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Performance Overview for April Dralle on case Amina Johnson*
The following table summarizes your performance on each section of the case, whether you completed that section or not. Time spent: 2hr 48min 21sec Status: Submitted Case Section Status Your Score Time spent Performance Details Total Score 80% History Done 100% 14min 54sec 78 questions asked, 14 correct, 0 missed relative to the case's list Physical exams Done 100% 15min 57sec 44 exams performed, 12 correct, 0 partially correct, 0 missed relative to the case's list Key findings organizati on Done 6min 40sec 9 findings listed; 14 listed by the case Problem Statement Done 4min 24sec 84 words long; the case's was 57 words Diagnosis Done 0% 1min 10sec Management Plan Done 1hr 4min 17sec 953 words long; the case's was 231 words Exercises Done 85% (of score d items only) 3min 59sec 0 of 1 correct (of scored items only) 1 partially correct Attempt: 3189072 Report generated on 6/30/2024, 5:44:10 PM America/Indianapolis
History Notecard by April Dralle on case Amina Johnson*
Use this worksheet to organize your thoughts before developing a differential diagnosis list.
- 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.
- Characterize the attributes of each symptom using "OLDCARTS". Capture the details in the appropriate column and row.
- 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
Characteristi
cs
Aggravating
Relieving
Timing
Treatmen
ts
Severity
Attempt: 3189072 Report generated on 6/30/2024, 5:44:10 PM America/Indianapolis
Management Plan by April Dralle on case Amina Johnson*
Patient Information: AJ, 23, Female HPI: Amina, a 23-year-old female, presents with a sore throat, pharyngeal erythema, and tonsillar exudate. She has tender cervical lymphadenopathy and reports a temperature of 101.5°F. A headache and the absence of a cough accompany her symptoms. She has a history of recent infectious contact and has not received an influenza vaccination. Additionally, Amina had infectious mononucleosis at age 15. These findings suggest a potential upper respiratory infection, likely of bacterial origin, requiring further evaluation and management to confirm the diagnosis and initiate appropriate treatment. Current Medications: Drospirenone/ethinyl estradiol- 3 mg/ 0.02 mg tabs; 1 tab PO daily for contraception Acetaminophen as needed Allergies: NKDA PMHx: Immunizations up to date minus influenza vaccination Soc Hx: Full time law student. Lives with roommate who was recently sick with the same symptoms. Denies tobacco use and reports social alcohol use. Reports roommate and mother are her support system. Sexually active with one male partner, practices safe sex and uses oral contraceptive. Denies problems falling asleep or staying asleep. Fam Hx: Mother: hypertension ROS: GENERAL: Denies weight loss, weakness or fatigue. HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Denies hearing loss, sneezing, congestion, or runny nose. Complaints of sore throat. SKIN: Denies rash or itching. CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema. RESPIRATORY: Denies shortness of breath, cough or sputum. GASTROINTESTINAL: Denies diarrhea, constipation, or vomiting GENITOURINARY: Denies dysuria or hematuria NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: Denies muscle, back pain, joint pain or stiffness. HEMATOLOGIC: Denies anemia, bleeding or bruising. LYMPHATICS: Tender cervical lymphadenopathy. PSYCHIATRIC: Denies history of depression or anxiety. ENDOCRINOLOGIC: Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia. ALLERGIES: Denies history of asthma, hives, eczema or rhinitis. Physical exam: GENERAL: Pharyngeal erythema and tonsillar exudate, tender cervical lymphadenopathy, fever. No report of weight loss or fatigue. HEENT/Neck: Sore throat, no congestion, headache CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema. Chest/Respiratory: Denies shortness of breath, cough or sputum. ABDOMEN: Soft, nontender, bowel sounds present normoactive
Musculoskeletal/Osteopathic Structural Examination: No joint erythema or swelling in upper or lower extremity joints. Neurologic: Gait intact.
Follow-Up: Schedule a follow-up appointment in 1-2 weeks to reassess the patient’s condition and review test results. Re-evaluate if symptoms persist beyond expected recovery time or if there are any complications.
References Epstein-Barr Virus (EBV) Infectious Mononucleosis (Mono) Clinical Presentation: History, Causes, Physical Examination. (n.d.). Emedicine.medscape.com. https://emedicine.medscape.com/article/222040-clinical Gupta, M., & Shorman, M. (2020). Cytomegalovirus. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459185/ Stamm, D. R., & Stankewicz, H. A. (2020). Atypical Bacterial Pneumonia. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532239/ Wolford, R. W., & Schaefer, T. J. (2023). Pharyngitis. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519550/ Attempt: 3189072 Report generated on 6/30/2024, 5:44:10 PM America/Indianapolis
Social History
Category Data entered by April Dralle Social History Tobacco: denies Alcohol: Socially with law school friends Drugs: No illicit drugs Diet: Tries to eat healthy Activity: Walks to and from class Sleep: No complications sleeping Living situation: Lives with roommate who was recently sick Sexual history: Sexually active with one male partner
Review of Systems
Category Data entered by April Dralle General Fever 101. Integumentary / Breast Denies ecchymosis, rash, or petechiae HEENT / Neck Denies^ congestion,^ hearing^ loss,^ sinus^ pressure,^ or^ visual^ changes. Reports sore throat Cardiovascular Denies chest pain or palpitations Respiratory Denies cough or shortness of breath Gastrointestinal Denies diarrhea, constipation, or vomiting Genitourinary Denies dysuria or hematuria Musculoskeletal Denies joint swelling or limping Allergic / Immunologic Denies hives or itching Endocrine Denies polydipsia or polyuria Hematologic / Lymphatic Denies easy bruising or bleeding Neurologic Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. Psychiatric Denies depression or anxiety
Physical Exams
Category Data entered by April Dralle General Pharyngeal erythema and tonsillar exudate, tender cervical lymphadenopathy, fever. No report of weight loss or fatigue. Skin Elastic skin turgor, well hydrated. HEENT / Neck Sore throat, no congestion, headache Cardiovascular Denies chest pain, chest pressure or chest discomfort. No palpitations or edema. Chest / Respiratory Denies shortness of breath, cough or sputum. Abdomen Soft, nontender, bowel sounds present normoactive Genitourinary / Rectal Exam not performed Musculoskeletal / Osteopathic Structural Examination No joint erythema or swelling in upper or lower extremity joints. Neurologic Gait intact Psychiatric Denies depression or anxiety Lymphatic Tender cervical lymphadenopathy Attempt: 3189072 Report generated on 6/30/2024, 5:44:10 PM America/Indianapolis
