IHuman Case Study of A 15 Years Old Male Patient Reason for Encounter Shortness of Breath
COMPREHENSIVE IHUMAN CASE STUDY OF A 15 YEARS OLD MALE PATIENT REASON FOR ENCOUNTER SHORTNESS OF BREATH
WALDEN UNIVERSITY SOURCED CASE STUDY
HISTORY OF PRESENT ILLNESS (HPI)
Reason for Encounter:
A 15-year old male, presents with a four-day history of
sudden-onset Fatigue and Irritability, shortness of breath, fatigue, pleuritic chest pain, and a productive cough without wheezing.
History of Present Illness:
Onset: Symptoms began four days ago, following the resolution of a recent flu episode. Duration: Symptoms have persisted and worsened over the past four days.
Location: Symptoms are primarily centered in the chest and respiratory system. Characteristics:
• Aggravating Factors: Deep breaths exacerbate the pleuritic chest pain, and physical activity
increases shortness of breath and fatigue.
• Relieving Factors: Rest somewhat alleviates fatigue.
• Associated Symptoms: No wheezing reported, no recent asthma attacks despite a history
of childhood asthma, and tender anterior cervical lymphadenopathy.
• Previous Illness: Recently had the flu, which resolved before the onset of the current symptoms.
Review of Systems (ROS)
General:
Reports fever and chills.
Experiences significant fatigue.
No recent weight loss or changes in appetite. HEENT/Neck:
Neck: Tender anterior cervical lymphadenopathy noted.
Cardiovascular:
No chest pain unrelated to breathing.
No palpitations or syncope.
No known heart murmurs or history of heart disease.
Gastrointestinal:
Normal appetite, no nausea or vomiting.
No abdominal pain, diarrhea, or constipation. Genitourinary:
No dysuria, frequency, or hematuria.
No history of urinary tract infections or other genitourinary issues. Musculoskeletal/Osteopathic Structural
Examination:
No joint pain or swelling other than the respiratory-related symptoms.
No musclepainor weakness.
Neurologic:
No focal neurological deficits.
No headaches, dizziness, or changes in mental status. Integumentary/Breast:
No rashes or skin lesions.
No breast lumps or changes.
Psychiatric:
No anxiety, depression, or other psychiatric symptoms.
Normal mood and a ect.
Endocrine:
No history of thyroid issues.
No polyuria, polydipsia, or heat/cold intolerance. Hematologic/Lymphatic:
No easy bruising or bleeding.
Tender anterior cervical lymphadenopathy noted.
No history of anemia or other hematologic conditions. Allergic/Immunologic:
No known allergies.
No recent immunosuppressive conditions or treatments.
Childhood history of asthma, currently o therapy without recent attacks.
Past Medical History
Past Medical History:
Asthma: Diagnosed in childhood, currently o therapy, no recent attacks.
Recent Illness: Recent history of the flu which resolved before the onset of the current symptoms.
Hospitalizations/Surgeries:
Hospitalizations: None reported. Surgeries: None reported.
Preventive Health:
Vaccinations: Up-to-date, including annual flu vaccination.
Screenings: No significant preventive health screenings reported, given the patient's age.
Medications:
Current Medications: None reported.
Previous Medications: Used asthma medications during childhood, currently not on any therapy.
Allergies:
Drug Allergies: None reported.
Food Allergies: None reported.
Environmental Allergies: None reported.
Social History
Smoking:
Status: Denies smoking.
History: No previous history of smoking.
Alcohol:
Consumption: Occasional alcohol use.
Details: No specific quantity or frequency provided. Recreational
Drug Use: