CASE 1:

HPI:
32 YO M C/O RT TESTICULAR PAIN X 1 WEEK, CONSTANT, 7/10, ACHING, SUDDEN, GETTING WORSE, NO
PREVIOUS EPISODE, NON-RADIATING, NOTHING MAKES IT WORSE OR BETTER. PT REPORTS DYSURIA &
SMALL AMOUNT OF YELLOWISH DISCHARGE X 4 DAYS, THICK, NO MALODOR. DENIES FEVER, N/V,
NOCTURIA, URGENCY, OTHER OBSTRUCTIVE SYMPTOMS, JOINT PAIN, SKIN RASH.
ROS: -VE EXCEPT AS ABOVE
PMH: HTN-AMLODIPINE, COMPLIANT.
ALLERGY: NKDA
PSH: TONSILLECTOMY
FH: NOT RELEVANT
SH: SEXUALLY ACTIVE WITH WIFE, HAD 4 PARTNERS(FEMALES)WITHIN THE PAST 1 Y, INCONSISTENT
USE OF CONDOMS, NO H/O STD OR HIV TESTING, DRINKS 1 BEER/DAY, NO TOBACCO/ILLICIT DRUGS.
EX:
PT IS IN NAD
VS WNL
ABD: NL APPEARANCE, SOFT, NT/ND, NO HSM OR MASSES, TYMPANIC, +BS, -CVA TENDERNESS.
DDX:
*GONOCOCCAL URETHRITIS
RT TESTICULAR PAIN X 1 WEEK
DYSURIA
DISCHARGE X 4 DAYS
SEXUALLY ACTIVE
MULTIPLE SEXUAL PARTNERS
INCONSISTENT USE OF CONDOMS

*NON-GONOCOCCAL URETHRITIS
RT TESTICULAR PAIN X 1 WEEK
DYSURIA
DISCHARGE X 4 DAYS
NO JOINT PAIN, SKIN RASH

WU:
GENITAL EXAM
DOPPLER U/S-SCROTUM
CBC WITH DIFF, GENITAL EXAM, U/S TESTES
DISCHARGE CULTURE/GRAM STAIN, UA
HIV ELIZA, CHLAMYDIA/GONORRHEA PCR

CASE 2:
HPI:
50 YO M, C/O ABD PAIN X 2 HOURS. SUDDEN, CONSTANT, EPIGASTRIC, 7/10, TEARING IN NATURE,
GETTING WORSE, NO PREVIOUS EPISODE, NO AGGREV/ALLEV FACTORS, ASSOCIATED WITH SWEATING. PT
DENIES N/V, CHANGE IN BOWEL HABITS, PALPIATION, CHEST PAIN, SOB OR LIGHTHEADEDNESS, NO
RELATION TO FOOD, NO HEARTBURN
ROS:-VE EXCEPT AS ABOVE
PMH:-VE, ALLERGY:NKA, MEDS:-VE, PSH:-VE, FH: DAD-CIHRROSIS.
SH: SEXUALLY ACTIVE WITH WIFE ONLY. NO SMOKING/ILLICIT DRUGS. DRINKS EVERY NIGHT 8-10 BEERS
(CAGE 3/4 EXCEPT EYE OPENER). LIVES WITH WIFE, WELL SUPPORTED, NO STRESS
EX:
PT IS IN NAD
VS WNL
CVS: S1+S2+0, RRR, NO M/R/G, PMI NOT DISPLACED, +2 RADIAL PULSES B/L
ABD: NL APPEARANCE, SOFT, EPIGASTRIC TENDERNESS, ND, TYMPANIC, +BS IN 4Q
-VE MURPHY'S
DDX:
*AORTIC DISSECTION
ABD PAIN X 2 HOURS
SUDDEN, CONSTANT, EPIGASTRIC,
SWEATING, RADIATED TO THE BACK
NO RELATION TO FOOD, NO HEARTBURN
PT DENIES N/V, CHANGE IN BOWEL HABITS
-VE MURPHY'S

*ACUTE PANCREATITIS
ABD PAIN X 2 HOURS
SUDDEN, CONSTANT, EPIGASTRIC,
SWEATING, RADIATED TO THE BACK
DRINKS EVERY NIGHT 8-10 BEERS
NO PALPIATION, CHEST PAIN, SOB OR LIGHT HEADEDNESS
-VE MURPHY'S

WU:
CBC, AMALYSE, LIPASE, ALT/AST
U/S ABD
CT ANGIO
CASE 3:
HPI:

EX:

DDX:
*AORTIC DISSECTION
WU:
CBC,
CASE 4:
HPI:
22 YO F, C/O BILATERAL LOWER ABD PAIN STARTED WITH HER PERIOD 4 DAYS AGO. ITS CONSTANT, 7/10,
SHARP, SUDDEN, GETTING WORSE, NOTHING MAKES IT BETTER OR WORSE. PT DENIES PREVIOUS
EPISODE, RELATION TO FOOD, DYSURIA OR FREQUENCY, N/V OR BOWEL HABIT CHANGES.
OB: MENARCHE 13, PERIODS ARE REGULAR LASTS 5 DAYS, EVERY 28 DAYS, USUALLY USES 4 PADS/DAY,
BUT THIS TIME SHE USED 7/DAY. PT REPORTS HX OF YELLOWISH VAGINAL DISCHARGE 2-3 TIMES, DIDN'T
SEEK MEDICAL ADVICE THEN & IT RESOLVED BY ITS SELF. SHE HAD SPOTTING RED BROWMISH COLOR.
ASSOCIATED WITH PAINFUL CRAMPS. NEVER BEEN PREGNANT. LAST PAP SMEAR WAS LAST YEAR
(NORMAL).
ROS: -VE EXCEPT AS ABOVE
PMH: -VE ALLAEGY: -VE, MEDS:-VE, PSH:-VE
FH: NON CONTREBUTERY
SH: SEXUALLY ACTIVE WITH BF, NO OTHER PARTNERS DURING THE PAST 1 YEAR, INCONSISTENT WITH
THE USE OF CONDOMS, NO HX OF STD, NEVER BEEN TESTED FOR HIV, NO SMOKING OR DRUG USE, OCC
DRINING
EX:
PT IS NAD.
VS: WNL
ABD: NL APPEARANCE
+VE BS IN 4Q
TYMPANIC IN 4Q
LOWER ABD TENDERNESS, NO HSM OR PALPABLE MASSES
+VE REBOUND, +VE PSOAS, +VE OBTURATOR, +VE GAURDING
DDX:
*PID
SEVERE LOWER ABD PAIN
FEELING WARM
INCONSISTANT USE OF CONDOMS
SPOTTING
NO RELATION TO FOOD
HX YELLOWISH DISCHARGE
LOWER ABD TENDERNESS
*ECTOPIC PREGNANCY
SEVERE LOWER ABD PAIN
NO RELATION TO FOOD
LMP & SPOTTING, SUDDEN ONSET
LOWER ABD TENDERNESS
INCONSISITENT USE OF CONDOM
SEXUALLY ACTIVE
*APPENDICITIS
ABD PAIN
SUDDEN
SHARP
CONSTANT
NAUSEA
+VE REBOUND
+VE PSOAS
GAURDING

