This document presents a case report of a 2 year old Malay girl admitted to the hospital due to fever and vomiting for 2 days prior to admission and 3 episodes of seizures on the day of admission. Upon examination and investigation, she was diagnosed with complex febrile seizures presumed to be caused by meningitis. She was treated with antibiotics and anticonvulsants and discharged after 5 days with no further seizures and good response to treatment.
UG CASE PRESENTATION ON INGUINAL HERNIAAyesha Huma
I have added viva notes after this proforma for quick revision of important stuff asked in exam.
LINK FOR EXAMINATION VIDOES :
1. https://youtu.be/uO-w_9w5okI
2. https://youtu.be/Vc_ZH_-Oad4
UG CASE PRESENTATION ON INGUINAL HERNIAAyesha Huma
I have added viva notes after this proforma for quick revision of important stuff asked in exam.
LINK FOR EXAMINATION VIDOES :
1. https://youtu.be/uO-w_9w5okI
2. https://youtu.be/Vc_ZH_-Oad4
CC I have itchy white discharge”HPI Patient is a 32 African.docxtroutmanboris
CC: "I have itchy white discharge”
HPI: Patient is a 32 African American female who reports having increased vaginal itching and discharge times 2 days. She states that her vagina feels irritated and that the itch is progressively getting worst. She reports a thick white cottage cheese discharge is present. She reports that she used a Monistat 3 day 6 days ago but hasn't had any relief. She states that the pain is worst after sex.
PMH: Patient denies having any past medical history. She denies any past traumas or hospitalizations.
PSH: Patient denies having a history of trauma. Patient denies having any surgical history.
Allergies: Patient denies having allergies to latex, food or any medications.
Medications: Patient reports she is currently on no medications.
Social history: Patient reports that her entire family lives nearby. She states that she lives in a two-bedroom apartment alone. States that she drinks 3 glasses of 8oz glasses of wine with friends twice a week. Denies recreational drug use. Denies tobacco use. Reports that she is single. She denies having any new sex partners during the last 3 years. She states that she drinks 1 8oz cups of coffee daily. She reports that she has worked as a real estate agent for the last 2years. Reports no job-related stressors.
Family History: Patient reports that her mother is a live and has a medical history of that she was diagnosed with anxiety and depression at the age of 35. She states her father has a medical history of depression which he was diagnosed with at age 45. She reports her maternal grandmother had a history of COPD and CHF. She reports her maternal grandmother died from complications of chronic kidney disease at the age of 80. She reports that her maternal grandfather had a medical history of hypertension, she reports he is still alive at 88. Patient reports her paternal grandmother has a medical history of CHF and diabetes mellitus type 2. She reports her paternal grandmother is still alive at 85 but has dementia She states paternal grandfather had a medical history of COPD and CHF, she reports he died at age 85 from complications of diabetes mellitus type 2. She has two older sister who both have no medical history.
Health Promotion/Maintenace: Patient reports she had a flu shot in September 2017 in a private doctor's office. Reports she had a TDAP booster in 2014. Based on the patients age USPSTF recommends screening for cervical cancer every 3 years with cervical cytology alone in women aged 21 to 29 years. Reports she had a std screen 2 years ago. She reports that she has never had an abnormal pap smear. She states STD screen was negative. Reports she had a pap 4 years ago. She reports she does monthly self-breast exams at home. She reports that she eats 2 times daily. Reports she eats well balanced nutritious meals for each meal. She reportedly drinks approximately 30oz of water a day.
General: Patient reports having, fever, chills, and malaise
Skin: Pat.
SOAP NOTE SAMPLE FORMAT FOR MRCName LPDate.docxpbilly1
SOAP NOTE SAMPLE FORMAT FOR MRC
Name:
LP
Date:
Time:
1315
Age:
30
Sex:
F
SUBJECTIVE
CC:
“I am having vaginal itching and pain in my lower abdomen.”
