Case study 1
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School
Barry University *
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Course
623
Subject
Medicine
Date
Dec 6, 2023
Type
docx
Pages
2
Uploaded by SargentMink1678
Case study #1:
Mr. Smith, 32 year-old male, no significant medical history
Chief complaint:
Fever, sore throat, cough, and conjunctivitis
History of present illness:
Mr. Smith presents to the emergency department with a 5-day history
of fever, throat sore, cough, and conjunctivitis. He reports a sudden onset of symptoms with a
fever of 101
F (38.3
C), sore throat, dry cough, and redness in both eyes. He has also
⁰
⁰
experienced a headache, muscle aches, and fatigue. He denies any recent travel of sick contacts.
He has tried over-the-counter cough and cold medications without significant relief.
Past medical history:
Mr. Smith has no significant medical history. He does not have any
known allergies and has not had any recent surgeries.
Social history:
Mr. Smith is a non-smoker and does not consume alcohol. He works as an
accountant and has no significant exposure to chemicals or toxins. He lives with his wife and two
children and denies any recent sick contacts.
Physical examination:
Vital signs:
Temperature 100.8
F (38.2
C)
⁰
⁰
Heart rate: 90 beats/min
Blood pressure: 120/80 mm/Hg
Oxygen saturation: 98% on room air
General:
Mr. Smith appears mildly fatigued but is alert and oriented. He is not in acute distress.
Head, eyes, ears, nose, and throat:
Conjunctival injection (redness) in both eyes. Pharynx is
erythematous (red) with mild tonsillar enlargement. No exudate or tonsillar abscess noted. No
cervical lymphadenopathy (swollen lymph nodes).
Respiratory:
Clear breath sounds bilaterally. No wheezes or crackles.
Cardiovascular:
Regular rate and rhythm. No murmurs, rubs, or gallops.
Gastrointestinal:
Abdomen soft and non-tender. No hepatosplenomegaly (enlarged liver or
spleen).
Skin:
No rash or lesions noted.
Neurological:
Cranial nerves are intact. No focal neurological deficits.
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