Sample Patient Presentation

1
Sample Patient Presentation

• Mike Morgan
• UNC SoM

2
Identification and Vitals

• 37 yo male high school teacher
• Vitals
• Wt 185
• HR 68
• BP 120/80

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Chief Complaint

• Checkup for rash.
• Ive been on steroids for six weeks. The doctor
  told me to come in when I finished the pills.

4
History of Present Illness

• Rash, Hives from head to toe, including in my
  mouth and throat.
• After beginning taking Wellbutrin
• 5 day hospital stay
• Stevens-Johnson Syndrome diagnosis
• Received IV fluids and Prednisone
• Rash cleared
• Rash returned after leaving hospital
• Primary physician prescribed 5 wks Medrol to
  clear rash
• Rash is now gone

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Stevens-Johnson Syndrome (SJS)

• Characterized by epidermal necrolysis
• Discrete red macules
• Eosinophil infiltration of papillary dermis
• Hydropic degeneration of basal layer
• Sever cases may present subepidermal plister
  formation

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Clinical Manifestations
including in my mouth and throat.
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Past Medical History

• Patient diagnosed with Fibromyalgia 1 ya
• Occasional stiffness, soreness and muscle spasms
• Symptoms sometimes interfere with work and
  walking but do not affect sleep
• Currently presenting with stiffness in abdominal
  oblique region

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Medications and Allergies

• No current medications
• Allergies
• Penicillin
• Sulpha Drugs
• Wellbutrin

9
Family History

• Father has recently suffered a stroke at 65 years
  of age and is now bedridden at home
• Mother died of breast cancer at 62

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Social History

• 20 pack-year smoking
• Does not drink alcohol
• Wife died in MVC 2 years ago
• Sole caretaker of 3 children and father
• Reports There is too much on my plate
• Works as a high school teacher during the day and
  takes classes at night

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Typical Day
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Assessment

• Physical examination showed that the rash has
  completely disappeared.

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Problem List / Plan

• Follow-up on fibromyalgia. He is visiting a
  rheumatologist next month.
• Cessation of smoking.
• Lack of support at home.

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