Respiratory Case Study

Alternative Assignment

History of Present Illness

A 34-year old female patient sees her primary health care provider for ongoing complaints of headache and dizziness. Additional symptoms reported are dry cough, fatigue, sore throat, nausea, and chills.

Additional measures included:

·         Complete blood count

·         Complete metabolic panel

·         UA

·         CXR

·         X-ray of face/sinuses

·         IV fluids

Past Medical History

Recurrent headaches over the last 2 months. Cycling symptoms of cough, chills, and sore throat.

Patient has utilized the following to control the symptoms:

·         over-the-counter acetaminophen and ibuprofen

·         Vicks vaporub

·         Humidifier

·         ChlorTrimeton 4mg over-the-counter twice/day

Laboratory values and Medications

CXR showing consolidation and infiltrates in the left lower lobe and beginning in the right lower lobe

WBC 10,000

Hct 49

Urine specific gravity 1.030

Na+ 148

K+ 5.5

BUN 15.0

Habits and Activities

Patient is a runner, runs early in the morning in her neighborhood

Denies ETOH use

Denies street drug use

Denies tobacco use

Eats 5 small meals/day, does not eat red meat, is lactose intolerant

Does not take any medications other than those listed above, denies use of vitamins, supplements, or herbs

Review of Systems

VS:90/52; 98-24, 90%, 101.0 oral; Ht: 60” Wt: 105# BMI: 20.5

HENNT: pale yellow-green mucus draining through the night and early morning, and intermittently through the day, nasal turbinates swollen and reddened, tenderness palpated over the frontal and maxillary sinuses, throat red, mucous membranes dry and tongue with thick appearance

GI: abdomen flat, no masses, increased constipation

GU:urine concentrated

CV: pulses weak, difficult to palpate distally, no edema, HRRR, no murmur, no palpitations

Resp: chest wall movement symmetrical bilaterally, no use of accessory muscles

Neuro: A&O x3 but lethargic