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MarvindWebster
History HowdcandIdhelpdyoudtoday?
Dodyoudhavedanydotherdsymptomsdordconcernsdwedshouldddiscuss? Dodyoudhavedanydallergies,dsuchdasdmedications,dfooddand/ordlatex,dfordexample?dAred youdtakingdanydprescriptiondmedications?
Aredyoudtakingdanydover-the-counterdordherbaldmedications? Candyoudtelldmedaboutdanydcurrentdordpastdmedicaldproblemsdyoudhavedhad?dAnyd previousdmedical,dsurgical,dorddentaldprocedures? Dodyoudnowdordhavedyoudeverdsmokeddordcheweddtobacco?dH
avedyoudhaddanydcontactdwithdotherdsickdpeople?
Aredyoudsexuallydactive? Dodyoudexperience:dchestdpainddiscomfortdordpressure;dpain/pressure/dizzinessdwithdexertiondordget
tingdangry;dpalpitation;ddecreaseddexercisedtolerance;dblue/colddfingersdordtoes? Dodyoudhavedanydofdthedfollowing:ddizziness,dfainting,dspinningdroom,dseizures,dweakness,dnumbness ,dtingling,dtremor?
Dodyoudhavedanydofdthedfollowingdproblems:dfatigue,ddifficultydsleeping,dunintentionaldweightdlossdor dgain,dfevers,dnightdsweats? Howdhighdwasdyourdfever? Whendyoudurinate,dhavedyoudnoticed:dpain,dburning,dblood,ddifficultydstartingdordstopping,ddribbling
,dincontinence,durgencydduringddaydordnightdordanydchangesdindfrequency?
Howdsevered(1- 10)disdthedpaindindyourdchest?dDodyoudhavedanyd
paindindyourdchest? Havedyoudnoticed:danydbruising,dbleedingdgums,dnosedbleedsdordotherdsitesdofdincreaseddbleeding?
Dodyoudhavedanydofdthedfollowing:dheatdordcolddintolerance,dincreaseddthirst,dincreaseddsweating,dfre quentdurination,dchangedindappetite? Dodyoudhavedanydproblemsdwith:dnervousness,ddepression,dlackdofdinterest,dsadness,dmemorydloss,d
ordmooddchanges,dordeverdheardvoicesdordseedthingsdthatdyoudknowdarednotdthere? Dodyoudawakendatdnightdcoughing? Whatdtreatmentsdhavedyoudhaddfordyourdcough? Whatdaredthedeventsdsurroundingdthedstartdofdyourdcough?dIsd
theredanydpatterndtodyourdcough? Doesdanythingdmakedyourdcoughdbetterdordworse?dD odyoudhavedHIV?
Dodyouddrinkdalcohol?dIfdso,dwhatddodyouddrinkdanddhowdmanyddrinksdperdday? Havedyoudhaddadcoughdlikedthisdbefore? Dodyoudhavedproblemsdwith:dnausea,dvomiting,dconstipation,ddiarrhea,dcoffeedgroundsdindyourdvomi t,ddarkdtarrydstool,dbrightdreddblooddindyourdboweldmovements,dearlydsatiety,dbloating?
Dodyoudusedrecreationalddrugs?dIfdso,dwhat? Dodyoudhavedproblemsdwith:dmuscledordjointdpain,dredness,dswelling,dmuscledcramps,djointdstiffnes s,djointdswellingdordredness,dbackdpain,dneckdordshoulderdpain,dhipdpain?
Vitals:dblooddpressuredAbdo men:dpalpatedabdomen
Genitourinary:dgenitourinarydmaledexamd HEENT:dinspectdmouth/pharynxdLympha tic:dpalpatedalldlymphdnodesdMusculoskel
etal:dtestdstrength Neck:dpalpatedneckdNeurolog ical:dcranialdnerves
Neurological:dreflexesd– ddeepdtendondOrthostaticdblooddpress ured(BP)dSPO
Mentaldstatus
MarvindWebster
Chiefdcomplaint: Problems:dfeelsdawfuldanddexhausted,dhasdbodydachesdanddfeelsdreallydweak.dSoredthroat,dcoughing,d anddhasdadheadache.dMuscledachesdtoo
ChiefdcomplaintdSx/Sxdcharacteristicsdquestionsdmissed:
- Howdbaddisdyourdcough?