WU:
BHCG, CBC, U/A
U/S- ABD & PELVIS
PELVIC EXAM & CERVICAL CULTURES

CASE 5:
HPI:
30 YO F, C/O ABD PAIN X 2 HOURS, ACUTE ONSET, RLQ PAIN, SHARP, CONSTANT, 8/10, GETTING WORSE,
NONRADIATING, NO AGG OR RELIEVING FACTORS. PT DENIES, FEVER, NAUSEA, VOMITING, BOWEL HABIT
CHANGES, RELATION TO FOOD.
OB: LMP 2 MONTHS AGO, IRREGULAR (EVERY 2-3 MONTHS), REPORTS VAGINAL DISCAHRGE, YELLOWISH,
THINK, SCANTY, NO BLOOD OR BAD ODOR. NO SPOTTING OR PREVIOS PREGNANCIES.
ROS:-VE EXCEPT AS ABOVE
PMH:PID (TRESTED), ALLEGY:NKA, PSH:APPENDECTOMY. FH:NONCONTREBUTERY, SEXUAL HX: ACTIVE
WITH BF ONLY, INCONSISITENT USE OF CONDOMS, NO HX OF STD, OR HIV TESTING.
SH: NO SMOKING/ETOH/ILLICIT DRUGS
EX:
PT IS IN NAD
VS WNL EXCEPT
ABD: NL APPERANCE, SOFT, NT, ND, TYMPANIC, NO HSM OR MASSES, +BS -VE REBOUND

DDX:
*ECTOPIC PREGNANCY
ABD PAIN X 2 HOURS, RLQ PAIN
H/O PID
APPENDECTOMY
SEXUALLY ACTIVE
INCONSISITENT USE OF CONDOMS
 SHARP, CONSTANT
ACUTE ONSET
DENIES, FEVER, NAUSEA, VOMITING, BOWEL HABIT CHANGES

*OVARIAN TORTION
ABD PAIN X 2 HOURS, RLQ PAIN
APPENDECTOMY
SHARP, CONSTANT
ACUTE ONSET
DENIES, FEVER, NAUSEA, VOMITING, BOWEL HABIT CHANGES

*PID
ABD PAIN X 2 HOURS, RLQ PAIN
SEXUALLY ACTIVE
INCONSISITENT USE OF CONDOMS
VAGINAL DISCHARGE
DENIES, FEVER, NAUSEA, VOMITING, BOWEL HABIT CHANGES

WU:
CBC, ELECTROLYTE, DISCHARGE CULTURE/GRAM STAIN
US- PELVIS, BHCG, UA, URINE CULTURE
PELVIC EXAM

CASE 6:
HPI:
28 YO F, C/O GRADUAL ONSET ABD PAIN SINCE 6 M, INTERMITTENT, DIFFUSE, CRAMPY, 6/10, STEADY,
WORSE AFTER EATING BREAD OR CEAREAL, BETTER WITH DEFECATION. PT REPORTS DIARREAH,
WATERY, BROWN COLOR, NO MUCUS OR BLOOD, SOMETIMES BAD ODOR. +VE BLOATING & WT LOSS 2IBS
OVER 2 MONTHS. PATIENT DENIES N/V, FEVER, HX OF TRAVEL OR ILL CONTACT, RELATION TO MILK
ROS: -VE EXCEPT AS ABOVE
PMH:-VE ALLERGY:-VE MEDS:-VE PSH:-VE
FH: DAD HAS PUD
OB: LMP 2 WKS, REGULAR
SH: SEXUALLY ACTIVE WITH BF, CONSISTENT USE OF CONDOM, NO OTHER PARTNERS OVER THE PAST 1
YR, NO SMOKING OR DRUGS, 1 DRINK X 4 DAYS A WEEK

EX:
PT IS NAD
VS: WNL
ABD: NL APPEARANCE, SOFT, ND, NT
+VE BS IN 4Q
TYMPANIC IN 4Q
NT, NO HSM, NO MASSES
-VE REBOUND
DDX:
*CELIAC DISEASE
GRADUAL ONSET ABD PAIN
ALL OVER THE ABD
WATERY DIARREAH
NO FEVER
DURATION 6 MONTHS
RELATED TO BREAD OR CEREAL
NOT RELATED TO MILK
NO BLOODY STOOL
*IBS
 GRADUAL ONSET ABD PAIN
ALL OVER THE ABD
WATERY DIARREAH, NO BLOOD
RELIVED WITH DEFECATION
NO H/O TRAVEL
WU:
ANTI-ENDOMESYEAL, ANTI GLIDAIN, ANTI TRANSGLUTAMINASE
ENDOSCOPY & SMALL BOWELL BIOPSY, RECTAL EXAM & FOBT
STOOL EXAM FOR OVA & PARASITE, CBC
CASE 7:
HPI:
28 YO M, C/O DIARRHEA X 3 WEEKS. ITS STARTED GRADUALLY, BROWN WATERY STOOL, NO BLOOD OR
MUCUS. GETTING WORSE, 5-6 TIMES/DAY (USUAL BOWEL HABITS ONCE A DAY). ASSOCIATED WITH ABD
PAIN X 2DAYS, RLQ, 6/10, CRAMPY, RELIEVED AFTER DEFECATING, NO RADIATION. REPORTS BURNING
ANAL PAIN WHILE WHIPING. TENESMUS. PT DENIES ANY CONSTIPATION, BLOATING, RELATION TO MILK
OR STRESS, N/V, ORAL ULCERS/RASH/JOINT PAIN, NO TRAVEL HX OR ILL CONTACT.
ROS:-VE EXCEPT AS ABOVE
PMH:-VE, ALLERGY:NKA, MEDS:-VE, PSH:-VE, FH:NOT RELEVAENT
SH: SEXUALLY ACTIVE WITH WIFE ONLY, NO SMOKING/ALCOHOL/ILLICIT DRUG USE.
EX:
PT IS IN NAD
VS WNL
EYE: NO CONJUNCTIVAL PALLOR
MOUTH: NO ORAL ULCERS, MOIST MUCOSA
ABD: NL APPERANCE, SOFT, ND, NT, TYMPANIC, -VE HSM OR MASSES, +BS, -VE REBOUND, -VE ROVSING
DDX:
*IBD
DIARRHEA X 3 WEEKS
BROWN WATERY STOLL, NO BLOOD OR MUCUS.
ABD PAIN X 2DAYS, RLQ
BURNING ANAL PAIN. TINISMUS
DENIES ANY CONSTIPATION, BLOATING RELATION TO MILK OR STRESS, TRAVEL HX OR ILL
CONTACT
-VE REBOUND, -VE ROVSING

