I HUMAN
WEEK 3 NR602
COUGH & SOB CASE STUDY OF 16YO FEMALE PATIENT
LATEST UPDATE WITH COMPLETE SOLUTION
started with
MBOFFIN
, I Human Week 3 NR602
Kathleen Hamilton 16yo Female 5’5” 150lb
CC: Cough and SOB
History 75 questions
HPI: 16-year-old female comes to clinic with chief complaint of cough for the
past 3 weeks. Started with cold symptoms of runny nose and congestion, but
patient states that resolved after a week. Currently denies sputum, fever,
and chills. Shortness of breath for the past 3 days. Most concerning symptom
is SOB with mild exertion. Relieved with stopping to rest. Cough and SOB
worse at night. Patient has not tried any medications or treatments to relieve
symptoms. Does have a PMH of reactive airway and eczema. Patient also
reports being exposed to secondhand smoke often from neighbors in
apartment building. Patient is accompanied by mother today.
(OLDCARTS) Onset, Location, Characteristics, Aggravating, Relieving,
Treatments, Severity.
Cough – started 3 weeks ago after having cold like symptoms. Pt states
the cold symptoms lasted only a week, but the cough remains. Dry cough, no
sputum. Alleviating has not tried anything for relief. Aggravating, coughing
through the night for the past 3 days.
SOB – started 3 days ago. Chest does not feel well making breathing
harder. Wheezing. Exercise and nighttime make worse. Stopping activity and
resting will relieve symptoms brought on by activity. No treatments tried.
Sever enough to come to clinic.
Physical Exam 23 exams only
***Review EHR for VS
Problem Statement: K.H. 16-year-old female, chief complaint of cough and
shortness of breath. Cough started 3 weeks ago with cold symptoms of
rhinorrhea and congestion, which has since resolved. Cough is non-
productive of sputum. Patient denies fever, chills, headache, and fatigue. For
the past 3 days patient has been increasingly short of breath. Exacerbated
by minimal activity, relieved with termination of activity. SOB and cough
worse at night. Assessment positive for tachypnea, mild labored breathing,
bilateral expiratory wheezes, diaphragmatic excursion 4cm bilaterally, and
subcostal retractions. Negative for hyper-resonant lung fields, no
https://www.stuvia.com/user/mboffin
WEEK 3 NR602
COUGH & SOB CASE STUDY OF 16YO FEMALE PATIENT
LATEST UPDATE WITH COMPLETE SOLUTION
started with
MBOFFIN
, I Human Week 3 NR602
Kathleen Hamilton 16yo Female 5’5” 150lb
CC: Cough and SOB
History 75 questions
HPI: 16-year-old female comes to clinic with chief complaint of cough for the
past 3 weeks. Started with cold symptoms of runny nose and congestion, but
patient states that resolved after a week. Currently denies sputum, fever,
and chills. Shortness of breath for the past 3 days. Most concerning symptom
is SOB with mild exertion. Relieved with stopping to rest. Cough and SOB
worse at night. Patient has not tried any medications or treatments to relieve
symptoms. Does have a PMH of reactive airway and eczema. Patient also
reports being exposed to secondhand smoke often from neighbors in
apartment building. Patient is accompanied by mother today.
(OLDCARTS) Onset, Location, Characteristics, Aggravating, Relieving,
Treatments, Severity.
Cough – started 3 weeks ago after having cold like symptoms. Pt states
the cold symptoms lasted only a week, but the cough remains. Dry cough, no
sputum. Alleviating has not tried anything for relief. Aggravating, coughing
through the night for the past 3 days.
SOB – started 3 days ago. Chest does not feel well making breathing
harder. Wheezing. Exercise and nighttime make worse. Stopping activity and
resting will relieve symptoms brought on by activity. No treatments tried.
Sever enough to come to clinic.
Physical Exam 23 exams only
***Review EHR for VS
Problem Statement: K.H. 16-year-old female, chief complaint of cough and
shortness of breath. Cough started 3 weeks ago with cold symptoms of
rhinorrhea and congestion, which has since resolved. Cough is non-
productive of sputum. Patient denies fever, chills, headache, and fatigue. For
the past 3 days patient has been increasingly short of breath. Exacerbated
by minimal activity, relieved with termination of activity. SOB and cough
worse at night. Assessment positive for tachypnea, mild labored breathing,
bilateral expiratory wheezes, diaphragmatic excursion 4cm bilaterally, and
subcostal retractions. Negative for hyper-resonant lung fields, no
https://www.stuvia.com/user/mboffin