- Doesdanythingdmakedyourdcoughdbetterdordworse?
- Whatdaredthedeventsdsurroundingdthedstartdofdyourdcough?
AssociateddSx/Sxdcharacteristicsdquestionsdmissed:
- Dodyoudwheeze?
- Whatdtreatmentsdhavedyoudhaddfordyourdsoredthroat?
- Havedyoudhaddadsoredthroatdlikedthisdbefore?
RiskdfactorsdPMHdquestionsdmissed:
- AredyoudtakingdanydOTCdordherbaldmeds? Etiologydquestionsdmissed:
- Havedyoudhaddanydcontactdwithdotherdsickdpeople?
HPI/ROSdquestionsdmissed:
isdsuspecteddMarvindhasdthedfludaccordingdtodhisdreporteddsymptoms.dThedCDCd(2020)dreportsdthedflud isdhighlydcontagiousdanddcandbedcontagiousdfordupdtodaddaydbeforedadpatientdevendshowsdsymptoms.dItdi sdimportantdtodinquiredaboutdsymptoms;dweightdloss,ddiarrhea,dduration,dfatiguedanddvaccinedhistorydt odhelpdaidedindaddifferentialddiagnosis.dAskingdMarvindaboutdhisdhealthdhistory,dpriordfludvaccinesdand dhisdsocialdhistorydcandhelpdfurtherddeterminedaddiagnosis. PhysicaldExamdRationale Adfocuseddanddsystematicdphysicaldexamdisdonedofdthedmostdvitaldcomponentsdinddiagnosingda nddtreatmentdofdadpatient.dPerformingdadheaddtodtoedassessmentdanddvitaldsignsdcandbedcrucialdtodidenti fyingdpotentialdproblems.dStartingdwithdMarvin’sdbaselinedvitalsdanddidentifyingdhisdelevateddtemper aturedisdindicativedofdandinfection.dWhiledlisteningdtodMarvin’sdheart,dlungsdanddabdomendadditionaldi nsightdcandbedobserveddanddpalpateddregardingdhisdcardiacdanddgastrointestinaldstatus.dPlayingdclosed attentiondtodauscultationdofdMarvin’sdcoughdcandbetterdidentifydifdthedcoughdisdindthedupperdordlowerdai rwaysdanddcandruledoutdasthmadanddwheezingdwhichdMarvindhaddasdadchild.dItdisdimportantdtodruledoutd possibledupperdrespiratorydinfectionsdwhiledexaminingdthedHEENTdsystem.dMarvin’sdHEENTdexamd findingsdarednegative.dBickleydetdald(2017)dindicatesdauscultatingdlungdsoundsdfordfremitus,degophon ydordbronchophonydcandaidedindtheddeterminingdaddifferentialddiagnosis.d Oftendtimesdinfluenzadcandca usedstomachdpaindleadingdtoddiarrheadwhichdwoulddbedfounddwithdhyperactivedboweldsounds.dMarvin ’sdboweldsoundsdupondpalpationdanddauscultationdaredhoweverdnegative. CasedEvaluation Mydoveralldcasedevaluationdrevealeddareasdofdgrowthdanddopportunitydtodimprovedmydassess mentdanddphysicaldexamdskills.dItdisdimportantdtodfollowdthedheaddtodtoedapproachdtodbedconsistentdand dtodnotdskipdordrepeatdexamsdanddinterviewdquestions.dEnsuringdtodincludedseverity
