CAMILLA FRANKLIN I HUMAN NURSING CASE STUDY

Camilla Franklin is an 18-year-old college student who presents with a history of the flu which resolved and then was followed by a four-day history of sudden-onset, fevers, chills, shortness of breath, fatigue, pleuritic chest pain and a productive cough without wheezing. Physical examination is significant for a fever of 103.2 F (oral), tachypnea (rate 24/min), hypoxia, R middle and lower lobe coarse crackles and tender anterior cervical lymphadenopathy. He denies known sick contacts and has a childhood history of asthma now off therapy without recent attacks. Camilla Franklin Chief complaint: Problems: feels awful and exhausted, has body aches and feels really weak. Sore throat, coughing, and has a headache. Muscle aches too Chief complaint Sx/Sx characterisics questions missed: - How bad is your cough? - Does anything make your cough beer or worse? - What are the events surrounding the start of your cough? Associated Sx/Sx characteriscis qustions missed: - Do you wheeze? - What treatments have you had for your sore throat? - Have you had a sore throat like this before? Risk factors PMH questions missed: - Are you taking any OTC or herbal meds? Ecology questions missed: - Have you had any contact with other sick people? HPI/ROS questions missed: lOMoAR cPSD|2444 - How can I help you today - Do you have any other symptoms or concerns we should discuss - When did the pain in your chest start? - Does anything make the pain in your chest be琀琀er or worse - Where more precisely is the pain in your chest? - Does the pain in your chest radiate someplace else? Where? - How severe 1-10 scale is the pain in your chest? (4-5/10) - Have you had trauma to your chest? – no - How long does your chest pain last? - Is your chest pain precipitated by exercise? - Any change in your chest pain since it began? - Does the pain in your chest come and go? - Do you experience SOB, wheezing, diticulty catching your breath, chronic cough, sputum production? - Do you have problems with N/V, conspation, diarrhea, cofee grounds in your vomit, etc - Do you have any of the following problems with: fatigue, ditifculty sleeping, unintenonal weight loss, or gain, fevers, night sweats? - Do u have any problems with nervousness, depression, lack of interest, sadness, memory loss, or mood changes, etc - Do you drink alcohol? If so, what do you drink and how many drinks per day? - Has drinking alcohol ever caused you problems? - Can you tell me about your diet, what your normally eat? - Have you ever felt you needed to cut down on your drinking? - Has anyone suggested that you should reduce the amount of alcohol you drink? - Have you ever been annoyed at anyone for suggesng that you cut back on your alcohol consumption? - Do you presently have heartburn, a food or acid taste in your mouth? - When and what did you last drink? – wine around 10pm last night Chief Complaint: “I feel awful...I’m exhausted, short of breath, my fever is geing worse.” HPI: Camilla Franklin is an 18 yr old male who recently had the influenza virus two weeks ago which resolved, and today presents with a four day history of sudden onset fever 103.2, with lOMoAR cPSD|2444 chills, rigors, myalgia, productive cough without wheezing, fatigue, and sharp right sided pleuric chest pain that is aggravated with coughing and breathing. He reported a fever of 104 last night and took OTC Ibuprofen with no signicant improvement in his symptoms. He complains of a productive cough with green/yellow sputum with no relief aer taking cough syrup. Pt denies any recent travel or sick contacts. Patient reports he takes no daily prescripon medications or additonal OTC medications. ROS: Constutional: Positive for fever, chills, rigor, fatigue. Negave for appetite change, diaphoresis. HEENT: Positve for swollen glands; negative for headache, sore throat and dificulty swallowing Respiratory: Positive for dyspnea, productive green/yellow sputum, and shortness of breath, negative for wheezing Cardiovascular: Positive for right sided chest wall pain (6-8th intercostal spaces at midaxillary line), negative for leg swelling Gastrointesnal: Negative for rectal bleeding, blood in stool, conspation, diarrhea, nausea or vomting Endocrine: Negative for polydipsia and polyuria Genitourinary: Negative for decreased urine production, menstrual problem, pelvic pain, urgency or vaginal discharge Musculoskeletal: Posiitive for myalgia, negative for back pain, neck pain and neck sicness Allergic/Immunologic: Negative for food allergies