HPI:
Pt is a 30y/o AA female, who is a new patient that has recently moved to Miami. She seeks treatment today after unsuccessful self-treatment of vaginal itching, burning upon urination, and lower abdominal pain. She is concerned for the presence of a vaginal or bladder infection, or an STD. Pt denies fever. She reports the itching and burning with urination has been present for 3 weeks, and the abdominal pain has been intermittent since months ago. Pt has tried OTC products for the itching, including Monistat and Vagisil. She denies any other urinary symptoms, including urgency or frequency. She describes the abdominal pain as either sharp or dull. The pain level goes as high as 8 out of 10 at times. 200mg of PO Advil PRN reduces the pain to a 7/10. Pt denies any aggravating factors for the pain. Pt reports that she did start her menstrual cycle this morning, but denies any other discharge other that light bleeding beginning today. Pt denies douching or the use of any vaginal irritants. She reports that she is in a stable sexual relationship, and denies any new sexual partners in the last 90 days. She denies any recent or historic known exposure to STDs. She reports the use of condoms with every coital experience, as well as this being her only form of contraceptive. She reports normal monthly menstrual cycles that last 3-4 days. She reports dysmenorrhea, which she also takes Advil for. She reports her last PAP smear was in 7/2016, was normal, and reports never having an abnormal PAP smear result. Pt denies any hx of pregnancies. Other medical hx includes GERD. She reports that she has an Rx for Protonix, but she does not take it every day. Her family hx includes the presence of DM and HTN.
Current Medications:
Protonix 40mg PO Daily for GERD
MTV OTC PO Daily
Advil 200mg OTC PO PRN for pain
PMHx:
Allergies:
NKA & NKDA
Medication Intolerances:
Denies
Chronic Illnesses/Major traumas
GERD
Hospitalizations/Surgeries
Denies
Family History
Father- DM & HTN; Mother- HTN; Older sister- DM & HTN; Maternal and paternal grandparents without known medical issues; 1 brother and 3 other sisters without known medical issues; No children.
Social History
Lives alone. Currently in a stable sexual relationship with one man. Works for DEFACS. Reports occasional alcohol use, but denies tobacco or illicit drug use.
ROS
General
Denies weight change, fatigue, fever, night sweats
Cardiovascular
Denies chest pain and edema. Reports rare palpitations that are relieved by drinking water
Skin
Denies any wounds, rashes, bruising, bleeding or skin discolorations, any changes in lesions
Respiratory
Denies cough. Reports dyspnea that accompanies the rare palpitati.
SOAP NOTE SAMPLE FORMAT FOR MRCName LPDateTime 1315.docxrosemariebrayshaw
SOAP NOTE SAMPLE FORMAT FOR MRC
Name: LP
Date:
Time: 1315
Age: 30
Sex: F
SUBJECTIVE
CC:
“I am having vaginal itching and pain in my lower abdomen.”
HPI:
Pt is a 30y/o AA female, who is a new patient that has recently moved to Miami. She seeks treatment today after unsuccessful self-treatment of vaginal itching, burning upon urination, and lower abdominal pain. She is concerned for the presence of a vaginal or bladder infection, or an STD. Pt denies fever. She reports the itching and burning with urination has been present for 3 weeks, and the abdominal pain has been intermittent since months ago. Pt has tried OTC products for the itching, including Monistat and Vagisil. She denies any other urinary symptoms, including urgency or frequency. She describes the abdominal pain as either sharp or dull. The pain level goes as high as 8 out of 10 at times. 200mg of PO Advil PRN reduces the pain to a 7/10. Pt denies any aggravating factors for the pain. Pt reports that she did start her menstrual cycle this morning, but denies any other discharge other that light bleeding beginning today. Pt denies douching or the use of any vaginal irritants. She reports that she is in a stable sexual relationship, and denies any new sexual partners in the last 90 days. She denies any recent or historic known exposure to STDs. She reports the use of condoms with every coital experience, as well as this being her only form of contraceptive. She reports normal monthly menstrual cycles that last 3-4 days. She reports dysmenorrhea, which she also takes Advil for. She reports her last PAP smear was in 7/2016, was normal, and reports never having an abnormal PAP smear result. Pt denies any hx of pregnancies. Other medical hx includes GERD. She reports that she has an Rx for Protonix, but she does not take it every day. Her family hx includes the presence of DM and HTN.
