Assignment Problem: A 43-year-old man, a known case of diabetes mellitus and hypertension (both well controlled), with no history suggestive of high-risk sexual behavior, presented with a painless swelling over the left side of the neck since 30 days which was insidious in onset and gradually progressive; fever since 15 days which was of sudden onset, intermittent, relieved with medications and was associated with generalized body ache; diarrhea since 3 days which was sudden in onset, foul smelling, watery, non-bloody, 7-8 episodes per day. He has lost 4 kg of weight in 15 days. He was a vegetarian,?did not keep cats as pets and was not known to be having an immunocompromised state. On clinical examination, only the lymph nodes in the posterior triangle of the left side of the neck were palpable. These were non-tender and were not matted.
Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.
In SOAP format, list:
- Pertinent positive findings that validate your main diagnosis
- Pertinent negative findings that make you think of other differential diagnoses
- Treatment plan, including: pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.