*IBS
DIARRHEA X 3 WEEKS
BROWN WATERY STOLL, NO BLOOD OR MUCUS.
ABD PAIN X 2DAYS,
RELEIVED AFTER DEFECATING
NO ORAL ULCERS/RASH/JOINT PAIN, NO TRAVEL HX OR ILL CONTACT
-VE REBOUND, -VE ROVSING

WU:
CBC, ELECTROLYTE, P-ANCA, ASCA
ESR/CRP, STOOL EXAM FOR OVA & PARASITE
COLONOSCOPY WITH BIOPSY, RECTAL EXAM
CASE 8:
HPI:
25 YO M, C/O DIARREAH FOR 2 WKS. ITS CONSTANT, LOOSE WATERY, BROWN COLOR, NO BLOOD OR
MUCUS, 4-6/DAY, GETTING WORSE. PT REPORTS NAUSEA, ABD PAIN , CRAMPY, NON RADIATING, ALL OVER
NOTHING MAKES IT WORSE OR BETTER. PT DENIES VOMITING, BLOATING, JAUNDICE, FEVER, WT &
APPETITE CHANGES. POS H/O TRAVEL TO KENYA, BUT HE TOOK VACCINATION
ROS:-VE EXCEPT AS ABOVE
PMH:-VE
ALLERGY: ASPRIN (RASH),
MEDS: CIPROFLOXACIN & AMODIUM, BUT IT MADE HIS SX WORSE
FH:-VE
SH: SEXUALLY ACTIVE WITH WIFE ONLY, NO SMOKING, OR DRUG USE, ETOH COUPLE OF BEERS ON THE
WEEKENDS

EX:
PT IS NAD
NO CONJUNCTIVAL PALLOR, WELL HYDRATED ORAL MUCOSA
VS: WNL
ABD: NL APPEARANCCE
POS BS IN 4Q
TYMPANIC IN 4Q
NT, NO HSM, NO MASSES FELT
-VE REBOUND
DDX:
*PARASITIC DIARREAH
2 WEEKS H/O DIARREAH
GRADUAL ONSET
NO MUCUS OR BLOOD
H/O TRAVEL TO KENYA
NO JAUNDICE
NO FEVER
*PSEUDOMEMBRENOUS COLITIS
2 WEEKS H/O DIARREAH
CIPROFLOXACIN
IT MADE HIS SX WORSE
LOOSE WATERY, NO BLOOD
WU:
CBC, ELECTROLYTE
STOOL EXAM FOR OVA, LEUKOCYE & PARASITE
COLONOSCOPY
RECTAL EXAM
CASE 9:
HPI:
49 YO M,CAME IN FOR MEDS REFILL, HE DIDN'T GET IT IN THE MAIL FOR 2 WEEK. HYPERTENSIVE X 10
YEARS, LAST CHECKUP 1 YEAR AGO (NL), ON HCTZ/LISINOPRIL (ONCE/DAY, PO). COMPLAINT, DOESN'T
MONITOR AT HOME. HE FEELS OK APART FROM FEELING FATIGUE & DECREASED ENERGY SAME
THROUGHOUT THE DAY & SOB X 3-4 M WHEN HE WALKS (1 MILE) RELIEVED WITH REST. PT DENIES
ORTHOPNIA, PND, LEG SWELLING, CHEST PAIN OR PALPITATION, POLYURIA, FEREQUNCY.
ROS:-VE EXCEPT AS ABOVE
PMH: DMX2 YEARS (NO MEDS, NO CHECKUPS), NO H/O PREVIOUS MI
ALLERGY:NKA, MEDS:AS MENTIONED, PSH:-VE
FH: NO H/O CARDIAC DISEASE, SH: SEUALLY ACTIVE WITH GF ONLY, CONSISITENT USE OF CONDOMS, NO
SMOKING/ALCOHOL/ILLICIT DRUG USE. LIVES WITH GF, WELL SUPPORTED. WORKS AS.......
EX:
PT IS IN NAD
VS WNL
CVS: S1+S2+0, RRR, NO M/R/G, PMI NOT DISPLACED,
NECK: -JVD/CAROTID BRUIT
EXT: POWE 5/5 THROUGHOUT B/L
DECREASES SENSATION ON UL & LL B/L (GLOVE & STOCK DISTREBUTION)
+2 DTRS THROUGHOUT
+2 PULSES THROUGHOUT
NO LEG SWEALLING

DDX:
*DIABETIC POLYNEUROPATHY
PT DENIES ORTHOPNIA, PND, LEG SWELLING,
FATIUGUE
DM X 2 YEARS
NO MEDS, HOME MONITORING OR FOLLOW UP
NO FH OF CARDIAC DIS OR PREVIOUS MI
DENIES CHEST PAIN, PALPITATION, ORTHOPNIA, PND & LEG SWELLING
DECREASES SENSATION ON UL & LL B/L (GLOVE & STOCK)

*CHF
FATIUGUE
SOB
WHILE WALKING
HTN X 10 YEARS

*HYPERTINSIVE EMERGENCY
H/O HTN
MEDS DIDN'T COME IN THE MAIL FOR 2 WEEKS
NO DAILY MONITORING

WU:
CBC, BLOOD GLU, HBA1C, BUN/Cr
BNP, ECG, ECHO, CXR, LDL/HDL/CHOLESTEROL
UA, URINE MICROALBUMINURIA
CASE 10:
HPI:
34 YO M, CAME IN FOR MEDS REFILL, KNOWN HYPERLIPIDEMIC X 3 YEARS, TAKING STATINS(TWICE
DAILY)-PO, LAST CHECKUP WAS 1 Y AGO(NL), NO MEDS SIDE EFFECT, NOT COMPLAINT, FEELING WELL
APART FROM HAVING ED, CAN'T MENTAIN AN ERECTION X 2 M WITH LOSS OF MORNING ERECTION.
DENIES STRESS, LOSS OF LIPIDO, INJURY, INCONTINANCE, FEELING DEPRESSED, ANHYDONIA OR SUICIDAL
THOUGHTS,NO HEADACHE,NIPPLE DISCHARGE.
ROS:-VE EXCEPT AS ABOVE
PMH:AS ABOVE,NO HEART DISEASE/STROKE/DM,
ALLERGY:NKA, MEDS:AS ABOVE, PSH:NO PROSTATE SURGEY, FH:FATHER-DM&HTN, SH:SEXUALLY ACTIVE
WITH WIFE ONLY, SMOKES 1PPD/10 Y, NO ETOH/ILLICIT DRUGS
EX:
PT IS IN NAD
VS WNL
CVS: S1+S2+0, RRR, NO M/R/G, PMI NOT DISPLACED
EXT: +2 PULSES THROUGHOUT, -PEDAL EDEMA
NECK:-JVD/CAROTID BRUIT