Current Medications:
Protonix 40mg PO Daily for GERD
MTV OTC PO Daily
Advil 200mg OTC PO PRN for pain
PMHx:
Allergies:
NKA & NKDA
Medication Intolerances:
Denies
Chronic Illnesses/Major traumas
GERD
Hospitalizations/Surgeries
Denies
Family History
Father- DM & HTN; Mother- HTN; Older sister- DM & HTN; Maternal and paternal grandparents without known medical issues; 1 brother and 3 other sisters without known medical issues; No children.
Social History
Lives alone. Currently in a stable sexual relationship with one man. Works for DEFACS. Reports occasional alcohol use, but denies tobacco or illicit drug use.
ROS
General
Denies weight change, fatigue, fever, night sweats
Cardiovascular
Denies chest pain and edema. Reports rare palpitations that are relieved by drinking water
Skin
Denies any wounds, rashes, bruising, bleeding or skin discolorations, any changes in lesions
Respiratory
Denies cough. Reports dyspnea that accompanies the rare palpitations and is also relieved by drinking water
Eyes
Denies corrective lenses, blurring, visual changes of an.
Case#1A 24-year-old male graduate student without prior medical .docxtroutmanboris
Case#1
A 24-year-old male graduate student without prior medical or psychiatric history is reported by his mother to have been very anxious over the past 6 months, with increasing concern that people are watching him. He now claims to “hearing voices,” telling him what must be done to “ fix the country.” Important workup ? thyroid-stimulating hormone TSH, rapid plasma reagain (RPR), and brain imaging.
Questions:
1. What is the diagnosis of this patient?
2. What is the age onset of this disorder?
3. What socioeconomic group suffers from this disorder?
4. What is the subtype of this disorder in this patient ?
5. List five positive and negative symptoms that we can find in schizophrenia disorder>
6. What is the treatment?
7. What are five characteristics associated with better prognosis?
Case#2
Ms. Torrez is a 17-year-old Caucasian woman without prior psychiatric history who is brought to the Emergency room by ambulance after her parents called 911 when they found her having a seizure in their living room. She was admitted to the medical intensive care units in status epilepticus and was quickly stabilized with intramuscular lorazepam and fosphenytoin loading. Her heigh is 5 feet 6 inches, she is of medium build, and her weight is 101 lbs. (BMI16.3kg/m2). She does not suffer any medical conditions, and this is her first seizure. Laboratory workup shows an electrolyte imbalance as the most likely cause of the seizures. Although initially reluctant, she admits to purging with the use of ipecac several times this week. She reports that although she normally restricts her daily caloric intake to 500 calories, she regularly induces vomiting if her weight is above 100 lbs. Her last menstrual cycle was 1 year ago. Psychiatric consultation is requested in order to confirm the diagnosis
The on-call psychiatry notes in Terry’s chart
Patient appears underweight and younger than her stated age. She is mild distress, has a nasogastric tube in place, and exhibits poor eye contact. She reports feeling “sad” and admitted to experiencing constant preoccupation about her physical appearance and says, “I am fat; I hate my body.” She also reports insomnia, low energy levels, and history of self-harm behavior by cutting her forearms. She reports that she is careful hiding her symptoms from her parents, whom she describes as strict disciplinarians. She also expresses concerns that she will disappoint them.
Ms. Torrez’ parents describe her as a perfectionist. They say that she is involve in multiple school activities, takes advanced placement classes, and has been recently concerned about being accepted at her college of choice. They report that she maintains a 4.0 grade point average in high school, and they are expecting her to become a lawyer. Her parents have noticed that she is underweight and rarely see her eat but attributed this to stress from her many academic pursuits. Ms. Torrez’ mom was diagnosed with obsessive-compulsive disorder.
Qu.
