Date of Service: September 5, 2013Patti Wolfe is a 49-year-old patient of Dr. Mbadu's. Ms. Wolfe arrives today complaining of a productive cough, heaviness in her chest, achiness, and a fever of 102. She started one week ago with symptoms of a cold - runny eyes, nasal congestion, cough, and some wheezing. The cough was non-productive. She has taken over the counter (OTC) medications, but has not seen much improvement, and in fact her cough has become worse. Ms. Wolfe has a history of gastroesophageal reflux disease (GERD). She has had no recent weight loss or gain, she has been feeling well, though a little fatigued over the past week; she has no frequency or urgency of urination, does not have any blurred or double vision, and has had no night sweats. Dr. Mbadu conducts a physical exam

(PE) with the following findings: Head: Normocephalic. Eyes: Equal and reactive to light. Ears: Clear. Nose: congestion noted. Throat: Clear. Lungs: Rales and rhonchi are noted on auscultation. Dr. Mbadu writes an order for a chest x-ray which will be done as an outpatient at the local hospital. She instructs Ms. Wolfe to drink plenty of fluids, take Tylenol or ibuprofen for her achiness and fever, and to use a cool mist humidifier at night. Dr. Mbadu diagnoses the patient with Cough, ruling out pneumonia.What information is considered to be part of the history of present illness (HPI)?

What will be an ideal response?

She started one week ago with symptoms of a cold - runny eyes, nasal congestion, cough, and some wheezing. The cough is non-productive. She has taken over the counter (OTC) medications, but has not seen much improvement, and in fact her cough has become worse.