i-Human Case Study – Erin Bradley
1. What is the CC in this case study? What are important questions to ask the patient to
formulate the history of present illness and what did the patient tell you?
The CC, or chief
...
i-Human Case Study – Erin Bradley
1. What is the CC in this case study? What are important questions to ask the patient to
formulate the history of present illness and what did the patient tell you?
The CC, or chief complaint, is the patient’s reason for seeking care. In this case,
the chief complaint identified in the opening for the case was “Nausea, vomiting, feeling
shaky and hot along with a flutter in chest” (Kalinyak, 2019, case introduction). This was
confirmed by asking the patient “How can I help you today?”, to which she replied she
was weak and shaky with nausea, vomiting, and feeling hot. To formulate the history of
present illness (HPI), it is necessary to gain an understanding of when the symptoms
started, what were the events surrounding the start of her symptoms, what makes them
better or worse, how severe are they, do they interfere with the performance of daily
activities, how have the symptoms been treated and did the treatment help, and are there
any other associated symptoms. This information can be gathered with the help of
memory aids, such as OLD CARTS or PQRST (Bickley, 2017).
In completing the health history interview, Erin related she had been ill with what
she called the flu 1 week ago. She thought she was getting better but has had a persistent
fatigue, fever, and cough with progressive worsening over the last several days and the
development of nausea and vomiting 24 hours prior to her presentation. She states her
cough is occasionally productive but denies hemoptysis. She also denies chest pain;
however, she describes a “fluttering in her chest” feeling for the last couple of weeks
which worsens with exertion, such as climbing stairs. Erin reported a 6-month history of
lighter than normal menses and 1 recently skipped menstrual period, as well as an
unintentional 10-pound weight loss despite increased hunger and decreased exercise due to
exercise intolerance. She states she feels “weak all over and shaky”, is having problems
sleeping, is feeling anxious, and intolerant to heat. Erin is in obvious distress and unable
to identify aggravating or relieving factors, nor is she able to quantify severity of
symptoms. She denies any self-treatment of her symptoms.
2. What components of the physical exam are important to review in this case? What are
pertinent positive and negative physical exam findings to help you formulate your
diagnosis?
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