, symmetric to percussion. ABDOMEN: Soft, nontender and nondistended. No hepatosplenomegaly. EXTREMITIES: No clubbing, cyanosis or edema. SKIN: No rashes appreciated. Warm and dry.
IMPRESSION:
1. Right submandibular lymphadenopathy.
2. Chronic obstructive pulmonary disease with wheeze today.
3. Chronic anticoagulation, on Coumadin because of cardiomyopathy.
PLAN: We will check a CT scan of the neck on the patient today and refer him to Dr. John Doe. Certainly, this has been ongoing for quite some time. It was MM/DD/YYYY when he called our office. We will place him on prednisone 20 mg 2 tablets daily x5 days and 1 tablet daily x5 days and stop. He asked for an antibiotic, which I told him he does not need at this time. We will followup PT/INR on Friday. Side effects of prednisone discussed with him.