ofdchiefdcomplaintdfollowingdthedPOLDCARTSdacronymdduringdthedHPI.dNotdtodforgetdtodgodfurtherd indmydassessmentdanddaskdquestionsdpertainingdtodthedpatient’sdsoredthroatdsuchdasdseverity,dtiming,dan ddwhatdmakesdisdbetterdordworse.dOtherdassessmentsdmisseddincludedquestionsdregardingdwheezing,dse veritydanddrelateddproblemsdsuchdasddifficultydsleeping,ddizzinessdordseizures. Overall,dIdneeddtodpracticedsimulationdexercisesdtodbecomedmoredproficientdanddspecificdtodthedbodyd systemsdinvolveddforddiagnosticdanddtreatmentdpurposes.dIdwasdhappydtodseedIdhaddthedsamed“keydfin dings”dasdthedexpertdfeedback.dAlthoughdIdusedddifferentdwording,dthisdweekdIdmanageddtoddodmuchd betterdthisdweek.dAgain,dIdstruggleddtodmakedthedi- Humandsimulationdprogramdhappy.dIdaskeddquestionsdsimilardtodwhatdthedprogramdwanteddmedtodask ,dbutdbecausedIddiddnotdaskdthedexactdquestion,ditdindicatesdIdmisseddaskingdkeydquestions.dSlowingdd own,danddorganizingdmydheaddtodtoedapproachdisdkeydtodnotdmissingdkeydfactorsdsincedthisdsimulatio ndisdnotdbaseddondtimedbutdratherdefficiencydanddaccuracydofdskilldsetdanddcriticaldthinking.dIdalsodnee ddtodpaydcloserdattentiondtodthedamountdofdquestionsdaskeddanddthedqualitydofdeachdquestiondpriordtoda sking.
References
- coughingdupdyellowdanddgreenishdsputum
- drinkingorks dhotdteadhelpeddmakedthedcoughdbetterdadlittledindthedbeginningdbutdnodlongerdw
- nodhemoptysis
- notdmovingdisdthedonlydthingdthatdhelpsdwithdSOB
- nodwheezing
- coughingdmakesdhimdqueasy
- hxdofdsoredthroatdwithdthedfludbutdnotdnow
- pain 8 dintercostaldindchestddwhenspace,dcoughingdmidaxillarydordtakingdline) daddeepdbreathd(rightdthorax,d6-
- nodtightness
- nodsadness,ddepressiondordhopelessness
- medicaldhxdofdmilddasthmadasdadchild
- NKA
- Nodcurrentdmedicationsdprescribed-takingdOTCdibuprofen
- Unsuredofdimmunizations
- Diddnotdgetdthedfludvaccinedordpneumoniadvaccine
- Nodrecentdtravel
- Occasionaldbeer
- Deniesddrugdusedanddsmoking
- Coughdsyrupdnotdworking
- Coughingdkeepingdhimd up-dcoughsdwhendgoingdintodthedcold
- b/ldswollendlymphdnodesdindneck
- hoarseness
ProblemdStatement MarvindF.dWebsterdisdand18- yeardolddmaledcollegedstudentdwithdadhistorydofdchildhooddasthmadwhodpresentsdwithdacu tedonsetdofdlow- gradedfever,dnonproductivedcough,dsoredthroat,dfatigue,dmyalgiasdanddheadache.dThedph ysicaldexamdrevealsdanderythematousdpharynx,danteriordcervicaldadenopathydanddscattere ddbilateraldcrackles.dRiskdfactorsdincludedlackdofdannualdfludvaccine. Thedarticled“HospitalizeddPatientsdwithd 2009 dH1N1dInfluenzadindthedUniteddStates” statesdthatdhospitalizationdamongdpatientsdwithdinfluenzadisdmoredprevalentdindpatients
