NURSING 595 DIFFERENT VERSIONS OF THE ANSWER COMPLETE (EXPERT FEEDBACK) UPDATE

NURSING 595 DIFFERENT VERSIONS OF THE ANSWER COMPLETE (EXPERT FEEDBACK) UPDATE Subjective: CC: Bobby Kauk is a 18 year-old male who presents to college urgent care “feeling really sick” with fatigue, cough and shortness of breath. HPI: Pt reports feelings like he had the “flu” 10 days ago with relief of symptoms but then 4 days ago notes sudden onset of a productive fever, cough, fatigue and myalgias. He states a fever of 104 F at home accompanied by chills and has been taking Ibuprofen 400mg frequently, last dose being 4 hours prior to arrival. His cough is productive with thick green to yellow sputum and he feels as if it is coming from his lungs. His cough has no pattern and he has tried cough syrup with no relief. He notes body aches and fatigue that feels mild throughout his body and rest has made this better. Three days prior to his visit he also notes new onset of chest pain at the 6-8 ribs mid axillary line. He states that this chest pain worsens from a 2/10 with shallow breathing to a 7- 8/10 upon coughing. He states the chest pain feels like a stab or an ache. Not coughing makes his chest pain better. He also states he recently noticed shortness of breath with minimal effort, such as walking around his home or going up stairs. He states this is abnormal for him. Pt states he has not been around anyone with similar symptoms, although he does live in campus housing. PMH: Mononucleosis as a senior in high school and childhood asthma that has since resolved Surgical: Denies SH: Marital Status: Single Housing: Campus housing, Rangler Hall Dorms Employment: Student Hobbies/physical activities: N/A Recent Travel: Denies Pets: Denies Military Experience: Denies Diet: N/A. No recent change Smoking: Denies history EtOH: Occasional drinking Recreational substance use (past and present): Denies Sexual History: Not sexually active FH: Father, 57, good health. Mother 58, Hypertension Accidents/Injuries: Denies Hospitalizations: Denies Medications: Ibuprofen OTC, As needed for fever and myalgias. Last dose 400 mg 4 hours PTA Allergies: Denies Immunizations: +Denies receiving Influenza vaccine this year ROS: Limited due to problem visit General: +Fatigue, Fever Denies: Usual weight, recent weight change, weakness, , night sweats, anorexia, malaise Head: Denies: Headache, head injury Eyes: Denies: Vision, glasses/contact lens, date of last eye examination, pain, redness, excessive tearing, double vision (diplopia), floaters (spots in front of eyes), loss of any visual fields, history of glaucoma or cataracts Ears: Denies: Hearing loss, change in hearing, ringing in ears (tinnitus), ear infections Nose and Sinuses: Denies: Frequent colds, nasal stuffiness, hay fever, nosebleeds (epistaxis), sinus trouble, obstruction, discharge, pain, change in ability to smell, sneezing, post-nasal drip, history of nasal polyps Mouth and throat: +Sore Throat Denies: Soreness, dryness, pain, ulcers, sore tongue, bleeding gums, pyorrhea, teeth (caries, abscesses, extractions, dentures), hoarseness, history of recurrent sore throats or of strep throat or of rheumatic fever Neck: +Swollen lymph nodes Denies: Lumps, swollen glands, goiter (thyroid enlargement), pain Pulmonary: +Cough, Dyspnea, Pleuritic Chest pain Denies: change in chronic cough, wheezing, coughing up blood (hemoptysis), blue discoloration of lips or nailbeds (cyanosis), history of exposure to TB, history of a previous TB skin test and the results if done, recurrent pneumonia, history of environmental exposure