Advanced Physical Assessment - RF Human Report

PerformanceOverviewoncaseRebeccaFields Thefollowingtablesummarizesyourperformanceoneachsectionofthecase,whetheryoucompleted thatsectionornot. Status:Submitted CaseSection Status TotalScore Your Score Timespent PerformanceDetails 95% History Done 100% 53min 30sec 43questionsasked,22correct,0missedrelativetothecase'slist Physicalexams Done 88% 1hr4min 0sec 61examsperformed,13correct,1partiallycorrect,0missedrelativeto thecase'slist Keyfindings organization Done 26sec 6findingslisted;7listedbythecase Problem statement Done 2min23sec 89wordslong;thecase'swas57words Diagnosis Done Management plan Done Exercises Done 100% 100% (of scored items only) 13min8sec 25min 53sec 265wordslong;thecase'swas219words 7min59sec 1of1correct(ofscoreditemsonly) HistoryNotecardoncaseRebeccaFields Usethisworksheettoorganizeyourthoughtsbeforedevelopingadifferentialdiagnosislist. 1. Indicatekeysymptoms(Sx)youhaveidentifiedfromthehistory.Startwiththepatient'sreason(s)fortheencounter andaddadditionalsymptomsobtainedfromfurtherquestioning. 2. Characterizetheattributesofeachsymptomusing"OLDCARTS".Capturethedetailsintheappropriatecolumnand row. 3. Reviewyourfindingsandconsiderpossiblediagnosesthatmaycorrelatewiththesesymptoms.(Remembertoconsider thepatient'sageandriskfactors.)Useyourideastohelpguideyourphysicalexaminationinthenextsectionofthe case. HPI Sx= Sx= Sx= Sx= Sx= Sx= Onset       Location       Duration       Characteristics       Aggravating       Relieving       Timing/ Treatments       Severity       ProblemStatementoncaseRebeccaFields RFisa23yofemalecollegestudentwithpastmedicalhistoryofinfectiousmononucleosisatage15.Shepresentswithreports ofacuteonset2daysagooffever,sorethroat,headache,andswollenglandstobothsidesofherneck.Roommaterecentlyseen forsorethroatunknowndiagnosis.PhysicalassessmentrevealsTemperatureof101.5,mildtomoderatelyenlargedtonsilswith prominentexudatesbilaterally,erythematousposteriorpharynxwithreportedpainof11/10,andtenderbilatlymphadenopathy. PatientdeniesanyN/Vorweightloss,nofatigue.Neurosareintact. ManagementPlanoncaseRebeccaFields DiagnosticTests:COVID-19PCR,InfluenzaPCR,RapidInfluenzadiagnostictest,RapidStrepantigendetectiontest,Throat culture Medications:Antibiotics-Amoxicillin500mgQ12hx10days(CDC,2022).Antipyretic/Analgesicforsymptomreliefsuchas acetaminophen(Mustafa&Ghaffari,2020).TylenolES500mg2tabsevery6hoursPRNPain/Fevernottoexceed6tabletsin24 hours Suggestedconsults/referrals:Noreferralsatthistime.Iftonsilenlargementandexudatedonotimproveorworsenmayneed referraltoENT. Clienteducation:Washyourhandsoftenespeciallyaftercoughingandsneezingandbeforehandlingfoodoreating.Coveryour mouthwhenyoucoughorsneeze.Donotgobacktoworkorschoolandisolateyourselffromyourroommateuntilfeverisgone andyouhavebeenonyourantibioticfornolessthan12hours(CDC,2022).Takeyourantibioticstilltheyareallgoneevenif youbegintofeelbetterinafewdays(CDC,2022).Amoxicillinmaydecreasetheeffectivenessofyouroralcontraceptive.Usea backupmethodforbirthcontroltillantibioticsarecomplete(PDR,2022).SaltwatergarglesPRNforsorethroat. Follow-up:Cultureresultsshouldbereceivedin48hours.Followupin72hoursifthereisnoimprovementinsymptoms.If symptomsworsenseekmedicalassistanceimmediately. References Acetaminophen.(2022).https://www.pdr.net/drug-summary/Adults--39--FeverAll-acetaminophen-2639.1945 Amoxicillin,(2022).PrescribersDigitalReference.https://www.pdr.net/drug-summary/Amoxicillin-Tablets CDC.(2022).GroupAStreptococcal(GAS)Disease.https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html CDC.(2022).GroupAStreptococcal(GAS)Disease.https://www.cdc.gov/groupastrep/diseases-public/strep-throat.html Mustafa,&Ghaffari,M.