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    Anjani Ayuningtyas KD NIM: 18.1422.S (4B)

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    dilan milea
    The nurse took a clinical history of a 30-year-old patient named Paul Collins who presented with a cough and sore throat for the past 3-4 days. The patient reported worse coughing in the morning and a constant sore throat. On examination, the patient had green phlegm but no blood, fever, breathing issues, or weight loss. The patient's only medical history was high blood pressure and medication for diabetes. The nurse summarized the patient's symptoms and confirmed there was nothing else to add before proceeding with the appointment.

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    Anjani Ayuningtyas KD NIM: 18.1422.S (4B)

    Uploaded by

    dilan milea
    54 views4 pages
    The nurse took a clinical history of a 30-year-old patient named Paul Collins who presented with a cough and sore throat for the past 3-4 days. The patient reported worse coughing in the morning and a constant sore throat. On examination, the patient had green phlegm but no blood, fever, breathing issues, or weight loss. The patient's only medical history was high blood pressure and medication for diabetes. The nurse summarized the patient's symptoms and confirmed there was nothing else to add before proceeding with the appointment.

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    Clinical history

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    The nurse took a clinical history of a 30-year-old patient named Paul Collins who presented with a cough and sore throat for the past 3-4 days. The patient reported worse coughing in the morning and a constant sore throat. On examination, the patient had green phlegm but no blood, fever, breathing issues, or weight loss. The patient's only medical history was high blood pressure and medication for diabetes. The nurse summarized the patient's symptoms and confirmed there was nothing else to add before proceeding with the appointment.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    54 views4 pages

    Anjani Ayuningtyas KD NIM: 18.1422.S (4B)

    Uploaded by

    dilan milea
    The nurse took a clinical history of a 30-year-old patient named Paul Collins who presented with a cough and sore throat for the past 3-4 days. The patient reported worse coughing in the morning and a constant sore throat. On examination, the patient had green phlegm but no blood, fever, breathing issues, or weight loss. The patient's only medical history was high blood pressure and medication for diabetes. The nurse summarized the patient's symptoms and confirmed there was nothing else to add before proceeding with the appointment.

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    Anjani Ayuningtyas KD

    NIM: 18.1422.S (4B)

    CLINICAL HISTORY TAKING

    Nurse: My name is Anjani Ayu and I'm a nurse practitioner and you are?

    Patient : Paul Collins.

    Nurse: Before we start it I just wanted to confirm your details. So it's Mr. Collins,
    and you are 30 years old, and is this your address?

    Patient : Ya that's right, that's perfect.

    Nurse : Great, okay.

    Nurse: So, how can I help you today?

    Patient : Well I've had a cough for a few days and it's just driving me nuts really.

    Nurse : Right, how long has the cough been therefore?

    Patient : I suppose about three or four days.

    Nurse : Do you got any other symptoms with that cough?

    Patient : I've got a sore throat and that's quite bad as well.

    Nurse : Right, and the sore throat has it been there the same amount of time?

    Patient : Ya, both have the same time.

    Nurse : Okay, is it worst any particular time for the day or night?

    Patient: Well coughs are probably the worst first thing in the morning I noticed. It
    killing when I get up, sore throats there all the time really.

    Nurse: Are you able to swallow with that sore throat?


    Patient: Yes.

    Nurse : Ah okay, you can drink. What color is the muck that you're coughing up?

    Patient : It’s green really.

    Nurse: Okay, is that any blood in it?

    Patient: No.

    Nurse: Is there any area in your throat or anywhere your chest that’s painfull?

    Patiet : Well, main in my throat and neck I saw when I cough, after that, no they're
    just the sore throat.

    Nurse : Okay, does it travel anywhere else the sore throat of a radiation of pain?

    Patient : No, just that.

    Nurse : Okay, I just want to ask you more specific questions now, you said there's no
    blood in the phlegm, but is there any fever and you feeling sufery?

    Patient : first day I was little bit shaking like that but now not.

    Nurse : Okay, and what about breathlessness, so you've got any breathing problem or
    chest tightness?

    Patient : No, nothing at all.

    Nurse: Ah, okay. Have you had any unexplained weight loss at all?

    Patient : No.

    Nurse : Any recent travel abroad?

    Patient : No, it's been about a months ago.

    Nurse : Okay, I just want to go through some of your key sort of body system, just
    define about your overall health and can you tell me about, have you doing
    suffer with headaches?

    Patient : Sometimes I get headache.


    Nurse : How often do you get headache?

    Patient : Once the three months something like that.

    Nurse : And have you seen your doctor for that?

    Patient : No, I just take some painkillers and they're go away.

    MEDICAL HISTORY – PATIENT AND FAMILY

    Nurse : Im just going to list off just to probe your mind a bit in terms of medical
    history. Have you or any of your first-degree relatives of mom dad siblings
    ever suffered with any jaundice where you seen yourself go yellow?

    Patient : No.

    Patient : Any anemia at all?

    Patient : Nah.

    Patient : Good okay, have you ever had a heart attack or any member of your family?

    Patient : No.

    Nurse : Okay, what about TB? Anybody would TB or you’ve been..

    Patient : No.

    Patient : Good, any thyroid problems?

    Patient : No .

    Nurse : Okay, any traumatic fever? or rheumatoid arthritis?

    Patient : No.

    Nurse : Any heart problems?

    Patient : No.

    Nurse : Any high blood plessure?

    Patient : Yeah. I got high blood plessure.


    MEDICINES

    Nurse : Do you take any prescribed medicines?

    Patient : Um, I take metformin.

    Nurse : Okay, and no side effect with that?

    Patient : I do have an awful cough to start with but that't stop it.

    Nurse : It settled, okay.

    Nurse : Okay I just want to sum up Mr. Collins. You've had this coughing sore throat
    for the last three days and its sort of nothing makes it really better or do you
    have taken do paracetamol that’s helped a little bit, you've not had any blood
    in that phlegm, no fever, no unexplained weight loss, and you just really
    want us to short out your sore throat and cough.

    Patient : Yes please.

    Nurse : Okay is there anything else you want to add to that before we move on ?

    Patient : No.

    Nurse : Good, thank you.

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