DDX:
*HYPERLIPIDEMIA INDUCED ED
HYPERCHOLESTEROLEMIC X 3 YEARS
NOT COMPLAINT
SMOKES 1PPD/10 Y
CAN'T MENTAIN AN ERECTION X 2 M
DOESN'T MONITOR ON REGULAR BASES
DENIES LOSS OF LIPIDO, INJURY, INCONTINANCE, FEELING DEPRESSED, ANHYDONIA OR SUICIDE
NO STRESS
*SMOKING INDUCED ED
HYPERCHOLESTEROLEMIC X 3 YEARS
SMOKES 1PPD/10 Y
CAN'T MENTAIN AN ERECTION X 2 M
DOESN'T MONITOR ON REGULAR BASES
DENIES LOSS OF LIBIDO, INJURY, INCONTINANCE, FEELING DEPRESSED, ANHYDONIA OR SUICIDE
NO STRESS

WU:
CBC, ELECTROLYTE, BUN/CR
DOPPLER U/S- PENIS, GENITAL EXAM, ECG
CHOLESTEROL, SERUM GLU, HBA1C44W44WR
CASE 11:
HPI:

EX:

DDX:
*AORTIC DISSECTION
WU:
CBC,
CASE 12:
HPI:

EX:

DDX:
*AORTIC DISSECTION
WU:
CBC,
CASE 13:
HPI:

EX:

DDX:
*AORTIC DISSECTION
WU:
CBC,
CASE 14:
HPI:

EX:

DDX:
*AORTIC DISSECTION
WU:
CBC,
CASE 15:
HPI:

EX:

DDX:
*AORTIC DISSECTION
WU:
CBC,
CASE 16:
HPI:
40 YO F, C/O KNEE PAIN FOR 1 WEEK. SHE WENT TO A HIKING TRIP 2 WEEKS BACK. ITS CONSTANT,
SUDDEN, RT KNEE, 8/10, SHARP, GETTING WORSE, NONRADIATING, NO AGGREV/ALLEV FACTORS. PT
DENIES SWELLING, REDNESS, FEVER, TRAUMA, ORAL ULCERS HAIR LOSS, PHOTOSENSITIVITY, RASH, TICK
BITE, ILL CONTACT.
ROS:-VE EXCEPT AS ABOVE
PMH:-VE, ALLERGY
.:NKA, PSH:-VE, FH:NO H/O SLE, RA.
OB:LMP 4 WEEKS AGO, REGULLER, 3 TAMPONS/DAY.
SEXUAL HX:ACTIVE WITH BF ONLY, INCONSISTENT USE OF CONDOMS, NO H/O STD, NO HIV TESTING
SH:NO SMOKING/ILLICIT DRUGS, DRINKS 2 GLASSESE OF WINE/DAY ON THE WEEKENDS
EX:
PT IS IN NAD
VS WNL
RT KNEE: NL APPEARNCE, NO REDNESS SWELLING, DIFFUSE TENDERNESS, ROM COULDN'T BE ASSESES
DUE TO PAIN, INTACT SENSATION B/L, +2 KNEE DTRS, +2 PULSES B/L
-VE ANT. & POST DROWER TEST
-VE VARAUS & VALGUS STRESS TEST
GAIT WNL
DDX:
*GOUT
KNEE PAIN FOR 1 WEEK, MONOARTICULAR
NO FEVER, TRAUMA, ORAL ULCERS HAIR LOSS, PHOTOSENSITIVITY, RASH,
NO FH OF SLE, RA.
DRINKS 2 GLASSESE OF WINE
DIFFUSE TENDERNESS

*LYME DISEASE
KNEE PAIN FOR 1 WEEK
HIKING TRIP 2 WEEKS BACK
NO FEVER, TRAUMA, ORAL ULCERS HAIR LOSS, PHOTOSENSITIVITY, RASH,
NO FH OF SLE, RA.

*GONOCOCCAL ARTHRITIS
KNEE PAIN FOR 1 WEEK
SEXUALLY ACTIVE, INCONSISTENT USE OF CONDOMS
NO FH OF SLE, RA.
NO FEVER, TRAUMA, ORAL ULCERS HAIR LOSS, PHOTOSENSITIVITY, RASH, TRAUMA

WU:
CBC, ELECTROLYTE, URIC ACID
XR-RT KNEE, MRI-RT KNEE
LYME TITER IGG/IGM+120 , GONORREAH & CHLAMYDIA PCR
CASE 17:
HPI:

EX:

DDX:
*AORTIC DISSECTION
WU:
 CBC,
CASE 18:
HPI:

EX:

DDX:
*AORTIC DISSECTION
WU:
CBC,
CASE 19:
HPI:

EX:

DDX:
*AORTIC DISSECTION
WU:
CBC,
CASE 20:
HPI:

EX:

DDX:
*AORTIC DISSECTION
WU:
CBC,
CASE 21:
HPI:

EX:

DDX:
*AORTIC DISSECTION
WU:
CBC,
CASE 22:
HPI:

EX:

DDX:
*AORTIC DISSECTION
WU:
CBC,
CASE 23:
HPI:
17 YO F, C/O PAIN DURING URINATION X 1 WEEK. CONSTANT, GETTING WORSE. ASSOCIATED WITH
FREQUENCY & FEVER. PT DENIES URGENCY, NOCTURIA,HEMATURIA, ABD PAIN, N/V, WT & APPETITE
CHANGES, SKIN RASH OR JOINT PAIN. H/O PREVIOUS SIMILAR EPISODES TWICE BEFORE. TREATED WITH
ANTIBIOTIC
ROS: -VE
PMH:-VE, MEDS:-VE, ALLERGY: ASPRIN (RASH)
PSH: -VE, FH: -VE
OB: LMP 3 WKS, REGULAR.
SH: SEXUALLY ACTIVE WITH 3 PARTNERS DURING THE PAST YEAR, INCONSISTENT USE OF CONDOMS, NO
H/O STD, NEVER BEEN TESTED FOR HIV. SMOKED ONCE, NO ETOH OR DRUG USE.
EX:
PT IS NAD
VS WNL
ABD: NL APPEARANCE,
+VE BS IN 4Q
TYMPANIC IN 4Q
SOFT, ND, NT, NO HSM OR MASSES
-VE CVA TENDRENESS B/L
DDX:
*CYSTITIS
DYSURIA
FREQUENCY
NO FEVER, N/V
PREVIOUS HX
HX OF MULTIPLE SEXUAL PARTNERS
INCONSISTENT USE OF CONDOMS
* GONOCOCCAL URETHRITIS
DYSURIA
FREQUENCY
NO FEVER, N/V
PREVIOUS HX
HX OF MULTIPLE SEXUAL PARTNERS
INCONSISTENT USE OF CONDOMS
NO SKIN RASH & JOIT PSIN
*NONGONOCOCCAL URITHRITIS:
WU:
CBC, ELECTROLYTE
UA & URINE CULTURE
PELVIC EXAM, HIV VIRAL LOAD
CASE 24:
HPI:
67 YO F C/O VAGINAL BLEEDING X 2 WEEKS. 2 EPISODES, WORSENING. LMP WAS 25YRS AGO. MENARCHE
WAS AT 13YRS. USED HRT FOR 12YRS. REPORTS WEIGHT LOSS, LOSS OF APPETITE. DENIES ABD PAIN,
VAGINAL DISCHARGE, DYSURIA. BLEEDING HAS NO CORRELATION WITH SEXUAL ACTIVITY.
OB/GYN: G3P3, DOES NOT REMEMBER LAST PAP SMEAR RESULT, USED OCPS FOR 10YRS.
ROS: NONE
ALLERGIES: NONE
MEDS: HRT
PMH/PSH: NONE
FH: NONE
SH: 1PPD X 30YRS, 2-3GLASSES OF WINE/WEEKEND, NO DRUGS
EX:
PATIENT IS NAD
VS: WNL
HEENT: NO CONJUCTIVAL PALOR
ABD: SOFT, NONTENDER, NONDISTENDED, +BS, NO ORGANOMEGALY
DDX:
* ENDOMETRIAL CANCER
USED HRT FOR 12YRS
VAGINAL BLEEDING X 2 WEEKS
BLEEDING HAS NO CORRELATION WITH SEXUAL ACTIVITY
AGE
 REPORTS WEIGHT LOSS, LOSS OF APPETITE
*ENDOMETRIAL HYPERPLASIA
AGE (post-menopausal)
BLEEDING HAS NO CORRELATION WITH SEXUAL ACTIVITY
USED HRT FOR 12YRS
*CERVICAL CANCER
AGE
VAGINAL BLEEDING X 2 WEEKS
REPORTS WEIGHT LOSS, LOSS OF APPETITE
1PPD X 30YRS
WU:
PELVIC EXAM
PAP SMEAR
ENDOMETRIAL BIOPSY
CBC, ELECTROLYTES
CASE 25:
HPI:
48 YO F, C/O HEAVY MENSES X 6 MONTHS, LMP 2 WKS, MENARCHE 12, REGULAR PERIODS EVERY 20 DAYS,
LASTS FOR 6 DAYS, USED TO USE 3 & NOW 6 TAMPONS, G4,P3+1,SVD WITH NO COMPLICATIONS, PT
REPORTS URINARY FREQUANCY & ABD FULLNESS. PT DENIES VAGINAL DISCHARGE, DYSMENORRHEA,
SPOTTING, SYMPTOMS OF ANEMIA (SOB & PALPITATION) OR HYPOTHYROIDISM (SKIN CHANGES & HAIR
LOSS), CONSTITUTIONAL SYMPTOMS. OCP X 2 YRS, PAP SMEAR LAST YEAR (NL)
ROS:-VE EXCEPT AS ABOVE
PMH: - MEDS: VITAMIN, ALLERGY: -VE PSH: APPENDECTOMY,
FH: NOT RELEVENT.
SH: SEXUALLY ACTIVE WITH GF ONLY, H/O STD 1 YR AGO - TREATED, NEVER BEEN TESTED FOR HIV.
SMOKE 1PPD X 5 YRS. 2 BEERS ON THE WEEKENDS, - DRUG USE.
EX:
PT IS NAD
VS: WNL
- CONJUCTIVAL PALLOR, - THRYROID ENLARGEMENT OR LAD
ABD: NL APPEARANCE
+ BS & TYMPANIC IN 4Q
SOFT ND ND -HSM OR MASSES
DDX:
*FIBROID
HEAVY MENSES X 6 MONTHS
ABD FULLNESS
FREQUENCY
USING DOUBLE THE PADS SHE USED TO USE
NO CONSTITUTIONAL SYMPTOMS
NO SKIN CHANGES OR HAIR LOSS
*ENDOMETRIAL POLYO
HEAVY MENSES X 6 MONTHS
USING DOUBLE THE PADS SHE USED TO USE
NO CONSTITUTIONAL SYMPTOMS
NO SKIN CHANGES OR HAIR LOSS

WU:
CBC, ELECTROLYTE
PT/PTT & BLEEDING TIME, IRON STUDIES
PELVIC EXAM & U/S- PELVIS
CASE 26:
HPI:
50 YR OLD F C/O VAGINAL DISCHARGE X 2 MONTHS. YELLOWISH, FOUL SMELLING, NO BLOOD.
BEGAN AFTER SHE GOT A NEW BOYFIRND 2 MONTHS AGO. ALSO HAS VAGINAL PAIN, WORSE DURING SEX,
VAGINAL DRYNESS, ITCHINESS. DOES NOT USE LUBRICATION. DENIES DOUCHING, DYSURIA, FREQUENCY,
RASH, JOINT PAIN.
OB/GYN: G3P3, LMP 15YRS AGO, MENARCHE AT 13YRS, LAST PAP SMEAR 1 YR AGO NORMAL
ROS: NONE
ALELRGIES: NONE
MEDS: CHTZ, METFORMIN
PMH: HTN, DM X 2YRS
FH: NONE
SH: 1CIG/DAY X 12YRS, SOCAIL DRINKER. SEXUALLY ACTIVE WITH NEW BOYFRIEND ONLY, BUT HAS H/O
MULTPIPLE PARTNERS IN PAST 1 YR AND INCONSISTENT CONDOM USE.
EX:
PATIENT IS NAD
VS: WNL
ABD: NL APPERANCE, SOFT, NT, ND, NO HSM OR MASSES, TYMPANIC, +BS IN 4Q .
DDX:
*ATROPHIC VAGINITIS
DYSPARUNEA
VAGINAL DRYNESS
ITCHINESS
DOES NOT USE LUBRICATION
*VULVOVAGINITIS
YELLOWISH VAGINAL DISCHARGE
FOUL SMELLING
BEGAN AFTER SHE GOT A NEW BOYFRIEND 2 MONTHS AGO
*CERVICITIS
YELLOWISH VAGINAL DISCHARGE
FOUL SMELLING
BEGAN AFTER SHE GOT A NEW BOYFRIEND 2 MONTHS AGO
WU:
GENITOPELVIC EXAM
VAGINAL DISCHARGE ANALYSIS (PH, KOH PREP, WET MOUNT)
CBC WITH DIFF, CHLAMYDIA & GONORRHEA PCR
CASE 27:
HPI:
HX OBTAINED FROM FATHER OF A 4 YO M, C/O DRY COUGH X 2 WEEKS. 6 TIMES/DAY, EACH LASTING 2
MIN, MOSTLY AT NIGHT, WORSE WITH EXERCISE, ASSOCIATED WITH 2 TIMES POST-TUSSIVE VOMITING
(NO BLOOD), FEVER (UNDOCUMENTED). LOOKS IRRITABLE, NO SPECIFIC PATTERN. URI 3 WEEKS AGO.
MISSED HIS LAST DTP VACCINE. FATHER DENIES ANY SPUTUM, RHINNORIA, RASH, SOB, WHEEZING, ILL
CONTACT, CHANGE IN ACTIVITY OR SLEEP PATTERN. NO PREVIOUS EPISODE.
ROS:-VE EXCEPT AS ABOVE
PMH:-VE, ALLERGY:EGG(RASH), MEDS:-VE, PSH:-VE,
FH: MOTHER-HEY FEVER & FATHER SMOKES 1PPD AROUND THE KID,
BIRTH HX: NL SVD, FULL TERM, NO COMPLICATIONS
GROWTH: UP TO AGE, EATS ADULT DIET, ATTEND DAY CARE, LAST CHECKUP-2 MONTHS AGO(NL)
EX:

DDX:
*ASTHMA
COUGH X 2 WEEKS
MOSTLY AT NIGHT,
WORSE WITH EXCERSICE
FH OF HEY FEVER
EGG ALLERGY
 FATHER SMOKES 1PPD AROUND THE KID
H/O URI
NO ILL CONTACT

*WHOOPING COUGH
COUGH X 2 WEEKS
POST-TUSSIVE VOMITING
MISSED HIS LAST DTP VACCINE
IRRITABILITY
FEVER
NO WHEEZING

*BRONCHITIS
COUGH X 2 WEEKS
NO WHEEZING
FATHER SMOKES 1PPD AROUND THE KID

WU:
PHYSICAL EXAM
CBC, ELECTROLYTE, PERTUSSIS SEROLOGY
CXR, PEAK FLOW MEASURMENT, PFTS, METHACHOLINE CHALLENGE TEST
CASE 28:
HPI:
HX OBTAINED FROM GRANDFATHER OF 3.5 WEEKS OLD F C/O DIARRHEA X 3 DAYS. IT STARTED
SUDDENLY, GETTING WORSE, 4-5TIMES/DAY (USUAL 2), BROWN LOOSE STOOL, WATERY, NO BLOOD OR
MUCUS, NO RELATION TO FOOD OR PREVIOUS EPISODE, NO AGGRIVATING OR RELIEVING
FACTORS.REPORTS SIGNS OF DEHYDRATION (DECREASED URINATION, SUNKEN EYES, DRY MOUTH),
DROWSY & WEAK, CRYING ALOT & IRRITATED. DENIES ILL CONTACT, FEVER, VOMITING, ABD
DISTENTIONN, RASH OR RECENT URI.
ROS:-VE EXCEPT AS ABOVE
PMH: -VE,
ALLERGY:NKA,
PSH:-VE,
FH: NOT RELEVENT,
BIRTH HX: UNCOMPLICATED VAGINAL DELIVERY, FULL TERM,
GROWTH: UP TO AGE, IMMUN:UTD, DOESN'T ATTENT DAY CAR, DIET, BREAST FEEDING + FORMULA, LAST
CHECKUP-2 WEEKS AGO (NL
EX:

DDX:
*OSMOTIC DIARREAH/MILK ALLERGY
DIARRHEA X 3 DAYS
WATERY, NO BLOOD
NO FEVER
DROWSY & WEAK, CRYING ALOT & IRRITATED
NO ILL CONTACT OR DAY CARE ATTENDENCE
NO VOMITING

*VIRAL GASTROENTERITIS
DIARRHEA X 3 DAYS
ACUTE ONSET
DROWSY & WEAK, CRYING ALOT & IRRITATED

WU:
PHYSICAL EXAM
 CBC WITH DIFF, ELECTROLYTE, ROTAVIRUS IMMUNOASSAY
STOOL EXAMINATION FOR OVA/PH & PARASITE
CASE 29:
HPI:
HX OBTAINED FROM GRANDMOTHER OF A 2 YO M, C/O FEVER X 2 DAYS. THE FEVER IS UNDOCUMENTED,
NO SPECIFIC PATTERN,PARTIALLY RELIEVED BY TYLENOL, NO CHILLS. REPORTS RT EAR PULLING,
RHINORRHEA, COUGH WITH SCANTY WHITISH SPUTUM, IRRITABLE. PT DENIES EAR DISCHARGE OR
REDNESS, NO DIARRHEA, URINARY CHANGES. SIBLING HAD FLU 1 WEEK AGO & TREATED WITH
ANTIBIOTICS.ATTEND DAYCARE.NOT AS PLAYFUL,SLEEP IS POOR. NO CHANGE IN APPETITE.
ROS:-VE EXCEPT AS ABOVE
PMH: -VE, ALLERGY:NKA, MEDS:AS ABOVE, PSH:-VE, FH:NONE, BIRTH HX: UNCOMPLICATED VAGINAL
DELIVERY, PREMATURE, STAYED AT HOSPITAL 1 WEEK AFTER BIRTH. GRPWTH: UP TO AGE, IMMUN:UTD,
EATS ADULT DIET,
EX:

DDX:
*URI
FEVER X 2 DAYS
COUGH, RHINORRHEA
SCANTY WHITISH SPUTUM
H/O ILL CONTACT
IRRITABLE
ATTEND DAYCARE.
NOT AS PLAYFUL, POOR SLEEP.
NO DIARRHEA, URINARY CHANGES

*OTITIS MEDIA
FEVER X 2 DAYS
EAR PULLING
IRRITABLE
RHINORRHEA
ATTEND DAYCARE.
NOT AS PLAYFUL, POOR SLEEP.
NO DIARRHEA, URINARY CHANGES

