Case Analysis Tool Worksheet
Student's Name:
I. Epidemiology/Patient Profile
Name: Althea
Age: 5 years old
Chronic dx: No history of any chronic disease
Smoking: No history of smoking either actively or passively.
II. Prioritized Cues from Hx and PE.(Do not include lab, x-‐ray, or other diagnostic test results here.)
• Tier 1: The cues (may be positive or negative) that contribute most to the diagnosis of the active problem.
• Tier 2: These are cues of intermediate importance (list only positive cues).
• Tier 3: Of least importance (list only positive cues).
Tier 1 Tier 2 Tier 3
Dry cough Otitis media Colic
Sore throat
Fever with temperature of 38.6
Mouth petechiae appears on soft
palate and oropharynx-
erythematous having patchy white
exudate on tonsils.
Enlarged anterior cervical
lympnodes bilaterally measuring
1cm by 1 cm. The uvula is also
inflammed but in the midline.
Rash on the patient’s chest and
abdomen and consists of
numerous rough feeling papule.
Mild tarchycardia but no murmur.
Her heart rythm is normal.
Negative symptoms she does not
have ear pain, nausea, rhinorrhea,
diarrhea, vomiting or any
breathing problems.
III. Problem Statement
Althea is a 5-year-old female who has been healthy until two days ago when she started complaining of
fever. She also has a history of a sore throat, mild abdominal pains, dry cough, headache and decreased
appetited. She arrived at thehospital accompanied by her mother mainly because of fever and a sore throat.
Athea’s friend at school is being treated for streptococcal throat infection. On performing a physical
examination on Althea, the nose was clear with no rhinorrhea, the soft palate mouth petechie, oropharynx
was erythematous having patchy white exudate on the tonsils. The tonsils were moderately swollen and

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