Focused Case Study # 1
Case Study 1 - Julie
1) History Data
a. Chief Concern (CC)
· Julie complains of a “sore throat” for the past three days that keeps getting worse and “feels like she is swallowing knives.” She rates the pain in her throat as 7/10.
b. Complete History of Present Illness (HPI)
· Julie is concerned that there is redness in the back of her throat, and she has been having a hard time eating and drinking due to the pain. She also notes bad breath throughout the day for the past 3 days and has been coughing occasionally. Her last trip was a few weeks ago where she travelled by airplane to Puerto Rico.
· Medications:
1. Albuterol for asthma
2. Lisinopril 5mg QD for HTN
· Allergies: Shrimp & latex
· Tobacco use: Non-smoker.
c. Pertinent Past Medical History (PMH) (include surgeries and traumatic injuries)
· Childhood illnesses: Asthma (diagnosed at aged 14)
· Adult Illnesses
1. Medical: Hypertension (HTN), Asthma,
2. Surgical: Gallbladder removal (age 27),
3. OBGYN: Not reported
4. Psychiatric: No reported psychiatric illnesses
5. Other: Skin lesion biopsy at age 30 -
Health Maintenance Practices
1. Immunizations: Not reported
2. Screening tests: Skin lesion biopsy at 30 years old with a dermatologist.
3. Lifestyle issues: Non-smoker, occasional wine drinker (2-3 glasses a few nights a week). No reported drug use. Outdoor enthusiast, hikes regularly.
4. Home safety: Married and has a 3-year-old son. No domestic issues reported.
· Surgeries: Gallbladder removal at age 27.
· Traumatic injuries: No reported traumatic injuries.
· Current medications: (stated above)
· Allergies: Shrimp and Latex
· Psychosocial: Receptionist at a car dealership.
· Other: N/A
d. Family History
· Mother – 65 y/o, with hypertension, hyperlipidemia, and cerebrovascular accident.
· Father – 68 y/o, with hypertension, hyperlipidemia, coronary artery disease, and diabetes mellitus.
Please see last page for genogram
2). Review of Systems (ROS)
· General: Febrile (T:99.6), appears fatigued, and does not report weight changes.
· Skin: Appropriate for ethnicity. No lesions, rashes, skin warm to the touch.
· Head, Eyes, Ears, Nose, Throat (HEENT):
1. Head: No head trauma, normocephalic. No reported dizziness, headache, or vertigo.
2. Eyes: Extraocular muscles intact, PERRLA, BL red reflex intact. Doesn’t report vision problems, no noted tearing, redness, pain, glaucoma, or cataracts.
3. Ears: No reported hearing problems, vertigo, ear infections, tinnitus, or discharge.
4. Nose: No discharge or nasal polyps, patient doesn’t report issues with upper respiratory bleeding, or infection.
5. Throat (or mouth or pharynx): Pain 7/10 in the throat. Pharynx with bilateral tonsillar exudates, 3+R, 2+L. Uvula is midline and edematous. Tongue has strawberry patches.
Neck: Bilateral cervical lymphadenopathy noted on palpation.
Respiratory: Patient reports occasional cough, but does not report shortness of breath, pain with breathing, or wheezing. Lungs are clear posteriorly and bilaterally.
Cardiovascular: Heart sounds detect normal s1/s2, and no murmur revealed on auscultation.
Patient has hypertension (BP: 145/68) but is managing her blood pressure with lisinopril 5mg.
Patient has sinus tachycardia without ST elevation or depression. Patient’s heart rate is 107.
Doesn’t report any palpitations, chest pain, dyspnea, or orthopnea from given information.
Gastrointestinal: Patient reports pain with swallowing, but denies indigestion, nausea, or vomiting. No reported diarrhea, rectal bleeding, hemorrhoids or change in stool color. Patient had her gallbladder removed. Abdomen soft, non-tender to palpation.
Urinary: No reported urinary urgency, frequency, hematuria, flank pain, burning, or pain upon urination. No known kidney disease, stones, or incontinence.
Genital: Patient does not report any history of genital infections or discomfort. Patient has one partner (husband) from given information. Patient does not report contraception methods, or history of sexual transmitted infections.
Peripheral vascular: No reported leg pain or swelling. 2+ pulses bilaterally in upper and lower extremities.
