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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?
EB presents with the chief complaint of fever, nausea, vomiting, cough and palpitations. The history of present illness provides a thorough description of the chief complaint and associated problems. It is important to ask questions pertaining to the symptoms that will help in gathering information that will lead to a possible diagnosis. Some essential health history questions to ask EB are:
Why are you seeking help today? I feel bad. I am feeling hot, weak, and sweaty, probably from throwing up.
When did your fever start? I don’t really know. I had the flu last week, felt like I was getting better, but then I just felt worse each subsequent day. Really feeling shaky.
How often do you have fever? I don’t know I just feel hot and sweaty.
Do you have a cough? Yes, it was left over from the flu or cold I had, but now is getting worse
Have you had any contact with other sick people? Yes, lots of kids here at college have been getting sick with the flu
Do you have unusual heart beats (palpitation)? Yeah! I feel this funny skip in my chest. It really scares me. I feel like I am falling apart.
Are you taking any over the counter drug? Yes, a multiple vitamin, calcium tab, and Claritin for spring allergies. Tylenol for the flu last week.
Do you have problem with nervousness, depression, lack of interest, sadness, memory loss or mood changes or ever hear voices that you know are not there? I just get anxious but I think that just because I feel so sick.
Have you gained or lost weight unintentionally and despite normal appetite and exercise? I’ve been and losing weight. I eat like crazy except these last 24 hours, but I keep losing weight. I probably need to eat better. Probably should use protein shakes. I do seem to be eating all the time.