IHuman Case Study Christine Smith Assignment

Apply information from the iHuman Case Study to answer the following questions:

  • 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?
  • What components of the physical exam are important to review in this case? What are pertinent positive and negative physical exam findings to help you formulate your diagnosis?
  • Which differential diagnosis is to be considered with this case study? What was your final diagnosis?

Name: Christine Smith

Age: 33 years

Sex: F

Height: 5′ 6″

Weight: 130 pounds (BMI 21.0)

Temperature: 101.0 F (oral)

Pulse: 114 bpm – regular

Blood pressure: 120/60 mmHg

Respiratory rate: 14 bpm

SpO2: 98% on room air

I’ve been having a whole lot of pain on the upper side near my back. That’s called the flank, right?

The pain started out mild when I first woke up. After breakfast that morning I started feeling sick to my stomach, and then the pain got severe by the afternoon.

Pain is at Right here (points a few inches below the 12th rib on the right side).

Last couple days pain has been an 8.

Pain has been constant since it started….and getting worse.

Yes, nausea, and I’ve vomited three or four times…kind of lost track, and my appetite’s off. Oh, and I’ve been running a fever.

Oh, it’s localized, for sure. Right up here (points to flank). That’s called the flank, right?

Feeling overall lousy.

An infection? Maybe causing the symptom

Fever started Yesterday morning.

It started yesterday morning, a day after the pain and the nausea and vomiting started.

Acetaminophen helps.

It was up to 101 yesterday afternoon — that was the highest.

Not really — I can sleep in stretches

I have had a fever with colds sometimes.

Fever has been constant, but acetaminophen helps temporarily.

Yeah, I’m really worried about this pain I’m having.

What I ate last: Just a little dry toast this morning. For the most part, I’ve been eating nothing more than jello these last two days.

Toast in the morning, jello for lunch and dinner. I tried some soup but that didn’t go very well.

Water and juice this morning. Ginger ale, and jello are the only fluids I’ve had over the last two days.

Last Period – Two weeks ago I finished the last of the pack and had a normal amount of bleeding.

No, my bleeding is very regular and predictable on the Pill.

She has aching pain in the mid-circle.

I have not had a period since the pain started. Anyway, my pain isn’t in my lower abdomen.

It’s been difficult sleeping with the pain, but it’s fine once I get to sleep.

I’ve never had anything like this before.

I had some lower abdominal pain when I had urinary tract infections, but this pain is higher up and more severe. It’s really in my flank area.

No, doesn’t matter if I lie still, change position, or move around. Still hurts.

I have had three bladder infections. The first was about two years ago. I had another maybe eight months ago, and the last one was about two months ago.

I go to the dentist twice a year, so I don’t have problems there. I haven’t had any surgeries.

Hospitalized Just after my deliveries.

Just after my deliveries

Childhood illness The usual coughs, colds and tummy aches. Nothing remarkable.

Taking birth control pills — Ortho Tri-Cyclen 28. That’s all. The Pill prescribed by my PCP. I’ve been doing that since my last child was born.

Antibiotics I took for the urinary tract infection I had a couple months ago.

I took some for the urinary tract infection I had a couple months ago.

Yes, one beer or one glass of wine a week.

Yes, I have a husband and three children.

Yes. My youngest is 5.

Toast in the morning, jello for lunch and dinner. I tried some soup but that didn’t go very well.