Musculoskeletal: Patient walks herself into the exam room in no distress but looks fatigued. No report of joint stiffness, pain, or gout. No past traumas noted. No identified pain on activity. Psychiatric: Patient is alert and oriented to time, place, and person. No reports of anxiety, depression, or memory changes. Patient’s speech is normal and appropriate, with no changes in judgement or memory. No history of psychiatric disorders.
Neurologic: She is neurologically intact, without focal deficit. No reports of headache, fainting, seizures, or vertigo. Patient denies paralysis, sensation of tingling, numbness, or “pins and needles.” No evident tremors or involuntary movements. Hematologic: No reports of bruising, bleeding, or anemia.
Endocrine: No reports of excessive hunger or thirst, cold or heat intolerance, weight gain or loss, or hirsutism.
3). Physical Exam
General Survey: Julia is a 35-year-old African American female, appears tall, overweight, wellgroomed, responsive to questions, and shows no discomfort other than the pain in her throat.
Vital Signs: Height (Ht) 172.72cm (5’8”). Weight (Wt) 86.2kg (190 lbs.). BMI 28.9, (overweight). Blood pressure (BP) 145/68. Heart rate (HR) 107 beats per minute, sinus tachycardia. Respiratory rate (RR) 16, on room air. Temperature (T) 99.6oF.
Skin: Julie’s skin complexion is even, appropriate for ethnicity. Skin is warm to touch with no visible lesions, rashes or vesicles on noted. There are no signs of jaundice or noted discoloration. Head, Eyes, Ears, Nose, Throat (HEENT): Head: Normocephalic, atraumatic. Hair is evenly distributed, no visible lesions on scalp. Eyes: Bilateral red reflex intact. Extra-ocular muscles intact, PERRLA, 2+. Conjunctiva is pink with white sclera, visual fields are normal, vision in each eye is 20/20 without correction. Ears: Right and left auricles are clear, even color, and free of exudate. Right and left tympanic membrane is pearly gray in color, intact, and semitransparent. Voice-whisper test normal (patient can repeat words at 2 feet). Weber test shows equal hearing on both sides, Rinne test is normal (AC >BC). Nose: Free of discharge or polyps. Mucosa is pink with septum midline. No sinus discomfort, bleeding, or breathing complications through the nasal cavity. Mouth: Oral mucosa is moist with redness in the back of the throat. Pharynx with bilateral tonsillar exudates, 3+R, 2+L. Uvula is midline but edematous, tongue has strawberry patches.
Neck: Trachea midline. Neck is supple. Thyroid unpalpable.
Lymph nodes: Bilateral cervical lymphadenopathy on palpation.
Thorax and Lungs: Lungs are clear posteriorly, bilaterally. Patient is comfortably breathing in room air. Thorax is symmetrical anteriorly and posteriorly. Breath sounds are clear and lungs are resonant on percussion.
Axillae, and Epitrochlear Nodes: Nipples are normal shape, no discoloration, cracks, or discharge.
Cardiovascular System: Heart with normal S1 and S2, no murmur, rub, or gallop on auscultation. No jugular venous distention. No abnormalities in carotid pulses, no bruits or thrills noted. Apical pulse reveals no murmurs or splitting of S1 and S2. 2+ bounding pulses in bilateral upper and lower extremities with no edema noted. EKG shows sinus tachycardia without ST elevation or depression.
Abdomen: Abdomen is round, soft, non-tender to palpation. No visible or palpable masses or hepatomegaly on palpation. No tenderness in the costovertebral area. No guarding or rebound noted. Kidneys and spleen are not felt.
Extremities: Skin is warm to touch. No edema, discoloration, ulcers, or varicose veins noted. 2+ regular pulses in upper and lower extremities. Calves not red, swollen or-tender. Negative Homan’s sign bilaterally.
Musculoskeletal: No swelling or deformity noted in bilateral upper and lower extremities. Good range of motion in knees, hips, ankles, shoulders, elbows, head, and wrists. No pain on flexion and extension of the arms and legs. Neck flexion and extension normal. No localized tenderness.
Neurologic: Mental status: Alert and oriented X3 (place, person, and time). Appropriate affect, responsive and cooperative. Cranial nerves: I-XII intact. Motor. Strength 5/5 in upper and lower extremities bilaterally. Cerebellar: Stable gait, heel to toe walk intact, point to point movement test normal. Sensory: Romberg test negative. Senses to light touch, vibration, pinprick intact.
