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-=-=-=-=-=> 8 Case 8 scenario (sore throat) Doorway information about patient The patient is a 25 -year-old woman who comes to the clinic sue to a sore throat Vital signs . Temperature : 13.3’C (101F) . Blood pressure : 120/70 mmHg . Pulse : 90 /min . Respirations : 22/min Basic differential diagnosis . Viral pharyngitis . Bacterial pharyngitis - Group A streptococcal pharyngitis - Mycoplasma pneumonia - Neisseria gonorrhea . Epstein-Barr virus mononucleosis . Allergies rhinitis / postnasal drip . Chronic tonsillitis . Primary HIV ————— Case 8 cim. pt. instructions if the doctor sales you about anything other than these ,just say “no,” or provide an answer that a normal patient might give. you are a 25 -year-old woman who comes to the office with a sore throat History of present illness . Onset 3 days ago . Pain with swallowing food . Associated symptoms: - Headache - Body ache - Nasal congestion - Dry cough - Fever to 38.1’C(100.5F) . Symptoms partially relieved with Tylenol/acetaminophen . Boyfriend had similar symptoms 2 weeks ago but now better Review of system . No abdominal pain , pelvic pain , rash , chills , chest pain , or shortness of breath . Last menstrual period was 2 weeks ago Past medical / family/ social history . Frequent episodes of tonsillitis in childhood . 2 upper respiratory illnesses in the past 2 years . No pregnancies . No past surgeries . No current medications . No medication allergies . Parents and sister are healthy . Occupation : College student . Sexually active with boyfriend (condoms for birth control) . Smoking : No . Alcohol : No . Recreational drugs : No Physical examination Head and neck : . Oropharynx with tonsillar exudates . Tympanic membranes clear bilaterally . No sinus tenderness . No enlarged lymph nodes Chest/lungs: . Clear to auscultation bilaterally Heart : . Regular rhythm without murmurs, gallops , or rubs Abdomen ; . Non tender , non distended . Normative bowel sounds throughout . Tympanic to percussion . No hepatospenomegaly ————— Case 8 sim. pt. check list Following the encounter , check which of the following items were performed by the examinee History of present illness / review or system . Asked about the onset of sore throat . Asked about the course of symptoms over time . Asked about pain during swallowing . Asked about associated symptoms - Coughing and breathing problems - Nasal discharge/ congestion - Sinus pain and postnasal drip - Headache - Fever and chills - Nausea and vomiting - Joint pains and muscle aches - Swollen neck glands - Abdominal pain (especially left upper quadrant and pelvic pain) - Rash - Vaginal discharge . Asked about contacts with ill person Past medical /family/social history . Asked about similar episodes in the past . Asked about otters past medical issues . Asked about current medications . Asked about medication allergies . Asked about family health problems . Asked about occupation . Asked about tobacco , alcohol , and recreational drug use . Asked about sexual and reproductive history Examination . Washed hands before examination . Examined without gown , not though gown . Looked inside mouth . Palpated cervical lymph nodes . Examined both ears . Palpated spleen and liver . Palpated abdomen (superficial and deep) . Auscultated heart . Auscultated lungs . Examined skin for rash Counseling . Explained physical findings and possible diagnosis . explained further workup Communication skills and professional conduct . Knocked before entering the room . Introduced self and greeted you warmly . Used your name to address you . Paid attention to what you said and maintained good eye contact . Asked open-ended questions . Asked non;eating questions . Asked one question at a time . Listened to what you said without interrupting . Used plain English rather than technical jargon . Used appropriate transition sentences . Used appropriate draping techniques . Summarized the history and explained physical findings . Expressed empathy and gave appropriate reassurances . Asked whether you have any concerns/questions Differential diagnosis . Infectious mononucleosis . Viral pharyngitis . Bacterial (streptococcal) pharyngitis Diagnostic study/workup . CBC . Monospot test . Rapid streptococcal antigen test ————— Case 8 clinical summary Clinical Skills Evaluation Case 8 Patient Note The following represents a typical note for this patient encounter . the details amy 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). . 25-yo female with 3 days pop sore throat. . Initially , sore throat , sinus congestion , runny nose , fever , and dry cough . Sore throat has worsened with pain when swallowing. . Sick contact (boyfriend) had similar symptoms that resolved ROS : No chills , chest pain ,shortness of breath , nausea , vomiting m or abdominal pain PMHx : None PSHx : None Meds : None Allergies : None FHx : Noncontributory SHx : Denies tobacco and alcohol use Physical examination: 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 . Vital signs : Temperature , 38.3’C (101F); blood pressure , 120/70 mmHg; pulse , 90/min ; and respirations , 16/min . HEENT : Oropharynx with tonsillar exudates , TM clear bilaterally . Neck : no enlarged lymph nodes . Chest / lungs ; clear to auscultation bilaterally . Heart : RRR without M/R/G . Abdomen : non tender , non distended , normative bowel sounds thought ; tympanic to percussion ; no hepatosplenomegaly. Data interpretation : based on what you have learned form the history and physical examination, list up to 3 diagnosis that might explain this patient’s complaint(s) . List your diagnosis form most to least likely . for some cases , fewer than 3 diagnosis will be appropriate . then , enter the positive or negative findings form the history and the physical examination (if present) that support each diagnosis . Lastly , list initial diagnostic studies (if any) you would order for each listed diagnosis (e,g,, restricted physical exam maneuvers , laboratory tests , imaging , ECG , etc.). Diagnosis #1 : Bacterial pharyngitis History finding(s) . Sore throat . Fever Physical examination finding(s) . Fever . Tonsillar exudates Diagnosis #2 : Viral pharyngitis History finding(s) . Fever . Sore throat . Boyfriend with similar illness that resolved Physical examination finding(s) . Fever Diagnostic studies . Rapid strep test . Throat culture if rapid strep test is negative -=-=-=-=-=>
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