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-=-=-=-=-=> 12 Case 12 scenario (child fever) Doorway information about patient You will be speaking with the mother of a 1-year-old with fever Basic differential diagnosis . Respiratory tract infection . Ear infection . Exanthematous disease . Meningitis . Urinary tract infection . Gastroenteritis ————— Case 12 sim.pt. instruction This is a telephone encounter with the doctor , who is asking you questions on the phone input the child . If the doctor asks you about anything other than these , Just say “no,” or provide an answer that a normal patient might give. You are a 28-year-old woman who calls for evaluation of fever in your 1-year-old child History of present illness . Onset of fever 2 days ago . Fever to 38.9’C (102F) . Associated symptoms include dry cough , picking at the right ear , and vomiting ingested food without diarrhea . Had 1 episode of rhythmic jerking in both arms , with loss of urine ; afterward was silent and irritable for few minutes an then slept . Dose met appear drowsy or lethargic but has not been feeling well . Acetaminophen decreases the fever to 37.2’C (99F) transiently ; tepid sponge bathes also provide some relief . 3 year old sibling has no symptoms . No recent travel Review of systems . No rash . Passing normal yellow urine but cries while urinating Past medical history . No prior medical conditions , surgeries , or hospitalizations . Full-term delivery without complications . Breastfed until 2 months old , then changed to formula . Able to stand , hold objects in the hand , and say “Mama” and “ Dada” . Childhood vaccinations are up to date . At 9-month well-child visit , was at 75 percentile for height and 60 percentile for weight . Chile lives at home with mother , father , and 3-year-old sibling . Medications : Acetaminophen , liquid as needed . Allergies : None . Parents and siblings are all healthy ————— Case 12 sim. pt. checklist Following the encounter , check which of the following items were performed by the examinee History of present illness/ review of systems . Asked about the onset and severity of fever . Asked whether the fever is continuous or intermittent with spontaneous return to baseline . Asked whether the fever responds to any medications . Asked about associated symptoms , including: - Cough - Ear discharge - Nasal congestion / discharge - Pain - vomiting and diarrhea / bowel symptoms - Urinary symptoms - Rash . Asked about association with seizures (and further details including description , onset , associated incontinence or urine / bowel) . Asked about what happened after seizure : whether the child was irritable and if any body part was paralyzed . Asked about any exposure to infected individuals and history of travel Past medical /family/social history . Asked about similar episodes i the past . Asked about current medications and allergies . Asked about past medical issues (ear infections , convulsions, urinary tract infections),surgeries , and hospitalizations . Asked about motor and social development . Asked about prenatal and perinatal history . Asked about feeling habits . Asked about family health (especially seizures) Counseling . Explained the possible diagnosis . Explained further workup . Advised to give fluid and antipyretic . Discussed the need for a clinic visit for examination and testing Communication skills and professional conduct . introduced self and greeted you warmly . Used your name to address you . Paid attention to what you said and maintained good eye contact . Asked opened questions . Asked non-leading questions . Asked one question at a time . Listened to what you said without interrupting me . Used plain English rather than technical jargon . Used appropriate transition sentences . Expressed empathy and gave appropriate reassurances . Asked whether you have any concerns/questions Differential diagnosis . Febrile seizures . Meningitis . Acute otitis media . Urinary tract infection Diagnostic study/studies . CBC with differential count and erythrocyte sedimentation rate . Urinalysis . Lumber puncture ————— Case 12 clinical summary Clinical Skills Evaluation Case 12 Patient Note The following represents a typical note for this patient encounter . the detail may vary depending on the information given by the simulated patient. History : Describe the history you just obtained form this patient . Include only information (Pertinent positives and negatives) relevant to this patient’s problem(s). . Telephone encounter with motor of 1-yo child with 2 days of fever to 38.9’C (102F),cough , and pulling at the right ear . 2 episodes of vomiting but no diarrhea. . 1 episodes of vomiting but no diarrhea. . Crying when passing yellow urine . No lethargy . No previous infections or hospitalizations . No sick contacts; sibling has no symptoms . Birth history remarkable, normal developmental milestones. . Immunizations up to date. ROS : No recent travel or rashes PMHx : None PSHx : None Meds : Acetaminophen Allergies : None FHx : Parents and sibling are healthy Physical examinations : Describe any positive and negative findings relevant to this patient’s problem(s) . be careful to include only those parts of the examination performed in this encounter. . Not done as this is a telephone encounter Data interpretation : Based on what you have learned from the history and physical examination, list up to 3 diagnosis that might explain this patient’s complaint(s) . List your diagnoses from most to least likely . For some cases , fewer than 3 diagnosis will be appropriate . the , enter the positive and negative findings form the history and the physical examination (if present) that support each diagnosis . Finally , list initial diagnostic (if any) you would order for each listed diagnosis (eg,restricted physical examination maneuvers, laboratory tests , imaging ECG , etc). Diagnosis #1 : Acute otitis media History finding(s) . Fever . Pulling at right ear Physical examination finding(s) . None Diagnosis #2 : Urinary tract infection History finding(s) . Fever . Pain with urination Physical examination finding(s) . None Diagnosis #3 : Febrile seizure History finding(s) . Fever . Rhythmic tremor with fever that subside . Shaking movements while passing urine Physical examination finding(s) . None Diagnostic studies . Office visit for ear examination . Urinalysis . CBC with differential -=-=-=-=-=>
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