William Fredericks
42 y/o male
6’0’’ (183 cm)
215.0 lbs (97.7kg)
Reason for encounter: worsening headaches and facial pain, fever
Hx:
Hx of present illness:
OLDCARTS mnemonic
Onset:
Loca琀椀on:
Dura琀椀on:
Characteris琀椀cs:
Aggrega琀椀ng:
Relieving
Treatment
Severity
PMH:
HTN: 6 YEARS, Hypercholesterolemia x 6 years psoriasis since childhood
Sx hx: appendectomy at 29 y/o hospitaliza琀椀on appendectomy
Medica琀椀ons: Hctz 25 mg po DAILy
Mul琀椀vitamin daily OTC as needed
Tylenol ES Tylenol cold and 昀氀u advil naproxen
Allergies: grass, trees. Seasonal pollen, dust & mold with symptoms of itchy watery eyes, scleral
injec琀椀ons, sneezing, runny nose, nasal conges琀椀on
Preventa琀椀ve health:
Fitness, no exercise rou琀椀ne except for ac琀椀vey on job nutri琀椀on: typeical American diet high in meats and
carbs,
Stress reduc琀椀on: nothing works 50+ hours a week
Daily sleep 6-7 hrs with addi琀椀onal on weekends
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Previous ½ pack x 20 years, quit 4 years ago, no relapse alcohol intake 1-3 beers during the weeks, 2-4
beers, weekend no recent fecal occult blood sample or prostate exam
Childhood immuniza琀椀on: up to date does not receive seasonal 昀氀u shot or adult vaccina琀椀on S
Prior visit documented- update allergies, medica琀椀ons, OTC drugs.
Family Hx: father 71/yo obese, CAD mother 69 y/o obeses, hx of DM maternal GM. Hx DM; deceased 72,
sepsis r/t LE amputa琀椀on maternal GF: hx CV dz, decreased age 78 MI paternal GM; no PMH, decrased 82
. MI paternal GF: hx HTN, decease age 80, MI brother 47 y/o DM sister 39 y/o HTN
Social Hx:
Married wife 37 y/o HTNN child; son 11 y/o and daughter 16 y/o both health tobacco ½ pack per day x
20 years quit 4 years ago without relapse
ETOH 1-3 during the week; 2-4 on weekends drug use: non currently; experiment with marijuana in HS
and early adulthood
Review of Symptoms:
Ques琀椀ons for system not addressed in HPI
Choose ROS for those body system you do not have info on. Use large mul琀椀part ques琀椀on
Exercises:
- Complete any clinical exercise found that follow various case play sec琀椀ons
- When you’ve completed the exercises and clicked proceed, you will be taken to the next .
Current Visit:
1. How can I help you today? – good ques琀椀on
I am here because I feel really sick and am not ge琀񐀀ng be琀琀er. I have this HA which started about 2 weeks
ago. I was just ge琀񐀀ng over a cold at that 琀椀me. Over the last 2 weeks my headache got worse and more
of my heart hurt. It now hurts to move my eyes.
2. What other symptoms or concerns we should discuss?
yes, maybe 3 or 5? Days ago my runny nose, which had resolved, has restarted and changed from clear
to creamy. Then over the last day or two I started having low grade fever- around 99.5 to 100 F. I also
have this strange tooth pain/sensi琀椀vity and ear pain. I feel like I am falling apart. Its one thing a昀琀er
another. What a wreck I am!
When did HA start?
- I guess about 14 or more days ago
Is this the worst HA of your life?
Not really. I got hit in the head during li琀琀le league prac琀椀ce when I was a child. That was the worse HA I
ever had
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Does the HA awaken you from sleep?
- No
Dose HA keep you from sleeping?
- Somewhat, or rather it keeps me from falling asleep
Have you had HA like this before?
- Not this long or severe
HA comes on slowly
Does your HA come and go?
- No it is constant since it started
- HA does not radiate
Head ache does not awaken him from his sleep, has facial pain now. Forehead above eye. Bad
headache, does not pulsate
SOB when climb stairs, but I think that all due to my weight and that’s not new
DO you have a sore throat?
- Yup, it started with my coughing
Where more precisely is your facial pain?
- It is below my eyes (points to region surround eye bilaterally) and it also feels like I have a tooth
problem on the right. That pain comes and goes but the tooth looks 昀椀nd. I haven’t been to the
den琀椀st in probably 2 years. Do you think I need to go. Im quiet a mess aren’t I
What does the pain on your face feel like?
- It feels like pressure most of the 琀椀me. Some琀椀mes really bad. Like my face will explode
Does anything make the pain in your face be琀琀er or worse?
- Laying down makes it hurt worse. Bending over that’s really bad, like my face will explode it
feels best when I am in the shower with all the steam and acetaminophen helps a li琀琀le
Ues taking HTN DM and cholesterol
Are you taking any OTC or herbal medica琀椀ons
- Yes, Ive been trying varios pain and isnus meds. Oh yeah, and I take a vitamin every day a lto of
good that’s doing me
Do you have any problem with fa琀椀gue, di昀케cult sleeping or weight loss, fever or night sweats?
- I wish I had uninten琀椀onal wt loss, fa琀椀gue. Its not new that I get fa琀椀gue sort of easily. But maybe
since I am sick it is a li琀琀le worse. Is that it?
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Do you have problem with muscle or joint pian, redness, joint s琀椀昀케ness, joint swelling or redness
- Nope nothing right now, old knee issues abut not bothering at the moment
Do you have problem with nausea vomi琀椀ng, cons琀椀pa琀椀on or vomi琀椀ng
- Nope one of that, I got plent of other problems
Physical exam:
42 y/o M
72”
215 lbs
29.1 BMI
AxO x 4
37.7 oral
Pulse 82 Regular, strength, normal
BP L 130/82, R 130/82 assessment. Pulse pressure, normal
RR 18 Regular, e昀昀ort, unlabored
96%
Skin: warm and dry
Vital signs (op琀椀onal)
- You must look at vitals in the HER (current visit) to get credit.