Digital Clinical Experience Comprehensive (Head-to-Toe) Physi.docxmecklenburgstrelitzh
Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment
Week 9 SOAP NOTE
Doris Ofodile
Walden University
Nurs 6512
Advanced Health Assessment & Diagnostic Reasoning
Dr Kristin Curcio
July 31st, 2022
Patient Initials: T.J Age: 28 Gender: Female
SUBJECTIVE DATA:
Chief Complaint (CC): " I came in because I'm required to have a recent physical exam for the
health insurance at my new job"
History of Present Illness (HPI): Miss Jones is currently employed by Smith, Steven, Stewart,
Silver & Company. Before she begins work, a pre-employment physical must be completed.
Despite having a history of type 2 diabetes, in which she is able to control it by taking metformin,
dieting, and doing physical activity. For the past 4-5 months, she has been compliant with
metformin. By eating yogurt, Metformin has no longer caused any side effects for her. The last
time she saw a doctor was for her gynecology appointment four months ago in which the doctor
prescribed oral birth control pills to her after she was diagnosed with the polycystic ovarian
syndrome. Although, according to her, she is in good health and does not have any acute health
issues, or stressful events, and is looking forward to starting her new job.
Medications: Metformin 850mg PO BID, the last dose taken this morning.
Fluticasone propionate (Flovent) was 110 milligrams twice daily.( taken last in
Albuterol (Proventil) 90mcg 2 puffs every four hours PRN.( taken three months )
Drospirenone/ethinyl estradiol (dosage unknown). It was taken this morning.
Tylenol 500 mg PO PRN for headache, medication was taken last week.
Ibuprofen 600mg PO TID PRN to alleviate period cramps, was taken six weeks ago.
Zantac was taken for GERD (completed)
Tetracycline was taken because of acne (completed)
Allergies: Miss Jones is allergic to penicillin which causes an allergic reaction characterized by
hives and a rash. She is also allergic to cats and dust which triggers an asthma attack causing her to
itch, wheeze and sneeze. She denies allergic reactions to latex and foods.
Past Medical History (PMH): During her second and a half years of life, Miss Jones was
diagnosed with asthma. Her medication regimen includes Proventil and Flovent.
A diagnosis of diabetes was made at the age of twenty-four. Metformin is the medication she uses
to manage her diabetes, but she had trouble complying because she had side effects like gassiness,
which was later relieved with yogurt. As a result, she is better able to monitor her blood sugar
levels daily, which last read at 90. The patient also reports losing 10 pounds in four months. Also,
she reported that she slipped and hit her right foot, resulting in a healed wound.
At the age of 28, she was diagnosed with the polycystic ovarian syndrome which she manages by
taking birth control pills. Miss Jone’s menstrual cycle flows for five days and is regular. No
Sexually transmitted diseases or pregnancies have been reported.
At 38.
1. CASE PRESENTATION Qhasmira Bt Abu Hazir 2008409674 NurAmira Bt MohdAsri 2008409708 Nurjuliana Bt Noordin 2008402524
2. PATIENT DEMOGRAPHIC PATIENT NAME: FATIN AQILAH R/N: SB 00300220 PATIENT’S INITIAL: FA SEX: FEMALE AGE: 2YEARS AND 3 MONTHS ETHNIC GROUP: MALAY INFORMANT: MOTHER/FATHER RELIABILITY: FAIR WARD: 8C DATE OF ADMISSION: 24TH NOVEMBER 2010 DATE OF CLERKING: 29TH NOVEMBER 2010 DATE OF DISCHARGE: 1ST DECEMBER 2010
3. CHIEF COMPLAINT FA, a 2 years old Malay girl was admitted to the Sungai Buloh Hospital on 24th November 2010 due to fever and vomiting for 2 days prior to admission and 3 episodes of fits on the day of admission.
38. PAST MEDICAL HX She had no history of fit before. She also had never been hospitalized or undergone any surgery before. She had no long term illnesses.
