ASSESSMENT: After medical examinations and culture testing, symptoms were attributed to glandular fever ( Dx: mononucleosis). PLAN: MS will use pain relievers such as ibuprofen as indicated on the box, not exceeding 3,200 mg per day to make sure pain is WNL . Then, she will have adequate rest, gargle salt water for throat, and avoid strenuous activity until symptoms are gone. This is a virus so antibiotics cannot treat it. Date: 11/1/19 Time: 12:00 pm Signature(s): Julianne Williams
MEDICAL DOCUMENTATION 3 PART II- Narrative Assignment Patient Information PATIENT INITIALS: MS PATIENT AGE: 23 SEX : F OCCUPATION: Graduate student and Community Health Officer RISK FACTORS : Does not take any tobacco nor drink alcohol ( LC 11/1/14 1:05 PM) but she drinks occasionally with family. ALLERGIES: NKA CHIEF COMPLAINT: High fever, N/V/D , sore throat, fatigue, H/A , muscle and joint pains. HISTORY OF PRESENT ILLNESS: Hispanic female was reported to boss after coworkers noticed her symptoms. After talking and the employer believing she may be pregnant after feeling nauseous/throwing up, she was sent home. Patient’s fever continued to rise through the night with addition to severe headaches,
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- Fall '19
- Codeine, Julianne Williams