Week 1 NR 579
Good questions:
1. How can I help you today?
a. Can’t breathe…it’s worse now…hard talking…pain in back…
2. Do you have any other symptoms or concerns we should discuss?
a. Sweating nights…
3. Have you been having fevers?
a. No…don’t think so
4. When did you night sweats start?
a. Two weeks ago…
5. When did your difficulty breathing start?
a. 1-2 weeks …back
6. What are the events surrounding the start of your difficulty breathing?
a. No idea…ask mom…tired…
7. Does anything make your difficulty breathing better or worse?
a. Not anymore…
8. Do you wheeze?
a. No.
9. How severe is your difficulty breathing?
a. Bad…worse today… can’t…talk..
10. What are the events surrounding the start of her difficulty breathing? (Mom)
a. First she said she had this dull ache in her back at that time. I thought she pulled a
muscle or something. Then she started feeling short of breath when she was exercising
or doing something active, and now in the last couple hours it’s gotten really serious
11. Do you have a cough?
a. No cough.
12. Where more precisely is the pain in your back?
a. Right here (indicates midthoracic region).
13. Does anything make the pain in your back better or worse?
a. No…tried acetaminophen…ibuprofen…no help. Prednisone…helped a little. Mom….tell
them. (Mother interjects: “We were in the ER last week. They told us that Nikita has
fibromyalgia and gave her prednisone. It worked for only about 3 days, so Nikita
stopped.”)
14. What does the pian in your back feel like?
a. Sharp….really strong.
15. Does the pain in your back radiate someplace else? Where?
a. No…
16. How severe (1-10) is the pain in your back?
a. Ten!
17. Can you tell me about any current or past medical problems you have had?
a. Back pain…here before…please mom…tell them for me…(Mother interjects: “We were
here last week for back pain. They just focused on that and gave her prednisone for what
This study source was downloaded by 100000851606723 from CourseHero.com on 12-08-2022 10:49:49 GMT -06:00
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, they told us is fibromyalgia. The medication seemed to work for a few days, but
obviously, that didn’t work for long.”.
18. Any previous medical, surgical or dental procedures?
a. No
19. Do you have any allergies?
a. No.
20. Are you taking any prescription medications?
a. Doc gave me…steroids…last week…stopped…didn’t work.
21. Are you taking any OTC or herbal medications?
a. Yeah, acetaminophen and ibuprofen.
22. Tell me about the health of your grandparents. Parents and children.
a. No kids! Mom and dad are okay
23. ROS:
a. Do you have any problems with fatigue, difficulty sleeping, unintentional weight loss or
gain, fevers, or night sweats?
i. Yes, some of that stuf
b. Do you have any problems with an itchy scalp, skin changes, moles, thinning hair, or
brittle nails?
i. No
c. Do you have any problems with headaches that don’t go away with aspirin or Tylenol,
double or blurred vision, difficulty with night vision, problems hearing, ear pain, sinus
problems, chronic sore throats, or difficulty swallowing?
i. No
d. 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?
i. No
e. Do you experience SOB, wheezing, difficulty catching your breath, chronic cough, or
sputum production?
i. Breathing..you know that…
f. Do you have problems with nausea, vomiting, constipation, diarrhea, cofee grounds in
your vomit, dark tarry stool, bright red blood in your bowel movements, early satiety, or
bloating?
i. Uh…no.
g. Do you have problems with muscles or joint pain, redness, swelling, muscle cramps, joint
stifness, joint swelling or redness, back pain, neck or shoulder pain, or hip pain?
i. Yes…my back.
h. Have you noticed any bruising, bleeding gums, nose bleeds, or other sites of increased
bleeding?
i. No.
i. Do you have any problems with heat or cold intolerance, increased thirst, increased
sweating, frequent urination, or change in appetite?
i. Yes….sweat at night… other stuf.
