Updated today
Health Care exam material, 8 pages. Originally published on StudyMerit.
See the first 3 pages exactly as they appear in the document.
22 Correct Questions Required to Ask Q: Have you had any contact with other sick people? A: “My roommate had a bad sore throat earlier in the week. She got checked out at the clinic, but I don’t know what the diagnosis was”. Q: Any new or recent changes in medications? A: “No, just the same oral contraceptive pill” Q: Do you experience shortness of breath, wheezing, difficulty catching your breath, chronic cough, or sputum production? A: “No wheezing, problems breathing or anything like that. I’m sorry, what else did you want to know?” Q: Do you have any problems with muscle or joint pain, redness, swelling, muscle cramps, joint stiffness, or redness, back pain, neck or shoulder pain, or hip pain? A: “Uh… no” Q: Do you have a cough? A: Nope. Q: 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? A: None of that. Would that be important? Q: Do you have any problems with fatigue, difficulty sleeping, unintentional weight loss or gain, fevers, or night sweats? A: “I feel pretty lousy, but not weight loss. What else did you say you wanted to know about?” Q: Do you have a problem swallowing? A: “Boy do I! My throat hurts so much when I swallow. I really don’t want to eat, even though my appetite is okay” Q: Are you sexually active? A: “Yes. That is why I am on birth control, but only active with one partner” Q: Does anything make your sore throat better or worse? A: Acetaminophen maybe, but just for a bit. Ice cream helps for a while, too. I mean, it’s really bad! Q: Are you taking any over - the - counter or herbal medications? A: “Just acetaminophen”
Q: When did your sore throat start? A: “About two days ago; it seemed to come on pretty suddenly” Q: Do you have chills? A: “No, I wouldn’t say shaking chills; but yes, chills” Q: Have you had a flu shot this year? A: No Problem Statement (57 words long) : JJ is a 23 year - old female with a history of infectious mononucleosis at age 15. She presents with acute onset of sore throat along with fever (101.8 F), bilaterally swollen lymph nodes that are tender to touch, head ache, and difficulty swallowing. Patient symptoms began around 2 days ago following exposure to a sick roommate. Physical examination reveals fever of 101.5 F, bilateral cervical lymphadenopathy, erythema of the pharynx, and tonsillar exudate. Patient brea thing is unlabored and clear to auscultation bilaterally. Patient taking acetaminophen as needed to reduce fever, headache, and sore throat symptoms. Cold food temporarily improves sore throat. Patient denies receiving flu vaccine this year. COVID series completed. i. name or initials, age ii. chief complaint iii. positive and negative subjective findings iv. positive and negative objective findings HPI Sx = Sore throat Sx = Fever Sx = Headache Sx = Swollen/t ender lymph nodes Sx = Chills Sx = Pain with swallowin g Onset 2 days ago; came on suddenly 2 days ago; “It seemed to follow my throat getting sore” 2 days ago 2 days ago 2 days ago; “With the sore throat” Location Throat; all over Head Neck Generalized Throat Duration “There all the time” “It’s not always the same”; intermitten t
Characteristics “It’s like an ice pick in there!” Dull headache Lymph nodes swollen bilaterally ; tender to touch “I wouldn’t say shaking chills; but, chills, yes” “My throat hurts so much when I swallow. I really don’t want to eat, even though my appetite is okay” Aggravating Swallowing Hurts when touched Swallowing alone hurts Relieving Acetamino phen; ice cream Acetaminop hen “Acetamin ophen helps a bit” Timing/Treatments Comes and goes; “seems to be tied to my fever” Severity Pain is a 11 on a 1 - 10 scale 101.8 F Mild headache Management Plan (~219 words) : References Key findings (7 listed by case) : 1) Sore throat 2) Fever 3) Headache 4) Swollen/tender lymph nodes 5) Chills 6) Pain with swallowing MY FINDINGS 1) Fever (101.5 F)
That’s the free preview
You’ve read 3 of 8 pages. The whole document is yours with a free account, and it stays in your library.
NURS6501 · Walden University
NUR101 · Other
NUR635 · Other
Free
With a free account