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Comprehensive Camilla Franklin i- Human Case Study | 48-Year-Old

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Comprehensive Camilla Franklin i- Human Case Study | 48-Year-Old

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HPI:

Camilla Franklin is an 48 year old female who recently had the influenza virus two weeks ag
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o which resolved, and today presents with a four day history of sudden onset fever 103.2, wi
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th chills, rigors, myalgia, productive cough without wheezing, fatigue, and sharp right sided
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pleuritic chest pain that is aggravated with coughing and breathing. He reported a fever of 104 la
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st night and took OTC Ibuprofen with no significant improvement in his symptoms. He
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complains of a productive cough with green/yellow sputum with no relief after taking cough sy
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rup. Pt denies any recent travel or sick contacts. Patient reports he takes no daily prescription me
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dications or additional OTC medications.
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ROS:

Constitutional: Positive for fever, chills, rigor, fatigue. Negative for appetite change, diaphoresis.
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HEENT: Positive for swollen glands; negative for headache, sore throat and difficulty swallowing
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v Respiratory: Positive for dyspnea, productive green/yellow sputum, and shortness of breath,
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negative for wheezing rv rv




Cardiovascular: Positive for right sided chest wall pain (6- rv rv rv rv rv rv rv rv




8th intercostal spaces at midaxillary line), negative for leg swelling
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Gastrointestinal: Negative for rectal bleeding, blood in stool, constipation, diarrhea, nausea or vomit
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ing

Endocrine: Negative for polydipsia and polyuria
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Genitourinary: Negative for decreased urine production, menstrual problem, pelvic pain, urgenc
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y or vaginal discharge
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