Preview Patient Note

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) and the Educational Commission for Foreign Medical Graduates

(ECFMG

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CLINICAL SKILLS EVALUATION

PATIENT NOTE

HISTORY: Describe the history you just obtained from this patient. Include only information (pertinent positives and negatives)

relevant to this patient’s problem(s).

Ms. Bingham is a 24 yo woman who complains of worsening sore throat since yesterday

morning. She has never had a similar problem in the past. She has no difficulty

swallowing, but notes that swallowing makes the pain worse. Nothing makes it better.

There is no SOB or sensation of choking or dysphagia. She has fatigue and has had some

anorexia since the symptoms began. She has had some subjective fevers at home but has not

taken her temperature. She has had no cough or rhinorrhea. There are no sick contacts at

home or at work. She denies seasonal allergies and post-nasal drip.

ROS: No chest pain, cough, wheezing, abdominal pain, N/V, headache

PMHx: none

Meds: none; Allergies: none

PSHx: none

FHx: father with HTN

SHx: married with 2 children, No ETOH or drugs, monogamous with husband

PHYSICAL EXAMINATION: Describe any positive and negative findings relevant to this patient’s problem(s). Be careful to include only

those parts of examination you performed in this encounter.

She is in no acute distress, throat clear, abdomen soft, nontender and without

distension. There is no notable splenic or hepatic enlargement or tenderness.

DATA INTERPRETATION: Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might

explain this patient’s complaint(s). List your diagnoses from most to least likely. For some cases, fewer than 3 diagnoses will be

appropriate. Then, enter the positive or negative findings from the history and the physical examination (if present) that support

each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis (e.g. restricted physical exam

maneuvers, laboratory tests, imaging, ECG, etc.).

DIAGNOSIS #1: Viral Pharyngitis

HISTORY FINDING(S)

PHYSICAL EXAM FINDING(S)

Sore throat

Tender submandibular lymph nodes

Subjective fever

Fatigue

Anorexia

Pain with swallowing

DIAGNOSIS #2: Bacterial Pharyngitis/Retropharyngeal Abscess

HISTORY FINDING(S)

PHYSICAL EXAM FINDING(S)

Appropriate supporting

information is drawn from

the history and PE section

above and used to support a

likely diagnosis

Including a diagnosis without supporting

information would result in a lower score even if

the diagnosis is likely. Including two diagnoses on

the same line would result in a lower score.

The physical exam includes a cursory examination of the

throat. A higher level of detail such as specific mention of

erythema or exudate, and evaluation for regional

lymphadenopathy would result in a higher score.

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