William Fredericks Health Assessment Practice Exam (1 Solved Case)

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William Fredericks42 y/o male6’0’’ (183 cm)215.0 lbs (97.7kg)Reason for encounter: worsening headaches and facial pain, feverHx:Hx of present illness:OLDCARTS mnemonicOnset:Loca琀椀on:Dura琀椀on:Characteris琀椀cs:Aggrega琀椀ng:RelievingTreatmentSeverityPMH:HTN: 6 YEARS, Hypercholesterolemia x 6 years psoriasis since childhoodSx hx: appendectomy at 29 y/o hospitaliza琀椀on appendectomyMedica琀椀ons: Hctz 25 mg po DAILyMul琀椀vitamin daily OTC as neededTylenol ES Tylenol cold and 昀氀u advil naproxenAllergies:grass, trees. Seasonal pollen, dust & mold with symptoms of itchy watery eyes, scleralinjec琀椀ons, sneezing, runny nose, nasal conges琀椀onPreventa琀椀ve health:Fitness, no exercise rou琀椀ne except for ac琀椀vey on job nutri琀椀on: typeical American diet high in meats andcarbs,Stress reduc琀椀on: nothing works 50+ hours a weekDaily sleep 6-7 hrs with addi琀椀onal on weekendslOMoARcPSD|13778330

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Previous ½ pack x 20 years, quit 4 years ago, no relapse alcohol intake 1-3 beers during the weeks, 2-4beers, weekend no recent fecal occult blood sample or prostate examChildhood immuniza琀椀on:up to date does not receive seasonal 昀氀u shot or adult vaccina琀椀on SPrior visit documented- update allergies, medica琀椀ons, OTC drugs.Family Hx: father 71/yo obese, CAD mother 69 y/o obeses, hx of DM maternal GM. Hx DM; deceased 72,sepsis r/t LE amputa琀椀on maternal GF: hx CV dz, decreased age 78 MI paternal GM; no PMH, decrased 82. MI paternal GF: hx HTN, decease age 80, MI brother 47 y/o DM sister 39 y/o HTNSocial Hx:Married wife37 y/o HTNN child; son 11 y/o and daughter 16 y/o both health tobacco ½ pack per day x20 years quit 4 years ago without relapseETOH 1-3 during the week; 2-4 on weekends drug use: non currently; experiment with marijuana in HSand early adulthoodReview of Symptoms:Ques琀椀ons for system not addressed in HPIChoose ROS for those body system you do not have info on. Use large mul琀椀part ques琀椀onExercises:-Complete any clinical exercise found that follow various case play sec琀椀ons-When you’ve completed the exercises and clicked proceed, you will be taken to the next .Current Visit:1.How can I help you today? – good ques琀椀onI am here because I feel really sick and am not ge琀񐀀ng be琀琀er. I have this HA which started about 2 weeksago. I was just ge琀񐀀ng over a cold at that 琀椀me. Over the last 2 weeks my headache got worse and moreof my heart hurt. It now hurts to move my eyes.2.What other symptoms or concerns we should discuss?yes, maybe 3 or 5? Days ago my runny nose, which had resolved, has restarted and changed from clearto creamy. Then over the last day or two I started having low grade fever- around 99.5 to 100 F. I alsohave this strange tooth pain/sensi琀椀vity and ear pain. I feel like I am falling apart. Its one thing a昀琀eranother. What a wreck I am!When did HA start?-I guess about 14 or more days agoIs this the worst HA of your life?Not really. I got hit in the head during li琀琀le league prac琀椀ce when I was a child. That was the worse HA Iever hadlOMoARcPSD|13778330

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Does the HA awaken you from sleep?-NoDose HA keep you from sleeping?-Somewhat, or rather it keeps me from falling asleepHave you had HA like this before?-Not this long or severeHA comes on slowlyDoes your HA come and go?-No it is constant since it started-HA does not radiateHead ache does not awaken him from his sleep,has facial pain now. Forehead above eye. Badheadache, does not pulsateSOB when climb stairs, but I think that all due to my weight and that’s not newDO you have a sore throat?-Yup, it started with my coughingWhere more precisely is your facial pain?-It is below my eyes (points to region surround eye bilaterally) and it also feels like I have a toothproblem on the right. That pain comes and goes but the tooth looks 昀椀nd. I haven’t been to theden琀椀st in probably 2 years. Do you think I need to go. Im quiet a mess aren’t IWhat does the pain on your face feel like?-It feels like pressure most of the 琀椀me. Some琀椀mes really bad. Like my face will explodeDoes anything make the pain in your face be琀琀er or worse?-Laying down makes it hurt worse. Bending over that’s really bad, like my face will explode itfeels best when I am in the shower with all the steam and acetaminophen helps a li琀琀leUes taking HTN DM and cholesterolAre you taking any OTC or herbal medica琀椀ons-Yes, Ive been trying varios pain and isnus meds. Oh yeah, and I take a vitamin every day a lto ofgood that’s doing meDo you have any problem with fa琀椀gue, di昀케cult sleeping or weight loss, fever or night sweats?-I wish I had uninten琀椀onal wt loss, fa琀椀gue. Its not new that I get fa琀椀gue sort of easily. But maybesince I am sick it is a li琀琀le worse. Is that it?lOMoARcPSD|13778330

