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Marvin Webster History How can I help you today? Do you have any other symptoms or concerns we should discuss? Do you have any allergies, such as medications, food and/or latex, for example? Are you taking any prescription medications? Are you taking any over-the-counter or herbal medications? Can you tell me about any current or past medical problems you have had? Any previous medical, surgical, or dental procedures? Do you now or have you ever smoked or chewed tobacco? Have you had any contact with other sick people? Are you sexually active? Do you experience: chest pain discomfort or pressure; pain/pressure/dizziness with exertion or getting angry; palpitation; decreased exercise tolerance; blue/cold fingers or toes? Do you have any of the following: dizziness, fainting, spinning room, seizures, weakness, numbness, tingling, tremor? Do you have any of the following problems: fatigue, difficulty sleeping, unintentional weight loss or gain, fevers, night sweats? How high was your fever?
When you urinate, have you noticed: pain, burning, blood, difficulty starting or stopping, dribbling, incontinence, urgency during day or night or any changes in frequency? How severe (1-10) is the pain in your chest? Do you have any pain in your chest? Have you noticed: any bruising, bleeding gums, nose bleeds or other sites of increased bleeding? Do you have any of the following: heat or cold intolerance, increased thirst, increased sweating, frequent urination, change in appetite? Do you have any problems with: nervousness, depression, lack of interest, sadness, memory loss, or mood changes, or ever hear voices or see things that you know are not there? Do you awaken at night coughing? What treatments have you had for your cough? What are the events surrounding the start of your cough? Is there any pattern to your cough? Does anything make your cough better or worse? Do you have HIV? Do you drink alcohol? If so, what do you drink and how many drinks per day? Have you had a cough like this before?
Chest wall and lungs: auscultate lungs Heart: auscultate heart Abdomen: visual inspection abdomen Extremities: visual inspection extremities Musculoskeletal: inspect for muscle bulk and tone Vitals: pulse Chest wall and lungs: auscultate lungs Vitals: respiration Vitals: pulse Vitals: blood pressure Abdomen: palpate abdomen Genitourinary: genitourinary male exam HEENT: inspect mouth/pharynx Lymphatic: palpate all lymph nodes Musculoskeletal: test strength Neck: palpate neck Neurological: cranial nerves Neurological: reflexes – deep tendon Orthostatic blood pressure (BP) SPO Mental status
Marvin Webster Chief complaint: Problems: feels awful and exhausted, has body aches and feels really weak. Sore throat, coughing, and has a headache. Muscle aches too Chief complaint Sx/Sx characteristics questions missed:
- How bad is your cough?
- Does anything make your cough better or worse?
- What are the events surrounding the start of your cough? Associated Sx/Sx characteristics questions missed:
- Do you wheeze?
- What treatments have you had for your sore throat? - Have you had a sore throat like this before? Risk factors PMH questions missed:
- Are you taking any OTC or herbal meds? Etiology questions missed:
- Have you had any contact with other sick people? HPI/ROS questions missed:
chills, malaise, cough, arthralgias and myalgias are all relevant to signs and symptoms of the flu according to the CDC (2020). Determining Marvin’s cough and exhaustion came on suddenly can further narrow down his diagnosis. According to Papadakis et al (2019) a positive flu is suspected when a person has sudden onset symptoms of exhaustion and cough. It is suspected Marvin has the flu according to his reported symptoms. The CDC (2020) reports the flu is highly contagious and can be contagious for up to a day before a patient even shows symptoms. It is important to inquire about symptoms; weight loss, diarrhea, duration, fatigue and vaccine history to help aide in a differential diagnosis. Asking Marvin about his health history, prior flu vaccines and his social history can help further determine a diagnosis. Physical Exam Rationale A focused and systematic physical exam is one of the most vital components in diagnosing and treatment of a patient. Performing a head to toe assessment and vital signs can be crucial to identifying potential problems. Starting with Marvin’s baseline vitals and identifying his elevated temperature is indicative of an infection. While listening to Marvin’s heart, lungs and abdomen additional insight can be observed and palpated regarding his cardiac and gastrointestinal status. Playing close attention to auscultation of Marvin’s cough can better identify if the cough is in the upper or lower airways and can rule out asthma and wheezing which Marvin had as a child. It is important to rule out possible upper respiratory infections while examining the HEENT system. Marvin’s HEENT exam findings are negative.
