IHUMAN CASE STUDY: MARVIN WEBSTER, 18Y/O MALE CC. DRY COUGH, SORE THROAT, RIGHT EAR PAIN, FATIGUE, HEADACHE AND MYALGIACC: 18 y/o M
Chief complaint is a
... [Show More] short 1-2 statement or word phrase
from patient and should be listed in “quotes”
“I feel awful, I’m exhausted. I have body aches
and just feel really tired.”
HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts
Mr. Webster, an 18-yr-old male presented to the clinic with complaints of
persistent dry cough, sore throat, right ear pain, fatigue, headache, and myalgia.
He reports he has exercised induced asthma which has been latent and did not
receive his annual flu vaccine.
Onset: Most symptoms appeared 1-2 days ago
Location: Mostly throat, Headache and Ear
Duration: Every day and symptoms have persisted since onset.
Character: He reports 2/10 severity of ear pain which is non-radiating, and
sharp. Sore throat of 6-8/10 severity which is non radiating and feels like a razor
cut. Headache is mild and just annoying.
Aggravating/alleviating factors: Sore throat is aggravated by cough and
swallowing.
Related symptoms: Fatigue and myalgia with onset of other symptoms 1-2 days
ago. Denies exposure to any sick people.
Treatments: He has tried ibuprofen for pain
Significance: He feels exhausted and he is missing class
PMHx child/adult
illness/hospitalizations/immunizations
Childhood exercised induced asthma with no
recent exacerbations.
No hospitalizations, trauma or other injuries
Immunizations: States his immunizations are
SurgHx type/when/why/complications
Never for Surgical history.
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Case:
Date:
current for college. He has not received the Flu
vaccine this year.
FamHx
Grandparents (if known)/Parents/siblings/children
He has no knowledge of his grandparents
medical history.
Mother-age 58-Hypertension
Father-age 57-Healthy
SHx
Tobacco/vaping/ETOH/illicit drug use/occupational/environmental/relationships
Alcohol—Denies any recent alcohol intake, but occasionally drinks wine in the
night after studying.
Tobacco—Denies any history of smoking, vaping, or other tobacco use.
Denies Recreational drug use.
Relationships: Single
Full-time student, not planning on working during the first semester.
Denies any recent travel outside country in the past 2 weeks
Reproductive Hx
Female: Age of menarche/menstruation cycle
duration/gravida para status/Childbirth hx/sexual hx and
concerns/LMP/menopause
Breast/cervical screening (if any)
Male: Sexual hx and concerns/issues with fertility (if
any)/Testicular or prostate screening (if applicable)
Screening for STI’s (if applicable)
Male patient not currently sexually active
Allergies (Food, Drug, Environmental, etc.)
List of Medications/supplements (prescription, OTC, complementary
alternative therapies)
Ibuprofen used occasionally for pain.
Review of Systems: (ROS) Use this column to
document the ROS below.
General: Denies any weight gain or loss
HEENT: Denies vision changes. Complaints of sore
throat, cough, right ear pain and headache
Pulmonary: Denies shortness of breath. Reports
From the ROS: list/highlight the current symptoms/complaints to generate a
list of pertinent “reported or denied” symptoms below:
Pertinent Positive ROS: Reports headache; Sore throat that worsens with cough
and swallowing, 6-8/10 pain scale; sharp ear pain that does not radiate to any
part of the body rate scale of pain at 2/10. He feels exhausted and has aches and
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cough.
CV: Denies any chest pain.
GI: Denies nausea, vomiting, diarrhea or
constipation.
GU: No complaints of urinary problems
MS: Complaint of myalgia
Heme: No complaints of bleeding or bruising
Lymph:
Endocrine: No complaint of polyuria, polydipsia
Derm: Denies any rash or lesion.
Neuro: No complaints of tingling to Lower
extremities
Psych: Denies feeling hopeless and sad
pains all over his body.
Pertinent Negative ROS: Denies shortness of breath or wheezing and also
denies chest pain.
Physical Exam: (PE) Use this column to
document the PE below.
