COMPREHENSIVE CASE WEEK #4 I HUMAN CASE 25 YEAR OLD FEMALE REASON FOR ENCOUNTER: NEW RASH, Assignments of Health sciences

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Questions

1. How can I help her today

2. Does she have any other symptoms or concerns we should discuss

3. On what part of her body did the rash start and where did it spread

4. Has she been having fever

5. When did her fever start

6. Did she have any other problems two to four days before the rash

started

7. What treatments has she had for her rash

8. Does she have any allergies.

9. Is she taking any over the counter or herbal medications.

10. Is she coughing up any sputum.

11. How high is her fever.

Is her rash painful or itchy.

What treatments has she had for her cough.

How many stool diapers does your child have per day 14

How many wet diapers does your child have per day 15

Have is her appetite? Any recent changes.

Any contact with people with similar symptoms

Physical Exam

HR: 75, regular, normal

RR: 22, regular,

unlabored

BP: 90/62, normal, normal

A and O X 4

1. 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 = Rash

Sx =

Cough

Sx =

Runny nose

Sx =

Fever

Sx =

Onset Sudden Sudden Sudden Sudden

Location Abdomen,

then spread

to

arms and

legs

Duration day days days days

Characteristics Rapid

spread

Dry runny High

Aggravating Negative Negative Negative Negative

Relieving Negative Negative Negative Tylenol

Timing /

Treatments

Negative Negative Negative Went

down last

night with

tylenol

Use this worksheet to organize your thoughts before developing a differential diagnosis list.

2. Indicate key symptoms ( Sx ) you have identified from the history. Start with the patient's reason(s) for the encounter and add symptoms obtained from further additional questioning.
3. Characterize the attributes of each symptom using "OLDCARTS". details in the appropriate Capture the column and row. Case Section Status Your Score Time spent Performance Details Total Score 70% History Done 75% 43min 2sec (^90) questions asked, 12 to the case's list correct, 4 missed relative Physical exams Done 81% 58min 40sec (^57) exams performed, partially correct, 2 case's list 10 correct, 1 missed relative to (^) the Key findings organization Done 27sec 3 findings listed; 5 listed by the case Problem Statement Done 3min 45sec 56 words long; the case's was 77 words Differentials Done 40% 4min 10sec (^5) items missed in relative the to DDx, 2 correct, 3 the case's list Differentials ranking Done 100% (lead/alt score) 100% (must not miss score) 44sec Tests Done 100% 15min 18sec 2 tests to ordered, 0 case's correct, 0 missed relative the list Diagnosis Done 100% 10sec Management Plan Done 11min 54sec 34 words long; the case's was 37 words

History of Present Illness

Past Medical History

Medications

Category Data entered by Erne Diane Reason for Encounter Sudden onset rash legs. on abdomen that spread to arms and History of present illness Patient had a cough, and runny nose for the last two days. Mother noticed a rash on her abdomen in the morning that had spread to her arms and legs by the afternoon. Baby has previously taken Tylenol Category Data entered by Diane Erne Preventive health Has been meeting developmental milestones. Up to date with immunizations up to 18 months Category Data entered by Diane Erne Past Medical History None Hospitalizations / Surgeries Born full term ay 38 weeks, no complications Category Data entered by Diane Erne Allergies None Category Data entered by Diane Erne Medications Over the counter Tylenol Category Data entered by Diane (^) Erne

Allergies

Preventive Health

Family History

Social History

Category Data entered by Diane Erne General Skin rash, cough and runny nose. Integumentary / Breast Rash HEENT / Neck Runny nose, no eye or ear discharge Cardiovascular No shortness of breath, fainting or excessive sweating Respiratory Cough, no wheezing Gastrointestinal No vomiting or diarrhea Genitourinary Wears diapers Musculoskeletal No recent trauma Allergic / Immunologic Up to date for immunizations up to 18 months. Endocrine No history of diabetes, adrenal or thyroid dysfunction Hematologic / Lymphatic negative Neurologic No history of seizures Psychiatric Irritable and fussy Category Data entered by Diane Erne General Skin rash on abdomen and extremities. Skin Maculopapular pink rash on abdomen and extremities skin is warm and dry normal skin turgor HEENT / Neck Normal Cardiovascular Normal PMI, RR, no murmur or gallop Chest / Respiratory Normal respiratory effort, no wheezing or crackles Abdomen Soft and non-tender

Review of Systems

Physical Exams

Genitourinary / Rectal No daiper rash Category Data entered by Diane Erne Social History Lives with mother and father at home Family History No history of illness in family. Musculoskeletal / Osteopathic Structural Examination Normal gait and coordination, no swelling Neurologic Awake and alert Psychiatric Fussy and irritated Lymphatic No lymphadenopathy

• Severity Severe Moderate Moderate
• lOMoAR cPSD|