41. BIRTH HX She was born full term by spontaneous vertex delivery at SgBuloh Hospital. The birth weight was 3.15 kg. The delivery was uncomplicated and there was no resuscitation required. Antenatal, intrapartum and postnatal period were uneventful.
43. FEEDING HX She was not breastfed since birth and she was given formula milk instead. She was first introduced to solid foods when she was 6 months old. At that time, she was given Nestum. She started to eat rice at the age of 1 year old. Currently, she is given porridge together with vegetables, fish and sometimes chicken. She is still given the formula milk (DUMEX 123). DUMEX 4 scoops in 4 oz (120ml), 2-3 hourly, prepared by the mother herself.
44. IMMUNIZATION HX Her immunization was completed up to her age. There was no complication developed after each injection. Her latest immunization was MMR which she took when she was one year old.
45. DEVELOPMENTAL HX All of the developmental parameters were appropriate to her age.
46. FAMILY HX She is the only child. There was no history of febrile fits running in both of her parents during their childhood lives. None of them was having fever before the patient even got one. Besides, both of her parents were completely healthy. No history of asthma, hypertension and diabetes mellitus running in her parents. There was also no epilepsy history in the family; including uncles and aunties from both maternal and paternal side. No consanguity noted.
47. SOCIAL HX AND ENVIRONMENTAL HX Her father and mother are working together in nasilemak’s stall owned by family. Both of them are working during the day. Thus, the patient is taken care by her mother’s father (grandfather). The total income of her family is about RM1000 per month. They live in an apartment at Sg Way with complete basic amenities. Her father is not a smoker as well as her mother.
48. HX OF CONTACT There was no significant history contact
49. EFFECT OF THE ILLNESS She became less active ever since she got the fever. Both the parents were worried about her condition and whether these episodes of fits will recur. Her mother had to take leave from work while her father working to earn for the family.
51. Physical examination General examination She was sitting comfortably unsupported on her bed, holding marker pen and scribbling Conscious, cooperative, alert to person and place. No respiratory distress, no dysmorphic feature, no abnormal movement and no muscle wasting. well hydrated and well nourished
52. Vital sign Pulse rate: 126 bpm, normal rhythms&vol. Respiratory rate: 36 bpm Temperature : 37 dc Blood pressure: 86/75 mmHg Interpretation:NAD Anthropometry Height: 86 cm (at 50thcentile) Weight: 13 kg (at 50thcentile )
53. CNS EXAMINATION Central nervous system Mental status: She was alert and conscious. Speech: Can speak clearly with no difficulty. Cranial nerves: There was no nystagmus. All her cranial nerves were intact. Muscle tone: There was no hypotoniaand hypertonia Muscle power: all of her muscle power were 5/5
55. Cerebellar signs - she was able to walk steadily without support. Involuntary movement : no presence of any involuntary movement Signs of meningeal irritation : no neck stiffness, negative brudzinski’s and kernig’s sign Sensory function: cannot be tested Impression: no abnormality detected.
59. Systemic examination CVS, Resp., abdominal, CNS :all NAD Summary FA, a 2 years old Malay girl was admitted to SgBuloh Hospital on 24th November 2010 due to 3 episodes of generalized tonic-clonic fits on the day of admission associated with fever for 2 days and vomiting for 2 days prior to admission with no LP done.
60. Provisional diagnosis Complex febrile fits -points to support: Fever Recurrent seizures in one febrile event Age, febrile fits usually occur in 3 months to 6 years of age.
63. Electrolyte-: normal level of ca2+,Na2+ mg2+, PO42, random glucose indicate that there is no metabolic derangement in this patient hence - rules out fitting due to metabolic derangement
64. RENAL PROFILE normal renal profile and this result exclude any dehydration as she had reduced in oral intake(fluids and solid food)
66. LUMBAR PUNCTURE Lumbar puncture is performed to obtain cerebrospinal fluid (CSF) to rule out any CNS infection. However, parents of this patient refused lumbar puncture to be done to her daughter. Therefore, CNS infection was failed to be ruled out.
