Source Of Information Mother And Patient - 2081 Words

Hope A. Taitt SID# 201205672 Write Up #2 Source of Information: Mother and Patient; both reliable sources Chief Complaint: 16 year old female with past medical history of intermittent asthma presenting with malaise and back pain for two days and on the day of admission cough with dark yellow sputum. History of Present Illness/Interval History: The patient initially presented to the Emergency Department on Monday after developing severe lower back and leg pain accompanied by fatigue. The patient had attended and participated in her aunt’s wedding on Sunday evening and had spent a good portion of the evening dancing and helping out with the wedding. The patient took ibuprofen (200mg) twice without relief. On Monday, after being in too much pain to attend school, the patient presented to the ED. After doing x-rays of the lumbar spine, sacroiliac joints and sacrum which showed no abnormalities and ruling out a neurological cause for her pain, she was discharged with ibuprofen treatment for lower back pain secondary to strenuous exercise. The next day, (which is the day of admission) the patient had developed a cough which produced a dark yellow sputum and continued to have lower back pain. This prompted the mother to bring her back to the emergency department for further eval uation. On presentation back to the ED, she described the pain as being the same as the day before, rated an 8/10 in severity, non-radiating and constant. She could not describe the quality of the painShow MoreRelatedThe Womans Hospital of Texas Essay1663 Words   |  7 Pagesranking of #40 in Texas, recognized in Gulf Coast and ranked #13 in Houston metro area. 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