WU:
PHYSICAL EXAM
CBC WITH DIFF, ELECTROLYTE
PNEUMATIC OTOSCOPY, TYMPANOGRAPHY
CXR, SPUTUM CULTURE
CASE 30/31:
HPI:
HX OBTAINED FROM THE MOTHER OF 12 YO F, C/O WEIGHT LOSS (4LBS/4DAYS),UNINTENTIONAL, NOT
FOLLLOWING ANY DIET OR DOING VIGOURUS EXERCISE, PT REPORTS POLYURIA, POLYDIPSIA,
POLYPHAGIA. PT DENIES DYURIA, HEMATURIA,NOCTURIA, DIARREAH, TREMOR, HEAT INTOLERANCE,
HEAR RACING, SKIN/HAIR CHANGES, STRESS.
ROS:-VE EXCEPT AS ABOVE
PMH:-VE, ALLERGY:NKA, PSH:-VE IMMUN:UTD, FH: NO H/O THYROID DISEASE OR DM. BIRTH HX:
UNCOMPLICATED C/S DELIVERY-FULL TERM, GROWTH:UP TO AGE, GOOD PERFORMANCE AT SCHOOL,
LAST CHECKUP 6 MONTHS AGO (NL)
EX:

DDX:
*DM
WEAIGHT LOSS (4IBS/4DAYS),UNINTENTIONAL
 POLYDEPSIA
POLYURIA
POLYPHAGIA
NO DIARREAH, SKIN/HAIR CHANGES
NO TREMOR, HEAT INTOLERANCE, HEART RACING
NO FH OF THYROID DISEASE

*HYPERTHYROIDISM
WEIGHT LOSS (4IBS/4DAYS),UNINTENTIONAL
NO FH OF DM
INCREASED APPETITE
NO DIET OR DOING VIGOURUS EXERCISE

WU:
CBC, ELECTROLYTE, TSH, T3 & T4
SERUM FASTING GLU, HBA1C, U/A
URINE MICROALBUMINURIA
CASE 32:
HPI:
62 YO F, C/O BILATERAL HEARING LOSS X 7 M, GETTING WORSE. ITS FOR ALL SOUNDS,CAN LOCATE THE
SOURCE OF SOUND, CAN UNDERSTAND SPEECH, WORDS ARE NOT DISTORTED. PT REPORTS H/O USEING
HEARING AID, BUT IT DOESN'T HELP ANYMORE. PT DENIES ANY HEAD TRAUMA, HEADACHE, EAR PAIN OR
DISCHARGE, IMBALANCE, ANTIBIOTIC OR ASPRIN USE, RECENT URI, VERTIGO, TENITUS, N/V, EXPOSURE
TO LOAD SOUND.
ROS:-VE EXCEPT AS ABOVE
PMH: DM(METFORMIN), HTN(CAPTOPRIL) X 15 YEARS - WELL CONTROLLED
OSTEOPOROSIS (MED)
ALLERGY: -VE PSH: -VE
FH: NO HEARING LOSS
SH: 1PPDX15 YRS, 1-2 CUPS ON WEEKENDS, NO DRUG USE, NOT SEXUALLY ACTIIVE, LIVES ALONE,
SUPPORTED BY HER DAUGHTER

EX:
PT IS NAD
VS WNL
CRANIAL NERVES 2-12 INTACT
HEENT: THROAT, TM & EAR CANAL WNL
POS RINNE, LACK OF LATERALIZATION ON WEBER
DDX:
*PRESBYCOSIS
BILATERAL HEARING LOSS X 7 M
AGE
GETTING WORSE
HTN
DM
SMOKING
POS RINNE, LACK OF LATERALIZATION ON WEBER
PT DENIES ANY HEAD TRAUMA, HEADACHE, EAR PAIN OR DISCHARGE, IMBALANCE, ANTIBIOTIC
OR ASPRIN USE, RECENT URI, VERTIGO, TENITUS, N/V, EXPOSURE TO LOAD SOUND.

*OTOSCELOROSIS
BILATERAL HEARING LOSS X 7 M
AGE
GETTING WORSE
DENIES H/O TRAUMA OR FORIGN OBJECT INSERTION,
 NO EXPOSURE TO LOUD SOUNDS, H/O TRAUMA, SPINNING
NO RINGING, HEADACHE, NAUSEA & VOMITING, RECENT URI.

WU:
AUDIOMETRY
TEMPANOGRAPHY, BRAIN-MRI
BRAIN STEM EVOKED POTENTIAL, CBC & ELECTROLYTE
CASE 33:
HPI:
65 YO F, C/O DIZZINESS X 5 DAYS. FELT LIGHTHEADED, 3 EPISODE, EACH LASTED 3-5 SEC, GETTING
WORSE, WORSE BY MOVEMENT, NO CERTAIN POSITIONS, NOT BETTER BY ANYTHING. PT REPORTS URI 1
MONTH AGO, NAUSEA/VOMITING, PALPITATION, SOB VISUAL CHANGES DURING THE EPISODE. PT DENIES
TENNITUS, HEARING LOSS, FEVERM FALL, EAR FULLNESS.
ROS: -VE EXCEPT AS ABOVE
PMH: HTN X 20 YEARS (HTCZ) - COMPLAINT & WELL CONTROLLED
DIARREAH LAST WEEK, LASTED X 5 DAYS, 4-6 TIMES /DAY, RESOLVED BY ITS SELF
ALLERGY: -VE PSH:-VE
FH: NONE
OB: G4+P4+0, LMP 20 YRS, PAP SMEAR LAST YEAR (NL)
SH:1/2 PPD X 20 YRS, QUIT 5 YEARS AGO, NO ETOH OR DRUG USE. LIVES ALONE & WELL SUPPORTED
HEALTH MAINTENANCE: LAST YEAR COLONOCOPY, DEXA SCAN & MAMOGRAM (NL)
EX:
PT IS NAD
VS WNL
HEENT: PERRLA, EOMI, FUNDOSCOPY WNL
NEURO: CN 2-12 INTACT
CEREBELLAR FUNCTION INTACT
GAIT WNL
DDX:
*ORTHOSTATIC HYPOTENTION
DIZZINESS X 5 DAYS (LIGHTHEADED)
DURETIC USE
H/O DIARREAH
WORSE WITH MOVEMENT
VISIUAL CHANGES