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Do you have problem with muscle or joint pian, redness, joint s琀椀昀케ness, joint swelling or redness-Nope nothing right now, old knee issues abut not bothering at the momentDo you have problem with nausea vomi琀椀ng, cons琀椀pa琀椀on or vomi琀椀ng-Nope one of that, I got plent of other problemsPhysical exam:42 y/o M72”215 lbs29.1 BMIAxO x 437.7 oralPulse 82 Regular, strength, normalBP L 130/82, R 130/82 assessment. Pulse pressure, normalRR 18 Regular, e昀昀ort, unlabored96%Skin:warm and dryVital signs (op琀椀onal)-You must look at vitals in the HER (current visit) to get credit.Performing your physical exam:-Perform those physical assessment maneuvers as needed-Document in key 昀椀ndingsAssessment:-Organized Key 昀椀ndings by selec琀椀ngMSAP (Most Signi昀椀cant Ac琀椀ve Problem)-Mark other 昀椀ndings as:related, unrelated, unknown, or PMH/resolvedProblem Statement:-Short Summary of pa琀椀ent’s presenta琀椀on.-Should contain-demographics descrip琀椀ons:-chief complain-hx and physical exam key 昀椀nding-risk factors Keep it concise-lOMoARcPSD|13778330

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Yes, may 3 or 5 days ago runny nose, which had resolved, has restarted and changed from clear tocreamy. Then over the last day or two I started having low grade fever around 99.5 to 100 F I also have astrange tooth pain/ sensi琀椀vity and ear pain. I feel like I am falling apart. Its one thing a昀琀er the other.What a reck I amWhen did your cough start? I feel it started with my post-nasal drip- stu昀昀 going down the back of mythroat.When did the pain in your face start? – it started a昀琀er HA maybe 7 to 10 days agoLoca琀椀on: HA pain – above eye, forhead and now faceLoca琀椀on of ear pain:right ear pain, le昀琀 no issuesLoca琀椀on of face pain:below eye here (points to region surround eyes bilaterally and it also feels like Ihave tooth problems on the right. That pain comes and goes but the tooth looks 昀椀ne. I haven’t been toden琀椀st in probably 2 years. Do you think I should go.Characteris琀椀cs:have had HA like this before-> not this long or severeCharacteris琀椀cs: What does pain in your face feel like?like a lot of pressure most of the 琀椀me.Some琀椀mes really bad, like face will explodeCharacteris琀椀cs:HA awaken from sleep? NoCharacteris琀椀cs:Headache come and go?constant since it startedCharacteris琀椀cs:Been any changes in your headache over琀椀mestarted out mild but then worse.Characteris琀椀cs:does HA keep you from falling asleep?somewhat or rather, it keeps from fallingasleepCharacteris琀椀cs:what does the pain in your HA feel like?I don’t know, it feels like a bad HAAggrava琀椀ng:does anything make the pain in your face be琀琀er or worse: laying down makes it worse.Bending over that’s really bad like my face will explode. It feels best when I am taking a shower with allthe steam in the room. Acetaminophen helps a li琀琀le bitAggrava琀椀ng:does anything make your HA be琀琀er or worseHA feels less intense when I am in shower,and it worse when I am lying downRelievingTiming/treatment: what treatments have you tried for HAacetaminophen, sinus meds, but they bothstop workingTiming/treatment:how o昀琀en how you have headaches like this? Almost never. I remember one episodemaybe a year a go, but that was really mild by comparisonHow severe (1-10) is pain on your face; 6/10 now but that changes throughtout the day and nightIs this worse HA of your life: no li琀琀le league prac琀椀ce ge琀񐀀ng hit in the head was worse painlOMoARcPSD|13778330

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HPIhave you had any contact with other sick people?Yea my kids had colds recently along with severalof their friendsPMH:have you been taking your medica琀椀ons as prescribed? Yes are you taking OTC or herbalmedica琀椀ons? Yes various of pain and sinus meds. And vitamins every day.Exam:Skin: psoriasis elbows and knees, feet: skin on feet dry and crackingThickness distribu琀椀on pa琀琀erns typical for pa琀椀ent for gender and ageHEENT:Head:no visible scaliness, edema, masses, lumps, deformi琀椀es, scars, rashes, nevi, or other lesion andnontender. Head is normocephalic, no deformi琀椀es,Facial features symmetric: trachea midlineCap re昀椀ll x 3 secondsEyes:eyelids no ptosis, erythema or swellingConjunc琀椀vae: pink, no d/cSclerae: anictericOrbital area: no edema, redness, tenderness or lesions notedEyes: normal reac琀椀ve, PERRLA. H pa琀琀ern normal reac琀椀ve no nystagmusRed re昀氀ex bilaterally, op琀椀c disk sharpEars:normal appearing external structure, no deformi琀椀es, or edema, no discharge noted. Normalappearing external auditory canals, L tympanic membrane translucent. Non-injected, and pinkish-gray incolor on le昀琀, good li昀栀t re昀氀ex, normal movement.Right ear:tympanic membrane appears tense, mildly injected, poor li昀琀 re昀氀ex, and poor movement.Hearing intact rinne, and webers test.Nose:nose appear normal with no external lesion, redness, and irrita琀椀on around nostril. Inside noseerythematous and edematous membrane bilaterally, no polyps, purulent discharge noted, in posteriorregions, narrowing due to swollen turbinatesMouth:oropharynx shows mild erythema, tonsils without exudate. Tongue normal color symmetrical noswelling or ulcera琀椀on. No overt dental problems seen on R incisior site or intermi琀琀ent pain. Buccalmembranes no lesions noted, Odor suggest infec琀椀on in mouthNeck:no visible scars, deformi琀椀es or other lesion, trachea midline and freely mobile, thyroid 昀椀rm,normal size, sho琀琀y lymphadenopathyPalpate all lymph nodes: submental, submandibular, auricular, posterior auricular, posteriorlOMoARcPSD|13778330

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