Marvin Webster I human NR509 - I Human Marvin Webster Course Advanced Physical Assessment

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History:
How canI helpyou today? “I feel awful…I’m exhausted. I have a cough and body aches”
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Do youhave anyothersymptoms orconcerns we shoulddiscuss? “my throat issore, andI have a
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headache”
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Do you have any allergies?
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Areyoutakinganyprescriptionmedications? Are
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you taking OTC or herbal medications?
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Have youhadyourflushotthisyear? Sick
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contact?
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When did your cough start? 1q 1q 1q 1q




What aretheeventssurroundingthestartofyourcough?
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Does anything make your cough better or worse?
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Areyoucoughingupanysputum? When
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did your sore throat start?
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Doesanythingmakeyoursorethroatbetterorworse? How
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severe is your sore throat?
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Whattreatmentshaveyouhadforyoursorethroat? When
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did your headache start?
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Doesanythingmakeyourheadachebetterorworse? How
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severe is your headache?
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Do youexperiencechestpainorpressure;palpitations,pain/pressure/dizziness withexertionor
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getting angry; decreased exercise tolerance; or blue/cold fingers/toes?
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Do youhaveproblemswithN/V,constipation,diarrhea,coffee groundsinyourvomit,dark tarry stools,
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bright red blood in your bowel movements, early satiety, or bloating?
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Do youhaveproblemswithdizziness,fainting, spinning room,seizures,weakness,numbness,
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tingling, or tremor?
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EHR:
Reasonforencounter: “I feel awful,I’m exhausted. Ihave acoughandbody aches” 1q 1q 1q 1q 1q 1q 1q 1q 1q 1q 1q 1q 1q 1q




HPI: MW isan 18year old male college student whopresents withacute onset cough, sore throat,
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headache, and fatigue x4 days”
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ROS:
General:reportsfatigue q
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HEENT: patientreportsheadachethatrespondstoibuprofenandsorethroat denies 1q 1q q
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sinus problems, runny nose/congestion, double/blurred vision
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CV:denieschestpain,palpitations,andshortness ofbreath Resp:
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reports dry, non-productive cough
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deniesshortness ofbreath,difficulty breathing andwheezing 1q 1q 1q 1q 1q 1q 1q




GI:deniesnausea,vomiting,constipation,diarrhea,dark/tarrystools,coffee groundemesis, bright
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red blood in stools
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