Case 2:  Jeanette McDonald

Ms. McDonald is a 32 yo woman with a history of heroin abuse who is known to have AIDS. She
has schizophrenia and recently moved here from another state to hopefully get better care. She
has been without medical care for at least six months. Her sister, with whom she lives, brought
her in because she has been sick for several weeks with fevers and headaches and intermittent
vomiting. She notes that for the past several days, her sister has seemed confused but she has
refused to come to the ED. Today, a neighbor found her wandering outside in the cold without
her shoes or jacket.

PMHx: AIDS, with most recent CD4 count of 79 according to records she has in her purse. 
Schizophrenia, diagnosed at age 22.

SHX:  Heroin abuse since early 20’s, none for the past five years.  2 PPD cigarette smoker

Meds: none

ROS: as per HPI, unable to get more information

PE: 

Vital Signs:

o   Temp: 101.5 F

o   BP:  88/58
o   RR: 16
o   HR: 128
o   Pulse oximetry: 97% on room air

HEENT:  atraumatic head. Mucous membranes are dry. Meningismus noted when flexing neck

Neurologic:

o   Mental status: somnolent, with one word answers to questions. Knows her name but cannot
identify city, state, location or situation. Thinks it is summer (it is December)
o   Pupils: photophobic but pupils are reactive to light.  Extraocular movements are normal.
o   Muscle strength is symmetrical
o   Reflexes are diffusely hyperactive
o   Babinski’s are upgoing bilaterally

· Cardiac exam is notable for tachycardia and no murmur

· Pulmonary, abdominal and joint exams are all normal.

Simple Problem List

Write a simple problem list for Ms. McDonald. This list should include at least 10 items.
0 points: No answer
5 points: Fewer than 10 items included OR at least 10 items included, but some or all do not
accurately describe Ms. McDonald's case
10 points: At least 10 items included that accurately describe Ms. McDonald's case 

Processed Problem List

Write a Processed Problem List for Ms. McDonald, making sure to include Epidemiology, Time
Course, Syndrome Description, and Other PMHx.

0 points: No answer
4 points: Epidemiology, Time Course, Syndrome Description and Other PMHx are all included.
8 points: Epidemiology, Time Course, Syndrome Description and Other PMHx are all included AND
at least two of these four are consistent with the answers provided.
10 points: Epidemiology, Time Course, Syndrome Description and Other PMHx are all included
AND all four are consistent with the answers provided. 

Case Summary

Summarize this case in one sentence.

0 points: No answer or answer that does not reflect the case

5 points: One sentence description of the case, which uses the details included above and is
consistent with the example given. 

Tiered Differential Diagnoses

Four possible diagnoses for Ms. McDonald might be:

 Central Nervous System Toxoplasmosis

 Cryptococcal Meningitis

 Herpes Simplex Encephalitis

 Progressive Multifocal Leukoencephalopathy

Applying the concept of tiered differential diagnoses, classify these four diagnoses as being in Tier
I, Tier Ie, Tier II, or Tier III. It is possible that a tier may include none of these diagnoses.

0 points: None of the four diseases are in the correct tier

2 points: One of the four diseases is in the correct tier
3 points: Two of the four diseases are in the correct tier
4 points: Three of the four diseases are in the correct tier
5 points: Four of the four diseases are in the correct tier

Illness Script: Epidemiology

From the question on Tiered Differential Diagnoses, select one Tier I diagnosis, one Tier II
diagnosis, and one Tier III diagnosis. Then, write the Epidemiology for each of these three
diseases.

0 points: No submission
1 point: Epidemiology is included for only one of the three diseases
2 points: Epidemiology is included for only two of the three diseases
3 points: Epidemiology is included for all three of the three diseases
4 points: Epidemiology is included for all three diseases AND one out of three  are consistent
with the correct answers provided
5 points: Epidemiology is included for all three diseases AND two or three are consistent with the
correct answers provided 

Illness Script: Time Course

From the question on Tiered Differential Diagnoses, select one Tier I diagnosis, one Tier II
diagnosis, and one Tier III diagnosis. Then, write the Time Course for each of these three diseases.

0 points: No submission
1 point: Time Course is included for only one of the three diseases
2 points: Time Course is included for only two of the three diseases
3 points: Time Course is included for all three of the three diseases
4 points: Time Course is included for all three diseases AND one out of three are consistent
with the correct answers provided
5 points: Time Course is included for all three diseases AND two or three are consistent with the
correct answers provided 

Illness Script: Syndrome Statement

From the question on Tiered Differential Diagnoses, select one Tier I diagnosis, one Tier II
diagnosis, and one Tier III diagnosis. Then, write the Syndrome Statement for each of these three
diseases. 

0 points: No submission
1 point: Syndrome Statement is included for only one of the three diseases
2 points: Syndrome Statement is included for only two of the three diseases
3 points: Syndrome Statement is included for all three of the three diseases
4 points: Syndrome Statement is included for all three diseases AND one out of three  are
consistent with the correct answers provided
5 points: Syndrome Statement is included for all three diseases AND two or three are consistent
with the correct answers provided 

Illness Script: Mechanisms of Disease

From the question on Tiered Differential Diagnoses, select one Tier I diagnosis, one Tier II
diagnosis, and one Tier III diagnosis. Then, write the Mechanisms of Disease for each of these
three diseases.

0 points: No submission
1 point: Mechanisms of Disease is included for only one of the three diseases
2 points: Mechanisms of Disease is included for only two of the three diseases
3 points: Mechanisms of Disease is included for all three of the three diseases
4 points: Mechanisms of Disease is included for all three diseases AND one out of three  are
consistent with the correct answers provided
5 points: Mechanisms of Disease is included for all three diseases AND two or three are consistent
with the correct answers provided