NR 602 Week 5 iHuman Case 3 - Laina Nunez (LN)

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Term	Year 2022
Institution	NR 602 Primary Care of the Childbearing and Childrearing Family
Contributor	Racheal Ofori

Description

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LN is a 16 yo. female who presents to the clinic with a 3 week hx of dry cough and dyspnea, chest tightness, nasal congestion. Upon physical exam she is afebrile, has tachynpea and 02 sats of 94% RA. Decreased breath sounds and bilat. wheezes. Denies any tobacco use or illicit drug use. PMH hx of eczema, recent hx of URI, exposed to secondhand smoke with her father.

Eczema history in the past, exposed to secondhand smoke

Normal birth, full term. No medical problems, no major accidents or injuries. No surgeries. Father has eczema, otherwise healthy

Mother has no medical problems NO other significant family history

Currently is an only child, she lives in an apartment with her father. He had lost his job and works odd jobs since to pay the bills. Apartment has cockroaches and the neighbors smoke so she is constantly smelling smoke.

She denies any past or present use of alcohol, tobacco, or illicit drugs. She has never been sexually active. She denies any suicidal ideations.

ROS:

Constitutional:

No rashes, no bruising, no petechiae

No runny nose, no congestion. No eye or ear discharge, no conjunctivitis. No recent head trauma. No history of murmur, no history of fainting or excessive sweating

Cough x 3 weeks, increasing difficulty breathing, no wheezing No vomiting, no diarrhea, no constipation, no melena

No history of UTIs in the past, no dysuria No recent trauma, no weakness, no limping No history of seizures

Up to date for all immunizations

No history of diabetes, adrenal, or thyroid dysfunction No history of anemia

No suicidal ideations, some stress with the financial situation with her family and living situation.

98.6, 150 pounds, Respirations 26 and labored, 112/84, expiratory wheezes

PE:

General: Audible wheezing respirations heard with a frequent cough. Skin: Skin warm and moist, pink.

HEENT: Normocephalic head, trachea midline

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Past Medical History

PMH: Eczema. She has been moisturizing her skin daily and it has not been a problem for her lately. Hospitalizations/Surgeries: Normal birth. Full term. No medical problems. No major accidents or injuries. No surgeries. Preventive Health: Up to date on all immunizations. Last check up 3 years ago.

Medications: None

Allergies: No known allergies

Social History: She denies past or present use of alcohol, tobacco, or illicit drugs. Her father lost his stable job recently and has been working odd jobs since then to pay the bills. She had to move to an older building and it has cockroaches in it. She is exposed to 2nd hand smoke from the neighbors in her current building

Family History: Father - has eczema, otherwise healthy. Mother - no medical problems. No other significant family history