IHUMAN Case Study 5 Krista Hampton NURS 5308

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Instructions: Type patient encounter information directly into each box of the template similarly to your case studies. CC: 25 y/o F “I have this ugly looking rash on my upper thighs” HPI: Ms. ... Hampton is a 25 y/o female presenting with an itchy and tender rash bilaterally on her inner thighs, and her left inner forearm. The rash started about 36 hours ago after hiking in Napa with her boyfriend. She states she spent time hiking, tried a new sunscreen, tried new foods such as scallops and a new drink, as well as spending time in the hot tub with her boyfriend. She reports that her boyfriend does not have similar symptoms, and that she has not tried any treatments for the rash. PMHx: Child: “usual coughs and tummy ache nothing remarkable.” Adult Illness: Denies SurgHx Medical: None Surgical: None Obstetric: None Hospitalizations: None FamHx Maternal grandfather died of CVD at age 81. Grandmother (age 88) has prior heart attack, stent and HTN. Mother alive and well. Father alive and well, treated for HTN. Brothers - 35 and 32 both alive and well. Sister - 21 alive and well. SHx Tobacco: Denies ETOH: Socially Illicit Drugs: Denies Occupation: English teacher for 7 th and 8 th grade Case: Krista Hampton Relationship: Sexually active heterosexual female in a monogamous relationship Diet: Normal American Diet Reproductive Hx Age of menarche: “doesn’t remember.” Menstruation cycle duration: “seems fine to me,” regular periods Sexual hx and concerns: Denies concerns LMP: unknown Breast screening: Conducts self-breast exams Last Pap Smear: 1 year ago, with no signs of abnormalities Gravida para status/Childbirth hx: Nulliparous Allergies Ceclor (Cefaclor) second generation cephalosporin – Patient developed hives as child when taking this antibiotic for otitis media List of Current Medications/supplements: Birth control pill Supplements: None Review of Systems: (ROS) Use this column to document the ROS below. General: Denies unintentional weight loss or gain, chills, fever, and night sweats Eyes: Denies any vision changes, discharge, discomfort, dryness, or itching ENT: Denies any swelling, redness, rhinorrhea, or pain Pulmonary: Denies SOB at night or at rest or when lying down, denies cough, wheezing or difficulty catching breath CV: Denies palpitations denies heavy feeling or From the ROS: list/highlight the current symptoms/complaints to generate a list of pertinent “reported or denied” symptoms below: Case: Krista Hampton sensation of a “pounding heart GI: Denies NVD, constipation, or heartburn. States normal bowel movements GU: Denies pain, burning, blood in urine, denies difficulty starting or stopping urinating, dribbling, incontinence, urgency during night or day, or any changes in the frequency of urination MS: Denies muscle weakness, joint pain, stiffness, or swelling Heme: Denies bruising, bleeding gums, nose bleeds, abnormal bleeding, or history of anemia Endocrine: Denies heat and cold intolerance, increased thirst, increased sweating, frequent urination, or changes in appetite Derm: Patient states” Ugly looking rash on my upper thighs, now it’s on my left inner forearm too”, rash is “itchy and getting more tender” Neuro: Denies dizziness, lightheadedness, fainting, room spinning, seizures, or weakness Psych: Denies anxiety, depression, loss of energy or changes in interests Derm: Patient states” Ugly looking rash on my upper thighs, now it’s on my left inner forearm too”, rash is “itchy and getting more tender” Physical Exam: (PE) Use this column to document the PE below. Vitals: Height: 5' 5" (165.0 cm) Weight: 120 lb (55.0 kg) (BMI 20.0) Temperature: 98.6 F (oral) Pulse: 76 bpm - regular Blood pressure: 116/62 mmHg - supine/sitting From the PE: list/highlight the presence or absence of objective findings to generate a list of pertinent “(+) or (-)” symptoms below: [Show More]

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