General Description
You are in the outpatient clinic. Chris Parteneau is a third-year medical
student completing the third week of the medicine clerkship. Chris has
just stopped you in the hallway and has asked to present a patient to
you.
Chris Parteneau - Student Script
A Bright but Disorganized Student
Personal Information
You are a bright and enthusiastic student who often cannot see the forest
for the trees. Famous for disorganization, your presentations are always
long and filled with extraneous detail. You tend to dart off on tangents
and often invoke "zebras" when only "horses" are present. Always looking
for the rare diagnosis, you tend to order lots of tests. Be prepared with
lots of test data to support this part of your role.
Patient Case:
A 19 y/o college student has just returned from a trip to Wisconsin where
she went camping with her family. While there she was bitten by mosquitoes
and sustained one tick bite that she knows of. She also went hiking
through the woods several times and during at least two of those hikes
encountered poison ivy. Her nose was stuffy from allergies during the
camping trip and on returning her sinus congestion persisted. She decided
that this congestion was due to sinusitis so she took some Amoxicillin
that was left-over from her roommate who had a recent UTI. Over the next
several days she developed a rash.
The rash is a diffuse, salmon pink, maculo-papular eruption over the face,
neck, thorax, abdomen, and proximal extremities. It is pruritic and there
is some excoriation of the lesions over the arms. The mouth is pared. The
patient has no fever and generally feels healthy.
Mode of Case Presentation:
- Describe the rash in agonizing detail. Include a monologue on the
temporal evolution of the rash on each region of the body.
- Launch into a listing of diagnoses including measles, German measles,
fifth disease, viral examthemas, poison ivy, atopic dermatitis,
vasculitis, liver disease, kidney disease, Hodgkin's Lymphoma, iron
deficiency anemia, hyper and hypo thyroid diseases.
Answers to specific questions:
- If asked to restate the case in concise terms, you should hesitate and
say, "Well, this is a 19 y/o woman who went camping, was bitten by
mosquitoes and ticks, got poison ivy, took some Amoxicillin, and has a
maculo-papular rash. She has been scratching the rash and may have
sinusitis. She also has a lot of allergies."
- If asked, "What do you think the most likely diagnosis is?", you
should answer, "There are probably several causes of this rash and we have
to consider that she might have contracted Lyme disease because Wisconsin
is an endemic area for the deer tick."
- If asked, "did you ask if she ever has had a reaction to penicillin or
other medication before?", you should respond, "I didn't ask her that,
but most people who state that they are allergic to penicillin actually
aren't when they are tested, and the people with true severe penicillin
allergy are actually pretty rare."