Posted: September 6th, 2015

Family practice Clinic which employs physicians and nurse practitioners.

Setting: large urban city

Family practice Clinic which employs physicians and nurse practitioners.

Part 1: Today is another busy in your family practice clinic. You note your next visit is a work in for ear pain. The patients are a set of four year old twins. The entire family has been coming to the clinic for years which is probably why they were worked in despite your full schedule. You review the chart before entering the room to familiarize yourself with these patients.

When you enter the room you note a Caucasian woman who appears to be about 40 years old. She is well groomed and appropriately dressed for the weather. There are also two boys who appear to be about 4 years old who are sitting on the exam table playing games on their tablets and chatting to each other.

You introduce yourself as you always do and ask what brings them to the clinic today.

Mom states “Tommy woke up in the middle of the night saying his ear hurt so bad it woke him up. He says it hurts to touch. Pat has had a cold for a few and been talking about his ears popping and feeling stuffy. I thought it was just the cold. He woke up this morning and said his ear really hurts. He has also felt warm. “

HPI: Mom describes the boys as overall healthy and active 4-year-old children. Their older sister just got over a cold. The rest of the family has been well but Mom noticed she has a sore throat this morning and asks if you can look at her too as long as they are here. Her throat has hurt since yesterday, hurts worse when she swallows.

PMH:

Paddy: age 4. Fullterm pregnancy, NSVD twin gestation 5#2oz. No hospitalizations. NKDA. Daily medication – chewable children’s multivitamin with iron.

Tommy: age 4. Fullterm pregnancy, NSVD twin gestation 5#4oz. No hospitalizations. NKDA. Daily medication – chewable children’s multivitamin with iron.

Mary (mom) Mary: denied past illness or injuries. Hospitalized x 2 for childbirth, no surgeries. NKDA. Drinks alcohol socially, denies tobacco or illicit drug use. Sleeps 6-7 hours/night. No current medications. Takes a daily multivitamin and a B complex vitamin.

Social:

Paddy and Tommy live with both their parents, Mary and Patrick, and two older siblings. They are in a half day K4 program and Mom states they are doing well and like going to school.

Mary’s parents Katie and John also live in the home. Both are retired and help with childcare and household needs since both parents work full time. Patrick and John both smoke “but not in the house”. Mary has 2 siblings who are in good health. Patrick’s parents died in their 50s of brain tumor and leukemia. He has one brother in good health. Katie and John emigrated from Ireland in their 20s and have always lived in this area. Katie has a history of HTN and hyperlipidemia. John has a history of tobacco use since age 10, HTN and hyperlipidemia. They share their home with 2 dogs and a cat.

Discussion Questions Part One:

What further questions do you have for Paddy, Tommy and Mary at this visit?? Why?

What is your differential diagnosis list for this visit thus far for each patient with rationale?

Based on your differential diagnoses list, what exams will you perform at this visit?

Part 2.
Summarize the history and results of the physical exam for each patient. Discuss the rationale for choosing the primary diagnosis with ICD 9 codes. Include one evidence-based journal article that supports your rationale for each patient; develop a complete treatment plan that includes medications, any additional diagnostic tests, patient education, possible referrals, and plan for follow up. The guidelines for SOAP note documentation in Doc Sharing can assist you in writing this post and your SOAP note.

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