NURS5342
Advanced Health Assessment
LaMicha Hogan, APRN, MSN FNP-BC
Molly Toon, DNP, APRN, CPNP-PC Date
January 25, 2021
IHUMAN Practice Case Study:
... [Show More] Mr. Marvin Webster
Case:
Date:
CC: 18 y/o M
Chief complaint is a short 1-2 statement or word phrase
from patient and should be listed in “quotes”
“I feel awful, I’m exhausted. I have body aches
and just feel really tired.”
HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts
Mr. Webster, an 18-yr-old male presented to the clinic with complaints of
persistent dry cough, sore throat, right ear pain, fatigue, headache, and myalgia.
He reports he has exercised induced asthma which has been latent and did not
receive his annual flu vaccine.
Onset: Most symptoms appeared 1-2 days ago
Location: Mostly throat, Headache and Ear
Duration: Every day and symptoms have persisted since onset.
Character: He reports 2/10 severity of ear pain which is non-radiating, and
sharp. Sore throat of 6-8/10 severity which is non radiating and feels like a razor
cut. Headache is mild and just annoying.
Aggravating/alleviating factors: Sore throat is aggravated by cough and
swallowing.
Related symptoms: Fatigue and myalgia with onset of other symptoms 1-2 days
ago. Denies exposure to any sick people.
Treatments: He has tried ibuprofen for pain
Significance: He feels exhausted and he is missing class
PMHx child/adult
illness/hospitalizations/immunizations
Childhood exercised induced asthma with no
recent exacerbations.
No hospitalizations, trauma or other injuries
Immunizations: States his immunizations are
SurgHx type/when/why/complications
Never for Surgical history.
This study source was downloaded by 100000862386169 from CourseHero.com on 05-02-2023 15:22:48 GMT -05:00
Case:
Date:
current for college. He has not received the Flu
vaccine this year.
FamHx
Grandparents (if known)/Parents/siblings/children
He has no knowledge of his grandparents
medical history.
Mother-age 58-Hypertension
Father-age 57-Healthy
SHx
Tobacco/vaping/ETOH/illicit drug use/occupational/environmental/relationships
Alcohol—Denies any recent alcohol intake, but occasionally drinks wine in the
night after studying.
Tobacco—Denies any history of smoking, vaping, or other tobacco use.
Denies Recreational drug use.
Relationships: Single
Full-time student, not planning on working during the first semester.
Denies any recent travel outside country in the past 2 weeks
Reproductive Hx
Female: Age of menarche/menstruation cycle
duration/gravida para status/Childbirth hx/sexual hx and
concerns/LMP/menopause
Breast/cervical screening (if any)
Male: Sexual hx and concerns/issues with fertility (if
any)/Testicular or prostate screening (if applicable)
Screening for STI’s (if applicable)
Male patient not currently sexually active
Allergies (Food, Drug, Environmental, etc.)
List of Medications/supplements (prescription, OTC, complementary
alternative therapies)
Ibuprofen used occasionally for pain.
Review of Systems: (ROS) Use this column to
document the ROS below.
General: Denies any weight gain or loss
HEENT: Denies vision changes. Complaints of sore
throat, cough, right ear pain and headache
Pulmonary: Denies shortness of breath. Reports
From the ROS: list/highlight the current symptoms/complaints to generate a
list of pertinent “reported or denied” symptoms below:
Pertinent Positive ROS: Reports headache; Sore throat that worsens with cough
and swallowing, 6-8/10 pain scale; sharp ear pain that does not radiate to any
part of the body rate scale of pain at 2/10. He feels exhausted and has aches and [Show Less]