Patient Description Ms Jis 23 Year Old Female Who Presents To A Local Urgent Care Clinic Where You Are Working As An A 1 (36.85 KiB) Viewed 102 times
Patient Description Ms Jis 23 Year Old Female Who Presents To A Local Urgent Care Clinic Where You Are Working As An A 2 (27.28 KiB) Viewed 102 times
Patient Description Ms Jis 23 Year Old Female Who Presents To A Local Urgent Care Clinic Where You Are Working As An A 3 (23.46 KiB) Viewed 102 times
Patient Description: Ms. Jis 23 year-old female who presents to a local urgent care clinic where you are working as an APRN. Ms. J complains of a left earache that has progressively worsened over the past 6 days. She describes a "constant ache." She has a runny nose, cough, headache and has been feverish with intermittent chills. She said her temperature has been between 100 and 101.5. She has been taking acetaminophen, which helps with the fever but not the ear pain. On examination, you note Ms. J has bulging tympanic membranes bilaterally, but her left tympanic membrane is erythematous and dull which has resulted in distorted landmarks. T 101.3°F, BP 128/76, HR 98, RR 22, HT 63", WT 124 lbs
SUBJECTIVE Chief Complaint History of present illness Problem-focused review of systems Past Medical History Past Surgical History Family History Social History OBJECTIVE
Vital signs Physical Exam Diagnostic testing/laboratory findings ASSESSMENT Primary Diagnosis Differential #1 Differential #2 PLAN Therapeutic modalities Additional laboratory or diagnostic tests if needed Health promotion and disease prevention Patient education Follow-up
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