02 Jun Influenza Presentation Mike Taylor

Age: 27 Sex: Male Race/Ethnicity: Hispanic Marital Status: Married Occupation: Construction worker Insurance: Private Living Situation: Lives with wife, mother, and 4-year-old son

Chief Complaint (CC): Fever and body aches for three days.

Patient Statement

About three days ago I started feeling really run down, like I was coming down with something. The next day I developed a fever — I think it was around 102 — and I’ve had chills on and off since then. My whole body aches, especially my back and legs, and I have this pounding headache that won’t go away. I’ve also had a dry cough and a sore throat.

I did feel a little short of breath yesterday when I walked up the stairs, but I wasn’t sure if that was just because I was tired. I’ve also had some nausea and haven’t really felt like eating much. I haven’t had any vomiting or diarrhea.

A few people at work have been out sick with the flu. I didn’t get my flu shot this year because last time I got it, I felt sick afterward.

I’m mostly worried because I can’t afford to miss work, and my mom lives with us — she has diabetes — so I don’t want her getting sick.

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Using only the information provided in the initial patient presentation, complete a comprehensive adult health history as if you conducted the patient interview yourself. 

Expand the history as appropriate by identifying and documenting expected history findings. You may include your own version of history sections as you see fit. In other words, you can formulate your own health history of the patient as long as it is properly documented.

Your written submission must include the following sections: 

· Identifying Data 

· Chief Complaint (in patient’s own words) 

· History of Present Illness (fully developed provider-written narrative using OLDCART or OPQRST format) 

· Past Medical History 

· Surgical History 

· Current Medications (including OTC and supplements) 

· Allergies (including reactions) 

· Family History 

· Social History (including occupation, living situation, substance use) 

· Social Determinants of Health (employment stability, financial strain, housing, transportation, access to care, ability to isolate, vaccine hesitancy) 

· Vaccination History (including influenza and COVID status) 

· Focused Review of Systems 

Evidence-Based Practice Requirement 

Your documentation must incorporate a minimum of three evidence-based scholarly references published within the last five years (≤ 5 years old). Cite all sources in APA format.

References must support: 

· Clinical presentation and pathophysiology of influenza 

· Risk stratification and high-risk populations 

· Current influenza vaccination recommendations 

· Best practices in advanced health assessment documentation 

· Any portion of the “reflection” section

Acceptable Sources 

· Peer-reviewed scholarly journal articles 

· CDC clinical guidelines 

· IDSA clinical practice guidelines 

· WHO clinical guidance documents 

· Evidence-based advanced practice nursing resources 

Unacceptable Sources 

· Patient education websites (e.g., Mayo Clinic, Cleveland Clinic, WebMD, Healthline) 

· General health blogs 

· Wikipedia 

· Non–peer-reviewed commercial websites 

· This reflection is designed to strengthen clinical reasoning by evaluating your interviewing process and identifying opportunities to enhance assessment quality. 

· After completing your comprehensive health history, submit a 1-page reflection addressing the questions listed in the assignment template.  

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· Rubric

· NURS_6512_Module1_Assignment2_Rubric