Problem statement sample: NM is an 18 year old college student with history of childhood
asthma who presents with acute onset of low-grade fever,
... [Show More] fatigue, myalgia, right ear pain and
headache. Physical exam reveals an erythematous pharynx and right tympanic membrane,
anterior cervical adenopathy, and scattered bilateral crackles. Risk factor include lack of an
annual flu vaccine.
10 more in Associated Symptoms
1 more in SH
My problem statement:
NC is a 25-year-old woman with a 3-day history of dysuria, increased urinary frequency and
yellow, creamy, and mucous-like discharge. Denies fever, chills, myalgia etc. Physical exam
reveals mucopurulent discharge from cervical os, cervix appears friable with a vaginal pH of 4.0.
Risk factor includes multiple sexual partners, not using any protection against STIs and on birth
control.
Mother: diabetes mellitus
Father: HTN, CAD, hyperlipidemia
Older sister: Alive and well
Works as a consultant; travels frequently
Alcohol: 1 to 2 times per week; 4 to 5 drinks per occasion
No other substance use
Previous-smoker status: approximate 2 pack-year hx
Patient Information: Nancy Cambell
Name and Age: 25 years old
Height and Weight: 135 lbs
Vital Signs: #/# BP, # HR, # RR, # O2%, # Temp. 98.7, 78, 110/72, rr 14, 94ra
CC: 25 yo with pain with urination
HPI:
Problem Statement: Short summary of patents presentation. Should contain:
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NR602 IHUMAN CASE STUDY
1: Demographic description
2: Chief complain
3: Hx and PE key
4: Risk factors
Key Findings (# Key Findings):
Good Questions:
1. (Interviewing Question) How can I help you today? “Patient’s complaint” I have
burning when I pee. I was worried that I had another bladder infection but these
symptoms are a little different then the symptoms I had with my last UTI.
2. (Interviewing Question) Do you have any other symptoms we should discuss?
Vaginal discharge
3. Has there been a change in your urinary frequency? Well, yeah. Seems like I feel
I have to go every 10 to 15 or 20 minutes but I resist due to the pain.
4. When did pain with urination start? About 3 days ago
5. Is the pain better or worse at the start of urination? Worse when starting but it
doesn’t really let up.
6. What is the appearance, smell, texture and quantity of the vaginal discharge?
Yellow, king of mucousy, kind of creamy, not really too smelly.
7. Do you have vaginal discomfort or itching? No
8. How severe is your pain/discomfort with urination? Makes me not want to go
even though I have to!
PMH:
1. No patient record? Have you had any sexually transmitted infections? Not
that I know of.
2. Have patient record? Update allergies, medications, OTC drugs.
- Not taking any prescription medications.
- OTC Ibuprofen for headaches and cramps
ROS: 12
1. GENERAL: Any problems with fatigue, diff sleeping, weight loss or gain?
No
2. HEENT: Do you have any problems with headaches that don’t go away with
aspirin or Tylenol, blurred vision? Night sweats? Ear pain, sinus problem,
sore throat or difficulty swallowing?** – NO
3. SKIN/ HAIR/ NAILS: Any problems with itchy scalp, skin changes, moles,
thing hair or brittle nails? No
4. Cardiovascular: Do you experience any chest pain, discomfort, pressure,
pain dizziness with exertion or getting angry, palpitation, decrease
exercise, blue or cold fingers?- no
This study source was downloaded by 100000852290574 from CourseHero.com on 08-08-2023 02:51:08 GMT -05:00
https://www.coursehero.com/file/123943460/Case-2-Nancy-Campbelldocx/
5. Breast: Do you ever experience breast discharge, lumps, scaly nipples,
pain, welling, or redness? - n
6. Respiratory: Do you experience any problems with SOB, wheezing,
difficulty catching your breathe, chronic cough, sputum production? – no
7. Gastro: Do you have any problems with nausea, vomiting, constipation,
diarrhea, coffee grounds, dark tarry stool, bright red blood in Bm, or
boating?- no
8. Geni/GYN: Do you have any genital sores or discharge? NO sores, but we
were talking about the other.
9. Musc: Any problems with muscle or join tpain, redness, swelling, muscle
cramps redness, back pain, neck or shoulder pain or hip pain. -no
10.Hematologic: Have you noticed any bruising, bleeding, gums, nose bleeds,
or increased bleeding?-no
11.Endocrine: Any problems with heat or cold intolerance, increased thirst,
sweating, frequent urination, change in appetite?-no
12.Nruro: Any dizziness, fainting, spinning rooms, seziures, weakness,
numbness or tingling? – no
13.Psycho: Any problems with nervousness, lack of interest, sadness,
memory loss, or mood changes, or hearing voices? -no
14.
Family history:
No record? – obtain then.
SH:
No record? – then obtain
No etoh
No recreational drugs
No smoke
# 34 Are you using any form of birth control? – yes
Are you sexually active? Yes
Do you have pain with intercourse? NO but I haven’t had sex since this all started
Have you or are you having unprotected sex? I’m on the pill so I guess I’m
protected that way, for STDs not so much.
Do you use precautions to prevent STIs? Nothing other than the pill.
Do you have more than one sexual partner? Yes
Do you have new or multiple partners with the same sx? Well, no one has told me
he has any problem.
Exercises (# Questions Total):
1. Question 1 It is possible to develop a persistent chlamydia infection of the upper
genital tract, and subsequent infertility, in the absence of symptoms of physicalexam findings---true [Show Less]