COMPREHESIVE CAMILLA FRANKLIN IHUMAN CASE 48 YEARS OLD REASON FOR ENCOUNTER FATIGUE AND IRRITABILITY LATEST CASE REVIEW

COMPREHESIVE CAMILLA FRANKLIN IHUMAN CASE 48 YEARS OLD REASON FOR ENCOUNTER FATIGUE AND IRRITABILITY LATEST CASE REVIEW
History Questions for Camilla Franklin
Chief complaint
1.What brings you in today?
2.How long have you been experiencing these symptoms?
History of present Illness (HA):
1. When did your symptoms start?
2. Can you describe your symptoms?
3. Have you had any fever or chills?
4. Are you experiencing any 5hortne55 ot breath?
5. Do you feel fatigued?
Step 1: Comprehensive History Taking
1.1 Chief Complaint
• Document the primary concern: irritability.
1.2 History of Present Illness
• Onset: When did the irritability start?
• Duration: How long has she been experiencing irritability?
Frequency: Is the irritability constant or intermittent?
• Severity: How severe is the irritability?
• Associated Symptoms: Ask about other symptoms such as fatigue,
sleep disturbances, weight changes, mood swings, or other emotional
symptoms.
Step 1: History Taking
Chief Complaint (CC)
Definition: The main reason the patient has sought medical attention, stated in their
own words.
Example: "l've been feeling really tired and irritable."
History of Present Illness (HPI)
Definition: Detailed description of the patient's current symptoms and their
progression.
Key Aspects: Onset, duration, location, characteristics, aggravating and alleviating
factors, and associated symptoms.
Example:
HPI Questions and Answers:
1. Q: When did your symptoms start?
A: Approximately 2 months ago.
2. Q: How often do you feel tired and irritable?
A: It's persistent and happens every day.
3. Q: Can you describe your fatigue?
A: It's overwhelming and constant.
Physical Examination:
General: Appears fatigued, mild distress
Cardiovascular: Sl and S2 present, no murmurs, jugular venous
distention (JVD) observed
Respiratory: Bilateral crackles in the lower lung fields
Abdomen: Soft, non-tender, no hepatosplenomegaly
Extremities: 2+ pitting edema in both lower extremities
Diagnosis
Based on the symptoms and initial assessment, the following differential
diagnoses are considered:
1. Congestive Heart Failure (CHF)
2. Chronic Obstructive Pulmonary Disease (COPD) exacerbation
3. Renal Failure
To confirm the diagnosis, the following diagnostic tests are ordered:
• Electrocardiogram (ECG): To check for any cardiac abnormalities.
Chest X-ray: To look for signs of heart enlargement and fluid
accumulation in the lungs.
Echocardiogram: To assess heart function and structure.
Blood Tests:
• Complete Blood Count (CBC)
Basic Metabolic Panel (BMP)
• B-type Natriuretic Peptide (BNP) level
• Kidney Function Tests (Creatinine, Blood Urea Nitrogen)
6. Are you having any chest pain? If yes, is it sharp, and does it get worse with
deep breaths?
7. Have you noticed a cough? Is it productive? What color is the sputum?

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