67. BRAIN IMAGING (CT SCAN) To detect any brain pathology Findings: No intracranial bleeding No focal brain parenchymal lesion No hydrocephalus
68. CHEST X-RAY (not done) Chest x-ray was not indicated as there was no abnormality in the physical examination suggesting infection of lower respiratory tract. Altogether the history, physical examination and investigation had excluded a lower respiratory tract infection.
69. ELECTROENCEPHALOGRAPHY (EEG) to find out abnormal brain function EEG is recommended to be performed on children who are neurologically abnormal or experience a complex seizure.
71. DISCHARGED SUMMARY On the day of admission, she had multiple seizures attack: 1st episode occurred at home, lasted for 5 minutes and aborted spontaneously 2nd episode occurred at private clinic, lasted for 5 minutes and aborted spontaneously 3rd episode occurred at Emergency Department of HSB, lasted for 1 minute aborted by suppository Valium (diazepam) 5 mg 4th episode occurred in ward 8c around 3.30pm lasted for 1 minute and aborted by suppository Valium 5mg 5th episode occurred at 6pm in ward 8c, lasted for less than 1 minute and loaded with IV Phenytoin and started maintenance There was total of 5 episodes of fits and patient was febrile at that time No more episode since then. She had good response towards antibiotic given to her.
72. Management Control fever Take off clothing & tepid sponging Anti pyretic eg; syrup/rectal Paracetamol 15mg/kg 6hrly Antipyretic is indicated for patients comfort, but there is no evidence that by using it, it can reduce recurrence rate /risk of febrile convulsion. As for this patient, she was given syrup Paracetamol (200 mg) 6 hourly
75. Parents should be advisedon first aid measures during a convulsion; Not to panic, remain calm. Note time of onset of fit Loosen child’s clothing especially around neck Place child in left lateral position with head lower than the body Do not insert any object into mouth even if the teeth are clenched Wipe any vomitus of secretion from the mouth. Do not give any fluids/ drug orally Stay near the child until convulsion is over and comfort the child as she is recovering This is a very important point, as febrile fits can recur. Therefore his parents should be counsel about this upon discharged
76. Patient was treated as presumed meningitis. IV Ceftriaxone for 1/52(complete 7 days) she had good response toward antibiotic given Acyclovir
78. FEBRILE CONVULSION Convulsion occurring in association with fever in children between 3 months and 6 years of age, in whom there is no evidence of intracranial pathology or any metabolic derangement.
79.
80.
81. Causes of febrile fit Otitismedia (middle ear infection) Respiratory tract infection Urinary tract infection (infection of bladder,urethra/kidneys) Gastroenteritis Viral infection- such as chicken pox or influenza
82. Pathophysiology unclear It is generally believed that a febrile seizure is an age-dependent response of an immature brain to fever. This was postulated due to (80-85%) febrile seizure occurs between 3 months to 6 years of age ,with a peak at 18 months. It is well known that febrile seizure tend to occur in families because of it is an autosomal dominant inheritance.
83. Prognosis in Febrile Seizure it is a benign events with excellent prognosis 30% recurrence after 1st attack 48% after 2nd attack 2-7% develop subsequent afebrile seizure or epilepsy No evidence of permanent neurological deficits following febrile convulsions or even febrile status epilepticus No deaths were reported from simple febrile convulsion
84. Risk factors for subsequent epilepsy Neurodevelopmentalabnormality Complex febrile fits Family history of epilepsy Brief duration between onset of fever and initial convulsions
85. Lumbar Puncture It is also called a spinal tap is a common medical test that involves taking a small sample of CSF for examination. In a lumbar puncture, a needle is carefully inserted into the lower spine to collect the CSF sample.
86. Indications Suspected meningitis, encephalitis Intrathecal chemotherapy for oncology patient In selected patient being investigated for neurometabolic disorder
87. Contraindications Increased intracranial pressure due to space occupying lesions (from signs, symptoms, raised blood pressure, fundoscopic sign) Bleeding tendency (platelet <50, 000/mm3) or prolonged PT/APTT skin infection over site of lumbar puncture