Bickley et al (2017) indicates auscultating lung sounds for fremitus, egophony or bronchophony can aide in the determining a differential diagnosis. Often times influenza can cause stomach pain leading to diarrhea which would be found with hyperactive bowel sounds. Marvin’s bowel sounds upon palpation and auscultation are however negative. Case Evaluation My overall case evaluation revealed areas of growth and opportunity to improve my assessment and physical exam skills. It is important to follow the head to toe approach to be consistent and to not skip or repeat exams and interview questions. Ensuring to include severity of chief complaint following the POLDCARTS acronym during the HPI. Not to forget to go further in my assessment and ask questions pertaining to the patient’s sore throat such as severity, timing, and what makes is better or worse. Other assessments missed include questions regarding wheezing, severity and related problems such as difficulty sleeping, dizziness or seizures. Overall, I need to practice simulation exercises to become more proficient and specific to the body systems involved for diagnostic and treatment purposes. I was happy to see I had the same “key findings” as the expert feedback. Although I used different wording, this week I managed to do much better this week. Again, I struggled to make the i-Human simulation program happy. I asked questions similar to what the program wanted me to ask, but because I did not ask the exact question, it indicates I missed asking key questions. Slowing down, and organizing my head to toe approach is key to not missing key factors since this simulation is not based on time but rather efficiency and accuracy of skill
Papadakis, MA., McPhee, SJ., Bernstein, J. (2019). Quick Medical Diagnosis &
Treatment. New York, NY:
McGrawHill. http://accessmedicine.mhmedical.com/content.aspx? bookid=2566§ionid=206 887593. Accessed February 1, 2020. 18 year old male 6’ 185lbs Chief Complaint- Fatigue, shortness of breath, and cough Skin-Warm and dry
- Fever is getting worse
- c/o flu for about 2 weeks, felt better now feels sick again
- generalized body pain
- fatigue started about 4 days ago
- fever started 4 days ago as 101 went up to 104
- chills
- poor appetite
- cough started 4 days ago
- coughing up yellow and greenish sputum
- drinking hot tea helped make the cough better a little in the beginning but no longer works
- no hemoptysis
- not moving is the only thing that helps with SOB
- no wheezing
- coughing makes him queasy
- hx of sore throat with the flu but not now
- pain in chest when coughing or taking a deep breath (right thorax, 6- intercostal space, midaxillary line)
- no tightness
- no sadness, depression or hopelessness
- medical hx of mild asthma as a child
- NKA
- No current medications prescribed-taking OTC ibuprofen
- Unsure of immunizations
- Did not get the flu vaccine or pneumonia vaccine
- No recent travel
- Occasional beer
- Denies drug use and smoking
- Cough syrup not working
- Coughing keeping him up- coughs when going into the cold
- b/l swollen lymph nodes in neck
- hoarseness Problem Statement Marvin F. Webster is an 18-year old male college student with a history of childhood asthma who presents with acute onset of low- grade fever, nonproductive cough, sore throat, fatigue, myalgias and headache. The physical exam reveals an erythematous pharynx, anterior cervical adenopathy and scattered bilateral crackles. Risk factors include lack of annual flu vaccine. The article “Hospitalized Patients with 2009 H1N1 Influenza in the United States” states that hospitalization among patients with influenza is more prevalent in patients 65-years of age or older and those under the age of 7-years and young febrile patients are more likely to be tested for influenza than older adults with influenza often do not have a fever. The typical patient presents with a sudden onset of symptoms (fever, nonproductive cough, myalgias, headache, coryza and/or sore throat) (Jain, Kamimoto & Schmitz, 2011). our patient presented with most of these symptoms.
The patient history should focus on detecting symptoms consistent with community acquired pneumonia because pneumonia combined with influenza is the eighth leading cause of death in the United States (Watkins & Lemonovich, 2011). For the focused exam I began the exam with the head, ears, nose and throat because they all linked closely together. The patient reported a mild headache, further investigation is recommended to assess for life-threatening secondary causes (Bickley, 2017). Due to the new complaint of ear pain, assessing ears with the otoscope was necessary to see if anything significant was happening. In the case with Marvin the ear findings were reddened right tympanic membrane. The physical exam should include a detailed exam of the throat and neck, noting any erythema or exudate. The patient was noted bilateral red, erythematous and edematous pharynx with tender 0.8 cm to 1.0 cm anterior cervical lymph nodes. These findings along with low-grade fever prompted the rapid strep test. Another area of importance to examine is the abdominal area, noting whether the abdomen is soft and without distention. Assessing for notable splenic or hepatic enlargement or tenderness is important due to possible diagnosis of infectious mononucleosis, the patient symptoms follow the similar symptoms of this disease with fatigue, fever, pharyngitis and adenopathy (Porter & Kaplan, 2011). Patients should be asked about occupation, animal exposures, travel history and sexual history to help identify a specific infectious agent.
