marvin webster case study.docx

Marvin Webster History How can I help you today? Do you have any other symptoms or concerns we should discuss? Do you have any allergies, such as medications, food and/or latex, for example? Are you taking any presc ...

Marvin Webster History How can I help you today? Do you have any other symptoms or concerns we should discuss? Do you have any allergies, such as medications, food and/or latex, for example? Are you taking any prescription medications? Are you taking any over-the-counter or herbal medications? Can you tell me about any current or past medical problems you have had? Any previous medical, surgical, or dental procedures? Do you now or have you ever smoked or chewed tobacco? Have you had any contact with other sick people? Are you sexually active? Do you experience: chest pain discomfort or pressure; pain/pressure/dizziness with exertion or getting angry; palpitation; decreased exercise tolerance; blue/cold fingers or toes? Do you have any of the following: dizziness, fainting, spinning room, seizures, weakness, numbness, tingling, tremor? Do you have any of the following problems: fatigue, difficulty sleeping, unintentional weight loss or gain, fevers, night sweats? How high was your fever? When you urinate, have you noticed: pain, burning, blood, difficulty starting or stopping, dribbling, incontinence, urgency during day or night or any changes in frequency? marvin webster case study 2 How severe (1-10) is the pain in your chest? Do you have any pain in your chest? Have you noticed: any bruising, bleeding gums, nose bleeds or other sites of increased bleeding? Do you have any of the following: heat or cold intolerance, increased thirst, increased sweating, frequent urination, change in appetite? Do you have any problems with: nervousness, depression, lack of interest, sadness, memory loss, or mood changes, or ever hear voices or see things that you know are not there? Do you awaken at night coughing? What treatments have you had for your cough? What are the events surrounding the start of your cough? Is there any pattern to your cough? Does anything make your cough better or worse? Do you have HIV? Do you drink alcohol? If so, what do you drink and how many drinks per day? Have you had a cough like this before? Do you have problems with: nausea, vomiting, constipation, diarrhea, coffee grounds in your vomit, dark tarry stool, bright red blood in your bowel movements, early satiety, bloating? Do you use recreational drugs? If so, what? Do you have problems with: muscle or joint pain, redness, swelling, muscle cramps, joint stiffness, joint swelling or redness, back pain, neck or shoulder pain, hip pain? 3 Are you coughing up any sputum? When did your cough start? Do you have any problems with: headaches that don’t go away with aspirin or Tylenol (acetaminophen), double or blurred vision, difficulty with night vision, problems hearing, ear pain, sinus problems, chronic sore throats, difficulty swallowing? Have you ever been hospitalized? What is your name? Do you have pain anywhere? If so, where? Physical Exams Temperature Skin, hair, nails: inspect skin overall Chest wall and lungs: auscultate lungs Heart: auscultate heart Abdomen: visual inspection abdomen Extremities: visual inspection extremities Musculoskeletal: inspect for muscle bulk and tone Vitals: pulse Chest wall and lungs: auscultate lungs Vitals: respiration Vitals: pulse 4 Vitals: blood pressure Abdomen: palpate abdomen Genitourinary: genitourinary male exam HEENT: inspect mouth/pharynx Lymphatic: palpate all lymph nodes Musculoskeletal: test strength Neck: palpate neck Neurological: cranial nerves Neurological: reflexes – deep tendon Orthostatic blood pressure (BP) SPO2 Mental status Marvin Webster Chief complaint: Problems: feels awful and exhausted, has body aches and feels really weak. Sore throat, coughing, and has a headache. Muscle aches too Chief complaint Sx/Sx characteristics questions missed: - How bad is your cough? - Does anything make your cough better or worse? - What are the events surrounding the start of your cough? 5 Associated Sx/Sx characteristics questions missed: - Do you wheeze? - What treatments have you had for your sore throat? - Have you had a sore throat like this before? Risk factors PMH questions missed: - Are you taking any OTC or herbal meds?