Mystery Disease #2

Mystery Disease #2

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Context:

Betty G. presents with fatigue, lethargy and overall malaise. Her father states that she has been very lethargic and weak with very little appetite. Due to that she has been losing weight. Betty G. has also complained of her joints hurting (although Dad attributed this to a recent growth spurt). Her father also noticed that she has been running a fever for a few weeks along with an accompanying rash.

VS: BP 127/83, PULSE 86, RR 10, T 100F, BMI 17, WEIGHT 86

ROS (Review of systems):

When doing a review of systems we have a methodical way of organizing the patient’s complaints and obtaining better detailed information. Questions should be asked starting with general constitution and working from head to toe.

Section 1: (Red are patient/guardian responses and pertinent information – DO NOT ADD YOUR OWN)

Starting with general constitution:

Tell me more about how you are feeling. I am tired a lot. And my knees hurt. It is hard to play outside and run around.

To Father: When did you notice this starting? I guess about 4 months ago. She just didn’t want to go outside and play which is not like her.

How much weight has she lost? About 5 lbs, which is unusual because she has a good appetite.

When did you start noticing the rash? ~2 weeks ago. I thought it was viral and would go away.

Are her immunizations current? Yes.

ASSESSMENT:

GENERAL: 11 year old white female, alert and oriented x3 (A&O x3), acute distress (AD) in joint mobility, articulate and engaging, well groomed.

HEENT (head, eyes, ears, nose, throat): Normocephalic without evidence of trauma, PEERL (Pupils equal and reactive to light), mucous membranes slightly opaque and sticky. Neck supple has slight lymphadenopathy (swollen lymph nodes), no thyromegaly (goiter or enlarged thyroid) or carotid bruits (noisy carotid pulse) observed.

LUNGS: Clear to auscultation (CTA) bilaterally throughout

CARDIOVASCULAR: Heart rate regular w/out murmurs, rubs, gallops (HRR, w/out MRG’s), S1S2 intact. 2+ peripheral pulses bilaterally. Extremities w/out edema, clubbing, cyanosis

ABDOMEN: Central tender, with palpated splenomegaly and hepatomegaly, normal bowels sounds throughout

Skin: Petechiae present systemically

Section 3 Diagnoses: Short list of possible ailments. 15 points.

What is your short list of 3 diagnoses with a rationale why you chose those. The rationale should show a direct relationship to the findings and ROS: (This should be the 3 best possibilities. You need to be in the ballpark. In other words, if it is a fungal infection in the lungs and you put viral or bacterial, then you will points off BECAUSE there will be important information that leads you to that possibility. If you state cancer as a possibility or maybe COPD, then you will NOT get points off even if you do not put the actual case diagnosis.)

Section 4 Plan: Follow up tests/studies – 15 points

This section is important because you will chose THE MOST LIKELY DIAGNOSIS IN YOUR OPINION and follow up with that one diagnosis only. These tests should be specific in nature and allow you to determine whether or not the patient has that particular problem/disease. You should include information demonstrating you understand how the test is conducted, any principles behind it and predict what it will show. These tests can either be specific for the condition (if commercially available) or exclusive of other conditions (ruling the other stuff out).

How will you continue your work-up?

Lab work:

Section 5 Pathophysiology: 25 points. Even if your diagnosis is not the actual one, as long as you have a good explanation for the ONE you chose, you WILL GET FULL CREDIT. There are 4 criteria you should always address in this answer. 1) How does the disease/condition make the person feel sick (6 points), 2) what is a treatment for it (6 points), 3) how does the treatment work to counter the disease/condition (6 points), 4) how does it affect the patient’s symptoms (6 points).

Section 6 – Follow-up – 5 points

In this section, you describe different things you would look for and ask about in a follow up appointment with the patient. You will be responsible for determining how the patient is responding.