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1 marvin webster case studyMarvin Webster
History
How can I help you today?
Do you have any other symptoms or concerns we should discuss?
Do you have any allergies, such as medications, food and/or latex, for example?
Are you taking any prescription medications?
Are you taking any over-the-counter or herbal medications?
Can you tell me about any current or past medical problems you have had?
Any previous medical, surgical, or dental procedures?
Do you now or have you ever smoked or chewed tobacco?
Have you had any contact with other sick people?
Are you sexually active?
Do you experience: chest pain discomfort or pressure; pain/pressure/dizziness with exertion or
getting angry; palpitation; decreased exercise tolerance; blue/cold fingers or toes?
Do you have any of the following: dizziness, fainting, spinning room, seizures, weakness,
numbness, tingling, tremor?
Do you have any of the following problems: fatigue, difficulty sleeping, unintentional weight loss
or gain, fevers, night sweats?
How high was your fever?
When you urinate, have you noticed: pain, burning, blood, difficulty starting or stopping,
dribbling, incontinence, urgency during day or night or any changes in frequency?
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How severe (1-10) is the pain in your chest?
Do you have any pain in your chest?
Have you noticed: any bruising, bleeding gums, nose bleeds or other sites of increased
bleeding?
Do you have any of the following: heat or cold intolerance, increased thirst, increased sweating,
frequent urination, change in appetite?
Do you have any problems with: nervousness, depression, lack of interest, sadness, memory
loss, or mood changes, or ever hear voices or see things that you know are not there?
Do you awaken at night coughing?
What treatments have you had for your cough?
What are the events surrounding the start of your cough?
Is there any pattern to your cough?
Does anything make your cough better or worse?
Do you have HIV?
Do you drink alcohol? If so, what do you drink and how many drinks per day?
Have you had a cough like this before?
Do you have problems with: nausea, vomiting, constipation, diarrhea, coffee grounds in your
vomit, dark tarry stool, bright red blood in your bowel movements, early satiety,
bloating?
Do you use recreational drugs? If so, what?
Do you have problems with: muscle or joint pain, redness, swelling, muscle cramps, joint
stiffness, joint swelling or redness, back pain, neck or shoulder pain, hip pain?
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Are you coughing up any sputum?
When did your cough start?
Do you have any problems with: headaches that don’t go away with aspirin or Tylenol
(acetaminophen), double or blurred vision, difficulty with night vision, problems hearing,
ear pain, sinus problems, chronic sore throats, difficulty swallowing?
Have you ever been hospitalized?
What is your name?
Do you have pain anywhere? If so, where?
Physical Exams
Temperature
Skin, hair, nails: inspect skin overall
Chest wall and lungs: auscultate lungs
Heart: auscultate heart
Abdomen: visual inspection abdomen
Extremities: visual inspection extremities
Musculoskeletal: inspect for muscle bulk and tone
Vitals: pulse
Chest wall and lungs: auscultate lungs
Vitals: respiration
Vitals: pulse
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