This study source was downloaded by 100000851606723 from CourseHero.com on 12-08-2022 10:49:49 GMT -06:00
https://www.coursehero.com/file/178394936/Week-1-NR-579docx/
Good questions:
1. How can I help you today?
a. Can’t breathe…it’s worse now…hard talking…pain in back…
2. Do you have any other symptoms or concerns we should discuss?
a. Sweating nights…
3. Have you been having fevers?
a. No…don’t think so
4. When did you night sweats start?
a. Two weeks ago…
5. When did your difficulty breathing start?
a. 1-2 weeks …back
6. What are the events surrounding the start of your difficulty breathing?
a. No idea…ask mom…tired…
7. Does anything make your difficulty breathing better or worse?
a. Not anymore…
8. Do you wheeze?
a. No.
9. How severe is your difficulty breathing?
a. Bad…worse today… can’t…talk..
10. What are the events surrounding the start of her difficulty breathing? (Mom)
a. First she said she had this dull ache in her back at that time. I thought she pulled a
muscle or something. Then she started feeling short of breath when she was exercising
or doing something active, and now in the last couple hours it’s gotten really serious
11. Do you have a cough?
a. No cough.
12. Where more precisely is the pain in your back?
a. Right here (indicates midthoracic region).
13. Does anything make the pain in your back better or worse?
a. No…tried acetaminophen…ibuprofen…no help. Prednisone…helped a little. Mom….tell
them. (Mother interjects: “We were in the ER last week. They told us that Nikita has
fibromyalgia and gave her prednisone. It worked for only about 3 days, so Nikita
stopped.”)
14. What does the pian in your back feel like?
a. Sharp….really strong.
15. Does the pain in your back radiate someplace else? Where?
a. No…
16. How severe (1-10) is the pain in your back?
a. Ten!
17. Can you tell me about any current or past medical problems you have had?
a. Back pain…here before…please mom…tell them for me…(Mother interjects: “We were
here last week for back pain. They just focused on that and gave her prednisone for what
This study source was downloaded by 100000851606723 from CourseHero.com on 12-08-2022 10:49:49 GMT -06:00
https://www.coursehero.com/file/178394936/Week-1-NR-579docx/
, they told us is fibromyalgia. The medication seemed to work for a few days, but
obviously, that didn’t work for long.”.
18. Any previous medical, surgical or dental procedures?
a. No
19. Do you have any allergies?
a. No.
20. Are you taking any prescription medications?
a. Doc gave me…steroids…last week…stopped…didn’t work.
21. Are you taking any OTC or herbal medications?
a. Yeah, acetaminophen and ibuprofen.
22. Tell me about the health of your grandparents. Parents and children.
a. No kids! Mom and dad are okay
23. ROS:
a. Do you have any problems with fatigue, difficulty sleeping, unintentional weight loss or
gain, fevers, or night sweats?
i. Yes, some of that stuf
b. Do you have any problems with an itchy scalp, skin changes, moles, thinning hair, or
brittle nails?
i. No
c. Do you have any problems with headaches that don’t go away with aspirin or Tylenol,
double or blurred vision, difficulty with night vision, problems hearing, ear pain, sinus
problems, chronic sore throats, or difficulty swallowing?
i. No
d. 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?
i. No
e. Do you experience SOB, wheezing, difficulty catching your breath, chronic cough, or
sputum production?
i. Breathing..you know that…
f. Do you have problems with nausea, vomiting, constipation, diarrhea, cofee grounds in
your vomit, dark tarry stool, bright red blood in your bowel movements, early satiety, or
bloating?
i. Uh…no.
g. Do you have problems with muscles or joint pain, redness, swelling, muscle cramps, joint
stifness, joint swelling or redness, back pain, neck or shoulder pain, or hip pain?
i. Yes…my back.
h. Have you noticed any bruising, bleeding gums, nose bleeds, or other sites of increased
bleeding?
i. No.
i. Do you have any problems with heat or cold intolerance, increased thirst, increased
sweating, frequent urination, or change in appetite?
i. Yes….sweat at night… other stuf.
This study source was downloaded by 100000851606723 from CourseHero.com on 12-08-2022 10:49:49 GMT -06:00
https://www.coursehero.com/file/178394936/Week-1-NR-579docx/