65-yearsdofdagedordolderdanddthosedunderdthedagedofd7- yearsdanddyoungdfebriledpatientsdaredmoredlikelydtodbedtesteddfordinfluenzadthandolderdadult sdwithdinfluenzadoftenddodnotdhavedadfever.dThedtypicaldpatientdpresentsdwithdadsuddendons etdofdsymptomsd(fever,dnonproductivedcough,dmyalgias,dheadache,dcoryzadand/ordsoredthro at)d(Jain,dKamimotod&dSchmitz,d2011).d ourdpatientdpresenteddwithdmostdofdthesedsymptom s. Thedhistorydanddphysicaldexaminationdperformeddwasdadfocuseddexamdduedtodthe dpatientdwasdnotdnewdanddrecentlydhaddadphysicaldin.dThedpatientddoesdnotd needdtodbedhospitalizeddduedtodhisdconditiond(Bickley,dSzilagyid&dHoffman, d2017). Thedquestioningdprocessdshoulddflowdfromdgeneraldt odspecific.dStartingdwithdgeneraldquestionsdsuchdas;d“Whatdbringsdyoudindto day?”dYoudcandcontinuedtodaskdopen- endeddquestionsdanddthedflowdintodthedmoredfocuseddquestions.d“Aredyoud havedanydpain,”,d“Whereddoesditdhurt?”,d“candyoudpointdtodthedareadofdyour dheaddthatdhurts? Duringdthedinterviewdavoiddleadingdquestions,dthedgoaldisdtodhavedthedpatie ntddescribedwhatdtheydaredexperiencingd(Bickley,2017).dWhendaskingdques tionsdfordthedreviewdofdsystemsdaskdthedquestionsdasdclosed- dendeddquestiond(yes/no),dindadfocuseddexamdordinterviewditdisdnotdnecessa rydtodaskdalldthedquestionsd(Bickley,d2017).dAnswersdtodthesedquestionsdcan dassistdwithdaddifferentialddiagnosis,dthedpresencedordabsencedofdthesedsym ptomsdwhichdcandleaddtodmoredseriousddiagnosisd(Bickley,d2017).dAdcoupled ofdquestionsdthatdIdmisseddindmydinterviewdwered“aredyoudexperiencingdwh eezing?”dandd“doesdanythingdmakedyourdcoughdbetterdordworse?”dbothdared
whendassessingdthedseveritydofdasthma.dIndMarvin’sdcasedhedwasdfounddtodb edwithoutdsignificantdasthmadexacerbation,ddeniesdshortnessdofdbreathdbu tdwasdnotdtodhavedscattereddcracklesdindthedlowerdbases. Cracklesdmaydbecomed“finer”danddchangedfromdmiddtodlatedinspiratorydduri ngdrecoverydindasthmad(Bickley,d2017).
Thedpatientdhistorydshoulddfocusdonddetectingdsymptomsdconsistentdwithdcommun itydacquireddpneumoniadbecausedpneumoniadcombineddwithdinfluenzadisdth edeighthdleadingdcausedofddeathdindthedUniteddStatesd(Watkinsd &d Lemonovic h,d 2011).d Ford thed focusedd examd Id begand thedexamdwithdthedhead,dears,dno sedanddthroatdbecausedtheydalldlinkeddcloselydtogether.dThedpatientdreporte ddadmilddheadache,dfurtherdinvestigationdisdrecommendeddtodassessdfordlife- threateningdsecondarydcausesd (Bickley,d 2017).d Dued todthed newd complaint d ofdeard pain,dassessingdearsdwithdthedotoscopedwasdnecessarydtodseedifdanyth ingdsignificantdwasdhappening.d IndthedcasedwithdMarvindthedeardfindingsdwer edreddeneddrightdtympanicdmembrane.dThedphysicaldexamdshoulddincludeda ddetaileddexamdofdthedthroatdanddneck,dnotingdanyderythemadordexudate.dTh edpatientdwasdnoteddbilateraldred,derythematousdanddedematousdpharynxd withdtenderd0.8dcmdtod1.0dcmdanteriordcervicaldlymphdnodes.dThesedfindings dalongdwithdlow-gradedfeverdprompteddthedrapiddstrepdtest.
