Description

Multiple Versions for Practice

Week3 is another HEENT Focused Encounter (sore throat/pharyngitis/tonsillitis) commonly seen in primary care. Be sure to review the Week3 grading rubric as it is DIFFERENT from Week2. You have only ONE attempt for the Week3 case. The grading is more stringent.

This assignment also includes a Reflection. Please use the embedded worksheet to write your Reflection & do not alter it as it is a CU proprietary document. Be sure to upload your written work and not the BLANK worksheet.

iHuman case Attempt – Jenna A James

Jenna James 23-year-old female with a primary medical history of infectious mononucleosis at age 15. She presents today with an acute onset of fever of 101.5,heart rate of 96 beats per minute, bilateral tender cervical lymphadenopathy, sore throat, and headache that has been occur for the past 2 days. Recent contact with a sick roommate and up to date covid immunization records but lacks influenza vaccine. Physical examination revealed prominent tonsillar exudate, slightly enlarged tonsils, erythematous pharynx, no adventitious breath sounds, or excess work of breathing, and no cough.

iHuman case Attempt – Jenna A James

JM is a 23 year old female who presents for sudden onset of sore throat 2 days ago with headache, fever, and chills. Pt is currently in law school and had contact with sick roommate earlier in the week, reports history of mono at age 15. Pt denies cough, shortness of breath, dizziness, ear pain, neck stiffness, or chest pain. Did not receive influenza vaccine but reports receiving all covid vaccines. Physical exam shows fever of 101.5, bilateral cervical lymphadenopathy, pharyngeal erythema and tonsillar exudate bilaterally. Negative for abnormal breath sounds. Reports oral birth control pill and use of tylenol for symptom management, denies allergies to medications.

iHuman case Attempt – Jenna A James

Jenna James is a 23 year old college female who presents to the clinic with a fever and sore throat. She has a pertinent medical history of infectious mononucleosis at the age of 15. Patient also has an acute onset of bilateral swelling of her cervical lymph nodes, a fever of 101.8, and tonsillary exudate. She states she had a sick contact with her roommate of an unknown diagnosis. She has been experiencing symptoms for the past two days. Upon examination she has a current fever of 101.8, 96 bpm heart rate, no difficulty breathing, and no cough at present. She has been taking acetaminophen as needed to help with the sore throat.

iHuman case Attempt – Jenna A James

J.J. is a 24-year-old female with the chief complaint of a sore throat. She reports fever, headache, chills, and swollen neck glands. Denies cough, shortness of breath, and nasal drainage. Reports recent contact with sick roommate and lack of influenza vaccination. A physical exam reveals a fever of 101.5F, posterior pharyngeal erythema, halitosis, and tenderness to bilateral anterior cervical lymphadenopathy without nuchal rigidity and without hematosplenomegaly, but positive for mild to moderate tonsilar enlargement with tonsilar exudate. Pertinent negative findings include tympanic membranes without erythema, bulging or exudate, and clear lung sounds bilaterally.