Performing your physical exam:
- Perform those physical assessment maneuvers as needed
- Document in key 昀椀ndings
Assessment:
- Organized Key 昀椀ndings by selec琀椀ng MSAP (Most Signi昀椀cant Ac琀椀ve Problem)
- Mark other 昀椀ndings as: related, unrelated, unknown, or PMH/resolved
Problem Statement:
- Short Summary of pa琀椀ent’s presenta琀椀on.
- Should contain
- demographics descrip琀椀ons:
- chief complain
- hx and physical exam key 昀椀nding
- risk factors Keep it concise
-
lOMoARcPSD|13778330

Yes, may 3 or 5 days ago runny nose, which had resolved, has restarted and changed from clear to
creamy. Then over the last day or two I started having low grade fever around 99.5 to 100 F I also have a
strange tooth pain/ sensi琀椀vity and ear pain. I feel like I am falling apart. Its one thing a昀琀er the other.
What a reck I am
When did your cough start? I feel it started with my post-nasal drip- stu昀昀 going down the back of my
throat.
When did the pain in your face start? – it started a昀琀er HA maybe 7 to 10 days ago
Loca琀椀on: HA pain – above eye, forhead and now face
Loca琀椀on of ear pain: right ear pain, le昀琀 no issues
Loca琀椀on of face pain: below eye here (points to region surround eyes bilaterally and it also feels like I
have tooth problems on the right. That pain comes and goes but the tooth looks 昀椀ne. I haven’t been to
den琀椀st in probably 2 years. Do you think I should go.
Characteris琀椀cs: have had HA like this before-> not this long or severe
Characteris琀椀cs: What does pain in your face feel like?  like a lot of pressure most of the 琀椀me.
Some琀椀mes really bad, like face will explode
Characteris琀椀cs: HA awaken from sleep? No
Characteris琀椀cs: Headache come and go?  constant since it started
Characteris琀椀cs: Been any changes in your headache over琀椀me  started out mild but then worse.
Characteris琀椀cs: does HA keep you from falling asleep?  somewhat or rather, it keeps from falling
asleep
Characteris琀椀cs: what does the pain in your HA feel like?  I don’t know, it feels like a bad HA
Aggrava琀椀ng: does anything make the pain in your face be琀琀er or worse: laying down makes it worse.
Bending over that’s really bad like my face will explode. It feels best when I am taking a shower with all
the steam in the room. Acetaminophen helps a li琀琀le bit
Aggrava琀椀ng: does anything make your HA be琀琀er or worse HA feels less intense when I am in shower,
and it worse when I am lying down
Relieving
Timing/treatment: what treatments have you tried for HA acetaminophen, sinus meds, but they both
stop working
Timing/treatment: how o昀琀en how you have headaches like this? Almost never. I remember one episode
maybe a year a go, but that was really mild by comparison
How severe (1-10) is pain on your face ; 6/10 now but that changes throughtout the day and night
Is this worse HA of your life: no li琀琀le league prac琀椀ce ge琀񐀀ng hit in the head was worse pain
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HPI have you had any contact with other sick people? Yea my kids had colds recently along with several
of their friends
PMH: have you been taking your medica琀椀ons as prescribed? Yes are you taking OTC or herbal
medica琀椀ons? Yes various of pain and sinus meds. And vitamins every day.
Exam:
Skin: psoriasis elbows and knees, feet: skin on feet dry and cracking
Thickness distribu琀椀on pa琀琀erns typical for pa琀椀ent for gender and age
HEENT:
Head: no visible scaliness, edema, masses, lumps, deformi琀椀es, scars, rashes, nevi, or other lesion and
nontender. Head is normocephalic, no deformi琀椀es,
Facial features symmetric: trachea midline
Cap re昀椀ll x 3 seconds
Eyes: eyelids no ptosis, erythema or swelling
Conjunc琀椀vae: pink, no d/c
Sclerae: anicteric
Orbital area: no edema, redness, tenderness or lesions noted
Eyes: normal reac琀椀ve, PERRLA. H pa琀琀ern normal reac琀椀ve no nystagmus
Red re昀氀ex bilaterally, op琀椀c disk sharp
Ears: normal appearing external structure, no deformi琀椀es, or edema, no discharge noted. Normal
appearing external auditory canals, L tympanic membrane translucent. Non-injected, and pinkish-gray in
color on le昀琀, good li昀栀t re昀氀ex, normal movement.
Right ear: tympanic membrane appears tense, mildly injected, poor li昀琀 re昀氀ex, and poor movement.
Hearing intact rinne, and webers test.
Nose: nose appear normal with no external lesion, redness, and irrita琀椀on around nostril. Inside nose
erythematous and edematous membrane bilaterally, no polyps, purulent discharge noted, in posterior
regions, narrowing due to swollen turbinates
Mouth: oropharynx shows mild erythema, tonsils without exudate. Tongue normal color symmetrical no
swelling or ulcera琀椀on. No overt dental problems seen on R incisior site or intermi琀琀ent pain. Buccal
membranes no lesions noted, Odor suggest infec琀椀on in mouth
Neck: no visible scars, deformi琀椀es or other lesion, trachea midline and freely mobile, thyroid 昀椀rm,
normal size, sho琀琀y lymphadenopathy
Palpate all lymph nodes: submental, submandibular, auricular, posterior auricular, posterior
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William Fredericks Health Assessment Practice Exam (1 Solved Case)

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