Vitals (HR/BP/RR/T/SpO2/Ht/Wt/BMI%)
Temperature: 100.4
Pulse: 88
Blood pressure: 122/82 mmHg - Sitting
Respiratory rate: 16 bpm
SpO2: 98% on room air
Weight 185 lbs.
Height 6’0”
BMI 25.1
General:
HEENT: Normocephalic, head atraumatic,
Pupils reactive, Right ear shows slightly red
tympanic membrane, Bilateral red,
From the PE: list/highlight the presence or absence of objective findings to
generate a list of pertinent “(+) or (-)” symptoms below:
Pertinent Positive PE findings: Right eat shows red tympanic membrane,
bilateral red erythematous/edematous pharynx. Positive anterior cervical lymph
nodes. Scattered fine crackles of lungs on auscultation.
Pertinent Negative PE Findings: Negative for wheezing, Thoracic lymph node
non palpable. Symmetrical respirations and no abnormal retractions
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erythematous, and edematous pharynx.
Neck: Anterior cervical lymph nodes. Negative
thyroid enlargement
Pulm: Bilateral scattered fine crackles, Negative
for wheezing, Thoracic lymph node non
palpable, Symmetrical respirations, and no
abnormal retractions.
CV:HR 88. Normal heart sounds
GI: Soft round and no tenderness. BS active X 4
GU: Normal genitalia, no tenderness or masses
and no urethral discharge
Neuro: Cranial nerves I-XII intact, Normal gait
and posture
MSK: ROM normal, equal bilaterally.
Psych: No cognitive impairment
Lab/Radiology or other Diagnostic data:
Rapid Strep antigen detection test (RST/RADT)
- Negative
COVID – 19 PCR (swab)
Complete blood count (CBC) – Normal except
for slightly elevated WBC (11,500)
Rapid influenza diagnostic test (RIDT) -
Positive
Problem Statement: Mr. Webster is a 22-year-old male presenting with flu-like
symptoms for the past 1-2 days. He reports of non-radiating ear pain with a scale
of 2/10 that is sharp as well as a sore throat with intensity of 6-8/10 which is
aggravated by cough and swallowing. He also has a complaint of myalgia and
fatigue. He has a medical history of asthma with no recent exacerbation,
otherwise, PMH/Surgical HX/FH was reviewed and non-significant. Denies
recreational drug use and tobacco use; he reports occasional wine. PE findings
shows scattered fine crackles of the lungs, low grade fever, anterior cervical
lymph nodes, and bilateral red erythematous/edematous pharynx.
IHUMAN TOTAL CASE SCORES:
#1: 74%
List the differential diagnoses (Must not
Miss/Leading/Alternate/Concluding)
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#2: 58%
Based on patient’s age/risk factors, what
preventive screening would be recommended
at today’s or a future visit:
Grade A
Screening for High BP in adults 18 years and
older
HIV screening although not currently sexually
active, he has been in the past.
Grade B
Screening for unhealthy drug use in adults 18
years and older
*Include ICD 10 codes after each
Must not Miss/Leading
The myalgia, fatigue, low grade fever, nonproductive cough, ear pain and sore
throat is more indicative of influenza as well as the positive Influenza PCR
test. Influenza (J11.1) is the most conclusive diagnosis.
Covid – 19 (U07.1) must be ruled out since there is a pandemic and the
symptoms of cough and sore throat as well as the myalgia. Negative test rules
out COVID-19
Group A Streptococcus pharyngitis (Strep throat) (B95.0) ruled out by negative
strep antigen test.
Community Acquired Pneumonia (CAP) (J18.9) – negative hypoxia and
productive cough makes it a less like diagnosis.
Alternate
Asthma: although there is a medical history of asthma, it has been latent, and the
physical examination did not show any wheezing.
(ICD10data.com, 2021)
*Case Study Template adapted from the following sources: NP H & P (ReNursing.edu, 2018) and IHuman Patients by Kaplan (2020)
Reflective Thinking Exercises (start a new page)
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1. History-Taking: Describe your history taking scores and strengths you identified when gathering data. What went well?
Also, describe your challenges in gathering data and list areas of your personal needed improvement. Note any missed
areas that could be safety issues/errors leading to missed or incorrect diag [Show Less]