Â Julie is a 35 year old African American female who complains of a â€œsore throatâ€ for the past 3 days. Â
Focused Case Study # 1
Julie is a 35 year old African American female who complains of a â€œsore throatâ€ for the past 3 days. Julie was concerned because it is not getting any better, only worse. She had her friend look in her throat at work and was told to go to her primary care office for evaluation. Julie was also concerned because she saw some redness on the back of her throat. Julie states that when she tries to swallow â€œit feels like she is swallowing knives.â€ She has been having a hard time eating and drinking due to the pain. She has noted bad breath throughout the day over the past three days. She tried to take a Tylenol at home yesterday, but the pain did not improve. She admits to coughing occasionally. She gives the pain in her throat a 7/10 on the pain scale.
Julie works as a receptionist at a car-dealership. She is an avid outdoor enthusiast. She hikes regularly, and tries to travel when she can to tropical locations. Her last trip was a few weeks ago. She traveled by airplane to Puerto Rico. She drinks wine socially; admitting to 2-3 glasses a few nights a week. She denies smoking. She is married. Julieâ€™s husband is 39yo, and she has a 3yo son. Her husband has HTN, and her son has asthma. Julie uses albuterol as needed for her asthma, as she was diagnosed at age 14. She also takes lisinopril 5mg once daily for her HTN. She is allergic to shrimp, and latex. She develops anaphylaxis to shrimp and body wide rash to latex. Julie has a mother 65yo (HTN, HLD, CVA), and a father 68yo (CAD, HTN, HLD, DM).
She admits to having her gallbladder removed at age 27, and a skin lesion biopsied at age 30 with her dermatologist.
VS: T: 99.8, HR: 109, BP: 150/68, RR: 14 HT: 5â€™8, WT: 170lbs
EKG: Sinus Tachycardia, without ST elevation or depression
Julie appears unwell. She walks herself into the exam room in NAD, but looks fatigued. Head atraumatic, normocephalic. EOMI, PERRLA, 2+, BL red reflex intact. No nasal polyps or discharge. Pharynx with BL tonsillar exudates, 3+R, 2+L. Uvula midline, but edematous. Tongue with strawberry patches. BL cervical lymphadenopathy noted to palpation. Skin is appropriate for ethnicity, no lesions, rashes, warm to touch. Heart with normal s1/s2, no murmur auscultated. Lungs clear posteriorly, BL. Abdomen SNTTP. 2+ pulses in BL upper and lower extremities. Neurologically intact, without focal deficit.
Instructions: Reformat the above data as follows from Bates:
Your must include a full ROS and Physical Exam for full Credit
PMH (include surgeries and traumatic injuries)
Family History â€“ genogram (you can draw it and place on last page, or create in word document)
ROS â€“ complete inform
Case Study 1 – Julie
1) History Data
a. Chief Concern (CC)
Â· Julie complains of a â€œsore throatâ€ for the past three days that keeps getting worse and â€œfeels like she is swallowing knives.â€ She rates the pain in her throat as 7/10.
b. Complete History of Present Illness (HPI)
Â· Julie is concerned that there is redness in the back of her throat, and she has been having a hard time eating and drinking due to the pain. She also notes bad breath throughout the day for the past 3 days and has been coughing occasionally. Her last trip was a few weeks ago where she travelled by airplane to Puerto Rico.
1. Albuterol for asthma
2. Lisinopril 5mg QD for HTN
Â· Allergies: Shrimp & latex
Â· Tobacco use: Non-smoker.
c. Pertinent Past Medical History (PMH) (include surgeries and traumatic injuries)
Â· Childhood illnesses: Asthma (diagnosed at aged 14)
Â· Adult Illnesses
1. Medical: Hypertension (HTN), Asthma,
2. Surgical: Gallbladder removal (age 27),
3. OBGYN: Not reported
4. Psychiatric: No reported psychiatric illnesses
5. Other: Skin lesion biopsy at age 30 –
Health Maintenance Practices
1. Immunizations: Not reported
2. Screening tests: Skin lesion biopsy at 30 years old with a dermatologist.
3. Lifestyle issues: Non-smoker, occasional wine drinker (2-3 glasses a few nights a week). No reported drug use. Outdoor enthusiast, hikes regularly.
4. Home safety: Married and has a 3-year-old son. No domestic issues reported.
Â· Surgeries: Gallbladder removal at age 27.
Â· Traumatic injuries: No reported traumatic injuries.
Â· Current medications: (stated above)
Â· Allergies: Shrimp and Latex
Â· Psychosocial: Receptionist at a car dealership.
Â· Other: N/A
d. Family History
Â· Mother â€“ 65 y/o, with hypertension, hyperlipidemia, and cerebrovascular accident.
Â· Father â€“ 68 y/o, with hypertension, hyperlipidemia, coronary artery disease, and diabetes mellitus.
Please see last page for genogram
2). Review of Systems (ROS)
General: Febrile (T:99.6), appears fatigued, and does not report weight changes.
Skin: Appropriate for ethnicity. No lesions, rashes, skin warm to the touch.
Head, Eyes, Ears, Nose, Throat (HEENT):
Head: No head trauma, normocephalic. No reported dizziness, headache, or vertigo.
Eyes: Extraocular muscles intact, PERRLA, BL red reflex intact. Doesnâ€™t report vision problems, no noted tearing, redness, pain, glaucoma, or cataracts.
Ears: No reported hearing problems, vertigo, ear infecti