Med Surg Case Study #30: Jill Yesmin

Jill Yesmin | 28 years old

Chief Complaint: Jill complains of fatigue, shortness of breath, and chest discomfort for the past week.

Medical History:

• Previously healthy, no chronic illnesses.

• Recent upper respiratory infection two weeks ago.

• No known drug allergies.

• Immunizations up to date.

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Nurse's Note: Jill Yesmin presented to the ER with complaints of fatigue, shortness of breath, and chest pain. Reports chest pain as sharp, worsening with deep breaths. Patient appears tired and slightly anxious. Denies cough or hemoptysis, no recent travel or exposure to sick contacts.

Vital Signs:

• Blood pressure: 130/85 mmHg

• Heart rate: 110 bpm

• Respiratory rate: 22 breaths/min

• Temperature: 100.0°F (37.8°C)

• SpO2: 92% on room air

Provider Orders:

• Administer oxygen at 2 L/min via nasal cannula.

• Obtain a chest X-ray.

• Draw blood for CBC, CMP, CRP, and cardiac enzymes (Troponin I, CK-MB).

• Perform ECG.

• Start IV fluids (Normal Saline) at 75 mL/hr.

• Administer acetaminophen 650 mg PO for pain.

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