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NR509_iHuman_Week_3__Jenna_James.pdf

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NR509_iHuman_Week_3__Jenna_J

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Ihuman Case
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Ihuman case

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NR509_iHuman_Week_3__Jenna_James
22 Correct Questions Required to Ask

Q: Have you had any contact with other sick people?

A: “My roommate had a bad sore throat earlier in the week. She got checked out at the clinic, but I don’t
know what the diagnosis was”.

Q: Any new or recent changes in medications? A: “No, just the same oral contraceptive pill”

Q: Do you experience shortness of breath, wheezing, difficulty catching your breath, chronic cough, or
sputum production?

A: “No wheezing, problems breathing or anything like that. I’m sorry, what else did you want to know?”

Q: Do you have any problems with muscle or joint pain, redness, swelling, muscle cramps, joint

stiffness, or redness, back pain, neck or shoulder pain, or hip pain? A: “Uh… no”

Q: Do you have a cough? A: Nope.

A: None of that. Would that be important

Q: Do you experience chest pain discomfort or pressure; pain/pressure/dizziness with exertion or
getting angry; palpitations; decreased exercise tolerance; or blue/cold fingers and toes? ?

Q: Do you have any problems with fatigue, difficulty sleeping, unintentional weight loss or gain, fevers,
or night sweats?

A: “I feel pretty lousy, but not weight loss. What else did you say you wanted to know about?”

Q: Do you have a problem swallowing?

A: “Boy do I! My throat hurts so much when I swallow. I really don’t want to eat, even though my
appetite is okay”

Q: Are you sexually active?

A: “Yes. That is why I am on birth control, but only active with one partner”

Q: Does anything make your sore throat better or worse?

A: Acetaminophen maybe, but just for a bit. Ice cream helps for a while, too. I mean, it’s really bad!

Q: Are you taking any over-the-counter or herbal medications? A: “Just acetaminophen”

Q: When did your sore throat start?

A: “About two days ago; it seemed to come on pretty suddenly”

, Q: Do you have chills?

A: “No, I wouldn’t say shaking chills; but yes, chills”

Q: Have you had a flu shot this year?

A: No



Problem Statement (57 words long) : infectious mononucleosis at age 15. She presents with acute
onset of

sore throat along with fever (101.8 F), bilaterally swollen lymph nodes that are tender to
touch, headache, and difficulty swallowing. Patient symptoms began around 2 days ago
following exposure to a sick roommate. Physical examination reveals fever of 101.5 F,
bilateral cervical lymphadenopathy, erythema of the pharynx, and tonsillar exudate. Patient
breathing is unlabored and clear to auscultation bilaterally. Patient taking acetaminophen as
needed to reduce fever, headache, and sore throat symptoms. Cold food temporarily
improves sore throat. Patient denies receiving flu vaccine this year. COVID series completed.




i. name or initials, age ii.

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Ihuman case
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Ihuman case

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