(2020).DiagnosticMethods,ClinicalGuidelines,andAntibioticTreatmentforGroupAStreptococcal. Pharyngitis:ANarrativeReview.FrontiersinCellularandInfectionMicrobiology,10,563627–563627. https://doi.org/10.3389/fcimb.2020.563627 ElectronicHealthRecordoncaseRebeccaFields HistoryofPresentIllness Category DataenteredbyMarkStelle ReasonforEncounter "Ihaveareallybadsorethroat" Historyofpresentillness Rfisa23yearoldfemalewhopresentswithachiefcomplaintofsuddenonsetofsore throattwodaysago.Shealsoreportsaheadacheandfeverof101.5andswollenglands tobothsidesofherneck.Herroommaterecentlyseenforasorethroatunknown diagnosis.Shereportsthatshehasnotreceivedherinfluenzavaccinebutisuptodate onallothervaccinations.Shereportsthatsheisinarelationshipwithonepersonand occasionallyreceivesandperformsoralsex.StatessheistakingTylenolforfeverand pain,icecreammakesitfeelbetter.Throatpainratedat"11/10andfeelslikeandice pick." PastMedicalHistory Category DataenteredbyMarkStelle PastMedicalHistory Infectiousmononucleosisatage15 Hospitalizations/Surgeries None Medications Category DataenteredbyMarkStelle Medications DrospirenoneandethinylestradiolOTC:Tylenol Allergies Category DataenteredbyMarkStelle Allergies NKDA PreventiveHealth Category DataenteredbyMarkStelle Preventivehealth PapSmearat21Noinfluenzathisyear FamilyHistory Category DataenteredbyMarkStelle FamilyHistory Mother-Hypertension SocialHistory Category DataenteredbyMarkStelle SocialHistory Lawstudentwholiveswitharoommate.Nontobaccouser.Drinkssocially2-3drinks perweek.NoIllicitdruguse.Sexuallyactivewithamalepartner,monogamous ReviewofSystems Category DataenteredbyMarkStelle General Fever.Deniesweakness Integumentary/Breast Deniesrashorbruising HEENT/Neck Sorethroat.Denieseyeredness,eyedischarge,earache,oralulcers,congestion, rhinorrhea Cardiovascular Denieschestpainorpalpitations Respiratory Deniescoughordifficultybreathing Gastrointestinal Deniesanyvomiting,diarrheaorconstipation Genitourinary Deniesanydysuria Musculoskeletal Deniesanyjointswelling Allergic/Immunologic Negative Endocrine Deniespolyuriaorpolydipsia Hematologic/Lymphatic TenderCervicallymphadenopathybilaterally Neurologic Deniesanysyncopeorseizures Psychiatric Deniesdepressionoranxiety PhysicalExams Category DataenteredbyMarkStelle General Awake,alertandoriented.Noacutedistress.Welldeveloped,hydratedandnourished. Appearsstatedage Skin Skininwarm,dryandintactwithoutrashesorlesions.Appropriatecolorforethnicity. Nailbedspinkwithnocyanosisorclubbing. HEENT/Neck Head:Normocephalic,fullROMintheneck.Nofacialswellingorerythematic.Anterior andposteriorcervicallymphnodesareswollen.Ears:Tympanicmembranesarepearly greybilaterallywithvisiblelandmarksandconeoflight.Earcanalsarepatent.Eyes: PEERLA,sclera’sarewhiteincolor.Nose:Nosinuspainuponpalpation,nostrilsare patentwithnoerythemaordrainagenoted.Throat:posteriorpharyngealedema,mildto moderatelyenlargedtonsilswithexudatebilaterally Cardiovascular HRRR.Nomurmursnoted.Negativeforbilaterallowerextremityedema Chest/Respiratory Nosignsofrespiratorydistress.Chestwallissymmetrical.Lungsoundsareclearinall lobesbilaterallywithoutrales,ronchi,orwheezes.Resonanceisnormalupon percussionofalllungfields. Abdomen Abdomenissoft,symmetric,andnon-tenderwithoutdistention.Bowelsoundsare presentandnormoactiveinallfourquadrants.Nomasses,hepatomegaly,or splenomegalyarenoted. Genitourinary/Rectal Musculoskeletal/Osteopathic StructuralExamination Neurologic Sensationisintactbilaterally.Reflexes2+bilaterally.Cranialnervesareintact. Cerebellarfunctionisintact.Memoryisnormalandthoughtprocessisintact.Nogait abnormalitiesareappreciated. Psychiatric Lymphatic Tendercervicallymphadenopathybilaterallymeasuring1.5cm,mobileandrubbery