Influenza is often suggested based on typical symptoms during peak influenza season (Watkins, 2011). Our patient is at high risk due to the lack of receiving the influenza vaccine this year. Maneuvering through the program is still my biggest challenge. I have improved with my score, but it took over 200 questions and I still missed 2 important questions to ask. I reviewed the skilled interviewing techniques in chapter 3 of the textbook and still need a lot of practice with my patient interview. I continue to struggle with the physical exam with performing them on the computer, it is much easier to auscultate on a real person. I am happier at the end of the avatar exam, as my grade improved each time. Reference:
Bickley, L., Szilagyi, P.G., & Hoffman, R. (2017). Bates' Guide to
Physical Examination and
History Taking (12th ed.). Philadelphia, PA: Wolters Kluwer.
Jain, S., Kamimoto, A. M., & Schmitz, A. M., et al (,
2009). November. The New England
Journal of Medicine, (), 1935-1944. doi:10.1056/NEJMoa
Porter, R. S., & Kaplan, J. L. (2011). The Merck Manual (19th ed.).
Whitehouse Station, NJ: Merck Sharp & Dohme Corp.
Risk factors PMH questions missed:
- Are you taking any OTC or herbal meds? Etiology questions missed:
- Have you had any contact with other sick people? HPI/ROS questions missed:
- How can I help you today
- Do you have any other symptoms or concerns we should discuss - When did the pain in your chest start?
- Does anything make the pain in your chest better or worse - Where more precisely is the pain in your chest?
- Does the pain in your chest radiate someplace else? Where?
- How severe 1-10 scale is the pain in your chest? (4-5/10) - Have you had trauma to your chest? – no - How long does your chest pain last?
- Is your chest pain precipitated by exercise?
- Any change in your chest pain since it began?
- Does the pain in your chest come and go?
- Do you experience SOB, wheezing, difficulty catching your breath, chronic cough, sputum production?
- Do you have problems with N/V, constipation, diarrhea, coffee grounds in your vomit, etc
- Do you have any of the following problems with: fatigue, difficulty sleeping, unintentional weight loss, or gain, fevers, night sweats?
- Do u have any problems with nervousness, depression, lack of interest, sadness, memory loss, or mood changes, etc
- Do you drink alcohol? If so, what do you drink and how many drinks per day?
- Has drinking alcohol ever caused you problems?
- Can you tell me about your diet, what your normally eat?
- Have you ever felt you needed to cut down on your drinking?
- Has anyone suggested that you should reduce the amount of alcohol you drink?
- Have you ever been annoyed at anyone for suggesting that you cut back on your alcohol consumption?
- Do you presently have heartburn, a food or acid taste in your mouth? - When and what did you last drink? – wine around 10pm last night
Chief Complaint: “I feel awful...I’m exhausted, short of breath, my fever is getting worse.” HPI: Marvin C. Webster is an 18 yr old male who recently had the influenza virus two weeks ago which resolved, and today presents with a four day history of sudden onset fever 103.2, with chills, rigors, myalgia, productive cough without wheezing, fatigue, and sharp right sided pleuritic chest pain that is aggravated with coughing and breathing. He reported a fever of 104 last night and took OTC Ibuprofen with no significant improvement in his symptoms. He complains of a productive cough with green/yellow sputum with no relief after taking cough syrup. Pt denies any recent travel or sick contacts. Patient reports he takes no daily prescription medications or additional OTC medications. ROS: Constitutional: Positive for fever, chills, rigor, fatigue. Negative for appetite change, diaphoresis. HEENT: Positive for swollen glands; negative for headache, sore throat and difficulty swallowing Respiratory: Positive for dyspnea, productive green/yellow sputum, and shortness of breath, negative for wheezing Cardiovascular: Positive for right sided chest wall pain (6-8th intercostal spaces at midaxillary line), negative for leg swelling
Current Medications: OTC Ibuprofen OTC cough syrup Allergies: No known drug allergies Vital signs: Temp: 103.2 F Pulse: 120 bpm BP: 120/80 mmHg RR: 24 bpm O2: 91% RA Physical Findings: General: Alert and oriented x 4, calm, cooperative Skin: pink, warm and dry; no rash, lesions or icterus; tenting of the dorsal hand
HEENT: Head normal, atraumatic; normal conjunctiva, no scleral icterus, clear right and left tympanic membranes; exudative pharyngitis, no palatal petechiae Neck: Tender 1.0-cm to 1.5-cm anterior cervical lymph nodes, neck supple, full range of motion Lymphatic: Tender anterior cervical adenopathy; no posterior nodes palpable; no other regional lymphadenopathy Chest wall and lungs: Bibasilar pulmonary crackles, tachypnea, hypoxia Heart: Sinus Tachycardia Abdomen: soft, non-tender; no hepatosplenomegaly Extremities: no swelling or deformity; no cyanosis, clubbing or edema
