Chief Complaint Fatigue Explained for Students (Easy Guide)
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Key Explanation
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Original Question
Chief Complaint: fatigue, shortness of breath with productive cough​ History of Present Illness: Alfonso Smith (pronouns he/him/his), a 74-year-old male, presents with complaints of fatigue, dyspnea, and a cough with yellowish-red tinged sputum. He was diagnosed with a viral upper respiratory tract infection 2 days ago and states, “I am getting worse.” Up to date with influenza and COVID vaccinations. Negative influenza and COVID tests.​ Medications: Multivitamin, ferrous sulfate, calcium carbonate, metformin, Lipitor​ Past Medical History: type 2 diabetes mellitus, anemia, hypercholesteremia, COPD ​ Review of Systems:​ General: Clean, well-groomed appearance​ Neurological: Alert and oriented to person, place, time, and situation (A&O x 4)​ Cardiovascular: Tachycardic. S1 and S2 are present, and the capillary refill is less than 3 seconds Respiratory: Respirations shallow and rapid at rest; Inspiratory crackles​ Gastrointestinal: Reports regular, daily bowel movements. Denies abdominal pain​ Genitourinary: Denies any GI symptoms​ Musculoskeletal: Denies any pain. Ambulates unassisted Integumentary: Skin pink, warm, and dry Allergies: None reported​ Social History: Retired; lives with spouse​ Family History: No significant family history was reported​ Vital Signs: Temperature: 101.4 °F (38.6 °C); Heart rate: 102 bpm; Respiratory rate: 32 breaths per minute; Blood pressure: 136/76 mmHg; Pulse oximetry: 95% on room air For each potential order listed, specify if the action is indicated, nonessential, or contraindicated. Each order will have only one descriptor. Intravenous (IV) 0.9% normal saline (NS) infusion at 200 mL/hour Oxygen 2L-4L NC, keep SpO2 above 95% CBC with differential lab test Blood cultures x 2 Chest radiograph Consult surgery for lung biopsy Ambulate to restroom every shift Continuous cardiac monitoring with pulse oximetry Consult respiratory therapy for incentive spirometer use
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