IHUMAN Case Study #5 Krista Hampton NURS 5308

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Instructions: Type patient encounter information directly into each box of the template similarly to your case studies. CC: 25 y/o F “I have this ugly looking rash on my upper thighs” HPI: Ms. ... Hampton is a 25 y/o female presenting with an itchy and tender rash bilaterally on her inner thighs, and her left inner forearm. The rash started about 36 hours ago after hiking in Napa with her boyfriend. She states she spent time hiking, tried a new sunscreen, tried new foods such as scallops and a new drink, as well as spending time in the hot tub with her boyfriend. She reports that her boyfriend does not have similar symptoms, and that she has not tried any treatments for the rash. PMHx: SurgHx Child: “usual coughs and tummy ache nothing remarkable.” Adult Illness: Denies Medical: None Surgical: None Obstetric: None Hospitalizations: None 2 FamHx SHx Maternal grandfather died of CVD at age 81. Grandmother (age 88) has prior heart attack, stent Tobacco: Denies and HTN. ETOH: Socially Mother alive and well. Illicit Drugs: Denies Father alive and well, treated for HTN. Occupation: English teacher for 7 th and 8 th grade Brothers - 35 and 32 both alive and well. Sister - 21 alive and well. 3 Relationship: Sexually active heterosexual female in a monogamous relationship Diet: Normal American Diet Reproductive Hx Age of menarche: “doesn’t remember.” Menstruation cycle duration: “seems fine to me,” regular periods Sexual hx and concerns: Denies concerns LMP: unknown Breast screening: Conducts self-breast exams Last Pap Smear: 1 year ago, with no signs of abnormalities Gravida para status/Childbirth hx: Nulliparous Allergies Ceclor (Cefaclor) second generation cephalosporin – Patient developed hives as child when taking this antibiotic for otitis media List of Current Medications/supplements: Birth control pill Supplements: None [Show More]

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