Anotherdareadofdimportancedtodexaminedisdthedabdominaldarea,dnotingdwhetherdt hedabdomendisdsoftdanddwithoutddistention.dAssessingdfor
notabledsplenicdordhepaticdenlargementdordtendernessdisdimportantdduedto dpossibleddiagnosisdofdinfectiousdmononucleosis,dthedpatientdsymptomsdfol lowdthedsimilardsymptomsdofdthisddiseasedwithdfatigue,dfever,dpharyngitisd anddadenopathyd(Porterd&dKaplan,d2011).
Patientsdshoulddbedaskeddaboutdoccupation,danimaldexposures,dtraveldhistorydandd sexualdhistorydtodhelpdidentifydadspecificdinfectiousdagent. Influenzadisdoftendsuggesteddbaseddondtypicaldsymptomsdduringdpeakdinfluen zadseasond(Watkins,d2011).dOurdpatientdisdatdhighdriskdduedtodthedlackdofdrece ivingdthedinfluenzadvaccinedthisdyear.
Maneuveringdthroughdthedprogramdisdstilldmydbiggestdchallenge.dIdhavedimprovedd withdmydscore,dbutditdtookdoverd 200 dquestionsdanddIdstilld missedd 2 dimportantd questionsdtodask.d Idrevieweddthedskilledd interviewingdtechniquesdindchapte rd 3 dofdthedtextbookdanddstilldneeddadlotdofdpracticedwithdmydpatientdintervie w. Idcontinuedtodstruggledwithdthedphysicalde xamdwithdperformingdthemdondthedcomputer,ditdisdmuchdeasierdtodauscultat edondadrealdperson. Idamdhappierdatdthedenddofdthedavatardexa m,dasdmydgradedimproveddeachdtime.
Retrievedd fromd https://www.aafp.org/afp/2011/0601/p1299.html
MarvindWebsterdisdand18-year- olddcollegedstudentdwhodpresentsdwithdadhistorydofdthedfludwhichdresolveddanddthendwasdfolloweddbyd adfour-daydhistorydofdsudden- onset,dfevers,dchills,dshortnessdofdbreath,dfatigue,dpleuriticdchestdpaindanddadproductivedcoughdwitho utdwheezing.dPhysicaldexaminationdisdsignificantdfordadfeverdofd103.2dFd(oral),dtachypnead(rated24/min ),dhypoxia,dRdmiddledanddlowerdlobedcoarsedcracklesdanddtenderdanteriordcervicaldlymphadenopathy.d Heddeniesdknowndsickdcontactsdanddhasdadchildhooddhistorydofdasthmadnowdoffdtherapydwithoutdrece ntdattacks. MarvindWebster Chiefdcomplaint: Problems:dfeelsdawfuldanddexhausted,dhasdbodydachesdanddfeelsdreallydweak.dSoredthroat,dcoughing,d
anddhasdadheadache.dMuscledachesdtoo
ChiefdcomplaintdSx/Sxdcharacteristicsdquestionsdmissed:
- Howdbaddisdyourdcough?
- Doesdanythingdmakedyourdcoughdbetterdordworse?
- Whatdaredthedeventsdsurroundingdthedstartdofdyourdcough?
AssociateddSx/Sxdcharacteristicsdquestionsdmissed:
- Dodyoudwheeze?
- Whatdtreatmentsdhavedyoudhaddfordyourdsoredthroat?
- Havedyoudhaddadsoredthroatdlikedthisdbefore?
RiskdfactorsdPMHdquestionsdmissed:
- AredyoudtakingdanydOTCdordherbaldmeds? Etiologydquestionsdmissed:
- Havedyoudhaddanydcontactdwithdotherdsickdpeople?
HPI/ROSdquestionsdmissed:
- HowdcandIdhelpdyoudtoday
- Dodyoudhavedanydotherdsymptomsdordconcernsdwedshouldddiscuss
- Whenddiddthedpaindindyourdchestdstart?
- Doesdanythingdmakedthedpaindindyourdchestdbetterdordworse
- Wheredmoredpreciselydisdthedpaindindyourdchest?
- Doesdthedpaindindyourdchestdradiatedsomeplacedelse?dWhere?
