Concept notebook

Patient education

Identify the medical diagnosis or key problem for which the patient is seeking care.

You can choose to enter pathophysiologic information related to the medical diagnosis. (This is optional.)

You can choose to enter up to four risk factors related to the medical diagnosis. (This is optional.)

Karen James is a 57-year-old female who was admitted to the medical-surgical unit from her primary care physician’s office for treatment and evaluation of persistent and worsening influenza. She has a past medical history of asthma as well as depression and anxiety.

Ms. James has had influenza symptoms for three weeks that have worsened in the past three days. She is currently experiencing a fever and chills, pleuritic chest pain, a productive cough with green sputum, and fatigue. Ms. James has been on a Zithromax Z-pack for the past five days without any improvement in symptoms. Her primary cause for admission at this time is her shortness of breath and severe coughing episodes, which turn into brochospasms.