NURS 5308
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
...
NURS 5308
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: SurgHx
Child: “usual coughs and tummy ache nothing
remarkable.”
Adult Illness: Denies
Medical: None
Surgical: None
Obstetric: None
Hospitalizations: None
2
FamHx SHx
Maternal grandfather died of CVD at age 81.
Grandmother (age 88) has prior heart attack, stent
Tobacco: Denies
and HTN.
ETOH: Socially
Mother alive and well.
Father alive and well, treated for HTN.
Illicit Drugs: Denies
Occupation: English teacher for 7
th and 8
th grade
Brothers - 35 and 32 both alive and well.
Sister - 21 alive and well.
3
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
4
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:
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