- Howdsevered1-10dscaledisdthedpaindindyourdchest?d(4-5/10)
- Havedyoudhaddtraumadtodyourdchest?d–dno
- Howdlongddoesdyourdchestdpaindlast?
- Isdyourdchestdpaindprecipitateddbydexercise?
- Anydchangedindyourdchestdpaindsinceditdbegan?
- Doesdthedpaindindyourdchestdcomedanddgo?
- DodyoudexperiencedSOB,dwheezing,ddifficultydcatchingdyourdbreath,dchronicdcough,ds putumdproduction?
- DodyoudhavedproblemsdwithdN/V,dconstipation,ddiarrhea,dcoffeedgroundsdindyourdvomit,de tc
- Dodyoudhavedanydofdthedfollowingdproblemsdwith:dfatigue,ddifficultydsleeping,du nintentionaldweightdloss,dordgain,dfevers,dnightdsweats?
- Dodudhavedanydproblemsdwithdnervousness,ddepression,dlackdofdinterest,dsadness,d memorydloss,dordmooddchanges,detc
- Dodyouddrinkdalcohol?dIfdso,dwhatddodyouddrinkdanddhowdmanyddrinksdperdday?
- Hasddrinkingdalcoholdeverdcauseddyoudproblems?
- Candyoudtelldmedaboutdyourddiet,dwhatdyourdnormallydeat?
- Havedyoudeverdfeltdyoudneededdtodcutddowndondyourddrinking?
- Hasdanyonedsuggesteddthatdyoudshoulddreducedthedamountdofdalcoholdyouddrink?
- Havedyoudeverdbeendannoyeddatdanyonedfordsuggestingdthatdyoudcutdbackdondyourdalcoholdc onsumption?
- Dodyoudpresentlydhavedheartburn,dadfooddordaciddtastedindyourdmouth?
- Whendanddwhatddiddyoudlastddrink?d–dwinedaroundd10pmdlastdnight
ChiefdComplaint: “Idfeeldawful...I’mdexhausted,dshortdofdbreath,dmydfeverdisdgettingdworse.”
Musculoskeletal:dPositivedfordmyalgia,dnegativedfordbackdpain,dneckdpaindanddneckdstiffnessdAllergic/I mmunologic:dNegativedfordfooddallergies
Neurological:dNegativedfordseizures,dfacialdasymmetrydanddspeechddifficultydPsychiatric/Behavioral :dNegativedfordconfusion,ddysphoricdmooddanddsleepddisturbance.dThe
patientdisdnotdnervous/anxiousdanddisdnotdhyperactive
PMH:
Childhooddasthma,dnotdcurrentlydunderdtreatment
FMH:
Momd-dHTN
Socialdhx: Collegedstudent,ddeniesdtobaccoduse,dadmitsdtodoccasionaldsocialddrinking,dnotdsexuallydactive,dnodilli citddrugduse
CurrentdMedications: OTCdIbuprofen
OTCdcoughdsyrup
Allergies: Nodknownddrugdallergies
Vitaldsigns:
Temp:d103.2dF Pulse:d 120 dbpmdB P:d120/80dmmHgdR
R:d 24 dbpm O2:d91%dRA
PhysicaldFindings:
General:dAlertdanddorienteddxd4,dcalm,dcooperative
Skin:dpink,dwarmdandddry;dnodrash,dlesionsdordicterus;dtentingdofdtheddorsaldhand
HEENT:dHeaddnormal,datraumatic;dnormaldconjunctiva,dnodscleraldicterus,dcleardrightdanddleftdtympa
nicdmembranes;dexudativedpharyngitis,dnodpalataldpetechiae
Neck:dTenderd1.0-cmdtod1.5-cmdanteriordcervicaldlymphdnodes,dneckdsupple,dfulldrangedofdmotion
Lymphatic:dTenderdanteriordcervicaldadenopathy;dnodposteriordnodesdpalpable;dnodotherdregionaldly mphadenopathy
