OLDWITHFATIQUE AND IRRITABILITY CASE REVIEW WEEK10 (SC
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REENSHOTSAREAVAILABLE)2024UPDATE n n n n
Name: Camilla Franklin n n n
Age: 48 years Gender n n n
: Femalen
Chief Complaint:
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1. What brings you in today?
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2. How long have you been experiencing these symptoms?
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History of Present Illness (HPI):
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1. When did your symptoms start?
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2. Can you describe your symptoms?
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3. Have you had any fever or chills?
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4. Are you experiencing any shortness of breath?
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5. Do you feel fatigued?
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,6. Are you having any chest pain? If yes, is it sharp, and does it get worse with deepbr
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eaths?
7. Have you noticed a cough? Is it productive? What color is the sputum?
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8. Have you had any wheezing?
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Past Medical History (PMH):
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1. Do you have any chronic medical conditions, such as asthma?
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2. Have you had any recent illnesses or infections, like the flu?
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3. Have you had any hospitalizations or surgeries in the past?
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4. Are you currently on any medications?
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5. Do you have any known allergies?
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Family History: n
1. Is there any family history of respiratory conditions, such as asthma?
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2. Are there any other significant health issues in your family?
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Social History: n
1. Do you smoke or have you ever smoked?
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2. Do you drink alcohol? If so, how often?
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3. Do you use any recreational drugs?
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4. What is your living situation? Do you live in a dormitory?
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5. Have you been in contact with anyone who is sick recently?
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Review of Systems (ROS):
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1. Have you had any weight loss or changes in appetite?
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2. Are you experiencing any nausea or vomiting?
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3. Have you noticed any other joint pain or swelling?
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4. Are you having any headaches or dizziness? 5. Have you noticed any palpitationsor
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heart-related symptoms?
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, Reasonn forn Encounter:
Camillan Franklin,n ann 48-yearn old,n presentsn withn an four-dayn historyn of
sudden-
onsetnFatiguenandnIrritability,nshortnessnofnbreath,nfatigue,npleuriticnchestnpain,nandnan
productivencoughnwithoutnwheezing.
Historyn ofn Presentn Illness:
Onset:n Symptomsn begann fourn daysn ago,n followingn then resolutionn ofn an recentn flun episode.nDura
tion:nSymptomsnhavenpersistednandnworsenednovernthenpastnfourndays.
Location:n Symptomsn aren primarilyn centeredn inn then chestn andn respiratoryn system.nCh
aracteristics: