Today's case "sore throat" - cis2010

[ArchivalUser]

I'll be back soon.

[ArchivalUser]

gm mr..

introduction,eye contact,sitting,draping,asking whether feeling comfortable.

how long have u been ..
please tell me in details
persistent/off n on
progressive
aggravating,relieving factors
other associated symp
cough: if yes,color,quantity,blood,phlegm/dry,duration etc
fever
difficulty in swallowing
runny nose
headache
n/v
pain upper belly
relation to food
whether more when lying down
appetite
wt change

PMH: h/o BP,DM
medicine
hospitalization
occupation
bowel/bladder
drug allergy
FH: any medical ds

Sxh: ? multiple partner,protection

SH: smoking: PPD,duration
Alcohol
Drug: needle sharing

PE: HEENT
pULM
CVS
ABDO

Summerise: from History and PE

D/D: viral pharyngitis
IM
GERD
HIV infection
Pneumonia


Counselling: on smoking,alcohol,condom
ask about HIV screening
kissing history and safe practice
routine flu vaccine in fall

Closure: ask if any concern/qs is there
tell the nurse to give some medicine when asked for
thank for co-operation,greet



ask questions ,challenging qs.. answer will be accordingly. add pls.

[ArchivalUser]

great job...
i guess in HPI v shud ask abt any close ill contacts to rule out IM.and to wana to ask u for GERD-shud v ask abt any burning sensation and chest pain in this case with sore throat?

[ArchivalUser]

agree,add ill contact and heartburn. my bad! thanks.

[ArchivalUser]

Greeting as in Kaplan.
Ddx:Viral mcc,bacterial,IMN,hapatitis,HIV complications
Introduce urself,then ask for comfortness then drape with permission
Pls explain me more your about ....(sore throat)
Onset-Progression-Duration-
What makes it better/worse,ask anything u think could be related,such as
swallowing food
have u noticed ulcer/lesions
now ass sx:first ask any sx along with ur sore throat ,if he speaks spountanously then let him go if not ask for fever,runny nose,cough,watery eyes,rash,skin changes,pain/discomfort in belly,bowl habit change,Urinary symptom/change
-Any ill person in family or friends in past month
Current medication then Allergy
Transition to PMH then correct question
explain that u would like to know about his sexual life bcs it could be related to his present symptom/s(confidentially)**U CAN COUNSEL NOW
now transition for social Hx,**U CAN COUNSEL NOW-FHx
*Is there anything else u want to tell me?or do you have any special concern?
thank u mr/Ms....now i'd like to summarize whatever i've felt so far.pls correct me if i'm wrong or add whatever i've missed
**u can counsel now
Explain u would like to examine him then transition for WASHING HANDS;wash between fingers ,close with forarm and drain the water with hands upward,then dry
ask about Job or Feelings,or houshold during washing
Explain ur area need to be examined then permission ,start PE and tell him if its normal and healthy
transition for closure
give him ur impression,talk about other possibilitis,and the lab test/images you need to ask.explain each lab/image to him,inform him for next meeting with lab results soon,and reassure him that u will do ur best to make him feel better
**U can counsel either here if not yet
*ask if he understood whatever u have discussed
ask if any other questions or concern
thank u and take care

[ArchivalUser]

I forgot PE:here u go
HEENT:look gross at face/eyes then nostrils for any edema'redness'discharge
look inside mouth then pharynx .
press on sinuses
PUL:listen to lungs
ABD:abdomen for tenderness and organomegally

[ArchivalUser]

also lymphadenopathy and sinus tenderness in HEENT.

[ArchivalUser]

w/up
throat swab ;gram stain/culture,rapit strep Ag Teat
cbc,diff,Mono test
Hiv viral load/titer if indicated
SGOT/PT If indicated
Sinus xray if indicated
CXR if cough +,Sinuses XRay if PND/tenderness+

[ArchivalUser]

hey, cud u tell me plz how to ask abt child milestones..?i mean shud v ask every milestone like when did ur child started walking etc..?or just v can ask generally together..?i am really confused abt it..

[ArchivalUser]

yes LAP is SO Important,only cervical & submental is OK.