3/16/2024

Mrs. Fernandez Nypochamia is pleasant , 24 years old , missionary residing in Santo

domingo
Dominican Republic .
Referral . None
source and reliability. Self-referred .
Chief Complaint
“ I have a cough and fever “
Present Illness
Mrs. N reports increasing problems with Coughing and fever issues started a couple days
ago . The patient said she did not remember what she was doing exactly when she first
started coughing . The coughing is constant so it is not frequent . The patient said nothing
made it worse or better but she made it clear it was not an acute pain or coughing . the
patient , No allergie . No
tobacco use . No drug use . A drinkof alcool every week . She has no idea why she has this
coughing and this concerns
her a lot .
Past History
She had anemia history and She
never been hospitalized , no allergy , seen her obstetrician frequently ,
Family History
her mother is alive , her father died recently .They have no genetic disease in the family
Personal and sexual .
Born and Raised in the Dominican Republic , –she lives in an apartment and the bathroom is
inside and she has no ped , she does not drink coffee and drinks no alcohol. she is sexually
active . she has a few friend
Review of system
Skin : No rashes or other changes
Head , eyes , ears , noses , throat : no history of head injury eyes or nose
neck : no lump
breast : no lump
respiratory : coughing
cardiovascular : had arterial hypertension before
gastro : appetite good , no anal pain
urinary : no pain during miction
genital : no black spot on the skin
endocrine : no known thyroid disorder