Time Remaining :

Times Up!

for the history in the exam, I believe they expect us to write in

History : a paragraph.

- The 25yo f pt coming after a sexual & physical assault by 2 men.

for the history itself, I think you can add more about the story.
explore more about the story. where does this happen. was she
- vagina intercourse, condom-using is unknown. drunk?
like whether she is concious or uncouncious, if she is
—> it is good that you asked this. unconconsious how is the mechanism, whether she was drugged
- The pt did not take a shower afterward. or hit on the head for example.
does the patient know if there is any ejaculation?
- 3 hours ago, the pt got bruises in the L-lower jaw and a pain about 7/10 in the R-shoulder, no
numbness. what type of sexual intercourse involve? oral, anal, vaginal? if only
vagina, then you should also describe the pertinent negatives like
“denies oral and anal intercourse”
- On OCP, LMP 2 weeks ago. i think it is good that you asked abit of his menstrual
history. you can also asked if she had previous STD also in case like this the examiner would like to know how you
emphatize with patients. whether she has reported the case to the
- No vaginal or rectal bleeding afterward. before too. and also if she had any sexual partners in
the past. if she had have sex in the past, ask how many police? or if she intended to report afterwards?
partners she has had in the past 6 months.
RSO: (-) except as above
Allergies: NKDA
Medication: OCP
PMH: none
PSH: none
SH: Non-smoking, occasional EtOH, no illicit drugs, sexually active with girlfriend only. itsexual is good that you asked about the
history.

Physical Examination :
Pt is anxious and in distress.
VS: WNL —> in the exam, you should write down the vital signs. in the exam, you can copy paste the vital signs.
HEENT: Bruise on L-lower jaw, no law movement restricted.
CHest: breath sounds clear b/l. —> can do more description here. inspection, palpation, percussion, auscultation.
—> add whether there
Abdomen: Soft, nontender, nondistended, (+) BS 4 quadrants, no rebound, no hepatomegaly. is tenderness or not.

Extremities: Swelling on R-shoulder, ROM intact, sensation and pulses intact b/l.

Diagnosis 1 :
Shoulder injury i think the 1st diagnosis should be sexual abuse. then afterwards you can add other ddx.
shoulder injury STD are okay as ddx.

History Findings Physical Exam Findings

1) physical assault 1) Swelling on R-shoulder
2) pain about 7/10 in the R-shoulder 2. you can add tenderness on palpation, redness
on examination.
* for pain describe it with OLD CART. as appropiate. 3. if there is limitation of ROM you can include
onset, location, severity, acute/chronic, constant/intermittent, aggravating, too. in this case ROM is intact, maybe this
relieving, radiation for example exclude a fracture.
* for orthopedics the general exam has a
mnemonic of IPPROM (inspection, palpation,
Diagnosis 2 : pulse, and range of motion). you should write
which pulse is intact, eg. radialis, brachialis.

Sexually transmitted infections

History Findings Physical Exam Findings

1) sexual assault by 2 men
2) vagina intercourse, condom-using is
unknown
Diagnosis 3 :

History Findings Physical Exam Findings

Diagnostic Study/Studies - Labs

1) Pelvic exam
2) XR - R-shoulder & arm
3) Urine hCG
4) Vaginal wet mount, KOH prep
5) Cervical cultrure, Gonorrhea & Chlamydia tests i think the diagnostic study is good. if the sexual intercouse involve the oral or
anal area, the sample for culture, chlamydia gonorrhea test , wet mount,
should be done at those areas.
6) HIV antibody, VDRL, HBV antigen (HbsAg)

overall nice job!