Reflexes 2+ and normal in biceps, brachioradialis, Achilles, triceps, patellar, and plantar.
Babinski sign negative.
Back: Spine is straight and midline. Shoulders are symmetrical with even range of motion. Full range of motion and bending of the back. No localized tenderness.
Genital: External genitalia has no visible discharge, sores, or swelling. Patient denies pain on urination, during intercourse, or during menses. Patient has one partner (husband) from given information. Denies use of condom.
Rectal: No perirectal lesion or fissures. Rectal vault without masses. External sphincter tone intact. Stool normal color and negative for fetal occult blood.
4). List 3 Differential Diagnoses in descending order of suspicion (your 1st differential should be your primary).
1. Group A streptococcal pharyngitis
2. Infectious mononucleosis
3. Scarlet fever
6). List the pertinent positives/negatives to support your primary DD
Group A streptococcal pharyngitis
Positive sore throat
Positive for infection
Positive for cough
Negative body aches and chills
Negative for rash
Negative nausea & vomiting
Infectious mononucleosis
Positive lymphadenopathy
Positive fatigue
Positive for infected tonsils
Negative for swollen spleen
Negative for jaundice
Negative for skin rash
Scarlet fever
Positive tongue with strawberry patches
Positive sore throat
Positive for lymphadenopathy
Negative for red rash
Negative for blanching
Negative for flushed face
7). List additional history data that would support your primary differential diagnosis and why?
1. Do you have any trouble breathing?
Rationale: With infectious pharyngitis, the bacteria may cause a local inflammatory response that can cause airway obstruction.
2. Are you unusually tired or exhausted?
Rationale: With bacterial pharyngitis, the patient may suffer from general malaise and exhaustion.
3. Do you have any other symptoms of abdominal pain, nausea, and vomiting?
Rationale: These additional GI symptoms are common with Group A Strep.
Pharyngitis.
4. Have you recently been exposed to large crowds of people within the last week? Rationale: Transmission of Group A pharyngitis is typically acquired in crowded areas.
5. Do you know to have eaten anything new or skeptical in the last week?
Rationale: Some outbreaks of pharyngitis may occur due to improper food handling.
6. Have you recently been in contact with a person known to have a sore throat?
Rationale: Transmission of Group A pharyngitis is commonly spread through person-person contact.
7. Do you have any other symptoms of hoarseness, runny nose, or conjunctivitis?
Rationale: These additional viral symptoms can help confirm the diagnosis of
Group A Streptococcal Pharyngitis.
8. Do you feel body aches?
Rationale: Since the patient has a low-grade fever, it is very common to have body aches with Group A Streptococcal Pharyngitis.
9. Do you have chills where your body is shaking?
Rationale: In addition to body aches, the viral infection may cause chills and body shakes.
10. Have you noticed any recent changes in your appetite?
Rationale: Often with viral infections patients may present nausea and loss of appetite, which can cause nutritional deficiencies.
8). List any additional physical components that would support your primary differential diagnosis and why?
1. “Sore throat” for the past 3 days
Rationale: This is a symptom is typical of Group A Strep. Pharyngitis. The Incubation period is 2-5 days.
2. Difficulty swallowing due to pain and doesn’t improve with Tylenol.
Rationale: Persistent sore throat with Group A Strep. Pharyngitis is a common symptom.
3. Tongue with strawberry patches.
Rationale: This sign suggests palatal petechiae, that is common with Group. A Streptococcus Pharyngitis.
4. Lymphadenopathy on palpation.
Rationale: Strep. Pharyngitis is associated with cervical lymphadenopathy.
5. Fatigue.
Rationale: General fatigue and malaise is common in patients who have Group A Streptococcal infections.
Powered by TCPDF (www.tcpdf.org)
This study source was downloaded by 100000766549104 from CourseHero.com on 09-10-2022 15:02:16 GMT -05:00
https://www.coursehero.com/file/151720676/CASE-STUDY-JULIA-2-3docx/
This study source was downloaded by 100000766549104 from CourseHero.com on 09-10-2022 15:02:16 GMT -05:00
https://www.coursehero.com/file/151720676/CASE-STUDY-JULIA-2-3docx/
This study source was downloaded by 100000766549104 from CourseHero.com on 09-10-2022 15:02:16 GMT -05:00
https://www.coursehero.com/file/151720676/CASE-STUDY-JULIA-2-3docx/