*CAEDIAC ARRYTHMIA
DIXXINESS X 5 DAYS (LIGHTHEADED)
VISUAL CHANGES
PALPITATION
SOB

WU:
ORTHOSTATIC VITAL SIGNS
CBC, ELECTROLYTE
ECG, HOLTER MONITOR
CASE 34:
HPI:
30 YO F, C/O DIZZINESS X 2 DAYS. FEELS LIGHTHEADED, HAPPENED 2 TIMES, EACH LASTED FOR 3-4 SEC,
NO AGGREVATING OR RELEIVING FACTORS, NO RELATION TO POSITION. PT REPORTS FATIGUE &
PALPITATIONS. PT DENIES HEARING LOSS, TINNITUS, VERTIGO, LOC, VISUAL CHANGES, SOB, EAR
FULLNESS.
ROS:-VE EXCEPT AS ABOVE
PMH:-VE ALLERGY:-VE MEDS: VITAMIN & OCP, PSH: APPENDECTOMY
FH: DAD (HTN & DM), MOM DIED(STROKE)
OB: LMP 4 WEEKS AGO, REGULAR, HEAVY FLOW, 7-8 TAMPONS/DAY
SH:SEXUALLY ACTIVE WITH BF, INCONSISTENT CONDOM USE, NO H/O STD OR HIV TESTING, SHE'S UNDER
ALOT OF WORK RELATED STRESS
EX:
PT IS NAD
VS WNL
NO CONJUCTIVAL PALLOR
S1+S2+0, RRR, NO M,R,G
- JVD OR CAROTID BRUIT
+2 RADIAL PULSES B/L
NO PEDAL EDEMA
DDX:
*ORTHOSTATIC HYPOTENSION
DIZZINESS X 2 DAYS. ( LIGHTHEADED)
DECREASE WATER INTAKE
ALCOHOL INTAKE
NO HEARING LOSS OR VERTIGO
NO RECENT INFECTION
WORK RELATED STRESS
PALPITATION

*ANEMIA
DIZZINESS X 2 DAYS. ( LIGHTHEADED)
MENORRAGHIA
PALPITATION
FATIGUE

*CARDIAC ARRYMIA

WU:
CBC, IRON STUDIES, PERIPHERAL BLOOD SMEAR, RETICLUCYTE COUNT
ORTHOSTATIC VIATAL SINGS
ELECTROLYTE
CASE 35:
HPI:
65 YO F, C/O HEADACHE X1 WEEK, GRADUAL, ON & OFF, 8/10, TIGHT IN NATURE, BILATERAL TEMPORAL
AREAS, GETTING WORSE, ATTACK EACH NIGHT, LASTING FOR 20 MIN, BETTER WITH REST, WORSE WITH
LACK OF SLEEP, ASSOCIATED WITH FLASHES BEFORE THE ATTACKS, NAUSEA. PT DENIES TEARING,
RUNNY NOSE, VISUAL CHANGES, PHTOPHOBIA, NUMBNESS, WEEKNESS, RELATION TO MENSES, FEVER OR
WEIGHT LOSS, NECK STIFFNISS, HEAD TRAUMA. SHE HAD HX OF TENTION HEADACHE IN THE PAST.
ROS: -VE EXCEPT AS ABOVE
PMH: -VE ALLEGRGY: PENICILLIN (RASH) MEDS: IBOPROFEN (2 TABS/DAY)
PSH:-VE FH: MOM (MIGRAINE)
OB: G2+P2+0, LMP 20 Y AGO, PAP SMEAR WAS LAST YEAR (NL)
SH: NOT SEXUALLY ACTIVE, NO SMOKING OR DRUGS, DRINKS ETOH 2 GLASSES OF WINE EVERY OTHER
DAY (CAGE 3/4 EXCEPT EYE OPENER), SHE HAS STRESS & LIVING ALONE, WELL SUPPORTED BY FAMILY
EX:
PT IS NAD
VS WNL EXCEPT FOR BP: HIGH
HEENT: SINUSES NOT TENDER,PERRLA, EOMI, FUNDOSCOPY, THROAT WNL
NEURO: CN 2-12 INTACT
DDX:
*TENTION HEADACHE
HEADACHE
TIGHT IN NATURE
 PREVIOUS EPISODES
STRESS
BITEMPORAL
NO RADIATION
IMPROVE WITH SLEEP
LACK OF NEURO SIGNS

*MIGRAINE
NAUESA
FLASHES BEFORE THE ATTACK
HEADACHE
FH OF MIGRAINE

*HTN
HEADACHE
HIGH BP

WU:
CBC, ELECTROLYTE, ESR
CT- HEAD
CASE 36:
HPI:
65 YO F, C/O BITEMPORAL HEADACHE X 2 DAYS, 8/10, SQEEZING, ON & OFF, 5 TIMES/DAY, LASTED 20
MIN, NO RADIATION, RELIEVING OR AGGREVATING FACTORS. PT REPORTS,
DIZZINESS(LIGHTHEADEDNESS), NAUSEA, FATIGUE, H/O FALL 2 WEEKS AGO. PT DENIES ANY VISUAL
CHANGES,JAW CLUDICATION, NUMBNESS, WEAKNESS,PHOTOPHOBIA, AURA,JOINT/MUSCLE PAIN,
VOMITING, TEARING OR RUNNY NOSE. PT HAD PRIVIOUS EPISODES OF TENSTION HEADACHES.
ROS:-VE EXCEPT AS ABOVE
PMH & MEDS: HTN (HCTZ), ASA - NOT COMPLAINT WITH MEDS, LAST CHECK UP WAS 1 Y AGO, ALLERGY:-
VE PSH:-VE
FH: DAD (HTN)
SH: NOT SEXUALLY ACTIVE, SOMKE 1PPD/15 YEARS, NO ETOH OR DRUG USE. LINING ALONE, NO STRESS,
WELL SUPPORTED BY FAMILY
EX:
PT IS NAD
VS WNL EXCEPT FOR HIGH BP
HEENT: PERRLA, EOMI, FUNDOSCOPY, THROAT WNL
SINUSES NOT TENDER
NEURO: CN 2-12 INTACT
DDX:
*HYPERTENSIVE CRISIS
BITEMPORAL HEADACHE X 2 DAYS
H/O HTN
NOT COMPLAINT TO MEDS
LAST CHECK UP WAS 1 YEAR AGO
DIZZINESS
HIGH BP
NO FEVER

*SUBDURAL HEMATOMA
BITEMPORAL HEADACHE X 2 DAYS
H/O FALL 2 WEEKS AGO
NAUSEA
NO VOMITING, TEARING OR RUNNY NOSE.
NO WEAKNESS,PHOTOPHOBIA, AURA,
 NO VISUAL CHANGES, NUMBNESS,
NO FEVER

*SAH
HTN
NAUSEA
HEADACHE

WU:
CBC, ELECTROLYTE
NON CONTRAST CT- HEAD
LP- CSF ANALYSIS , ESR

CASE 37:
HPI:
32 yo m, c/o HEADACHE X 4 HOURS. STARTED SUDDENLY WHEN HE WAS HAVING SEX WITH HIS
GIRLFRIEND. CONSTANT, BILATERAL, OCCIPITAL, 10/10, POUNDING, NONRADIATING, GETTING WORSE,
WORSE BY LIGHT, NOTHING MAKES IT BETTER. PT DENIES NUMBNESS, WEAKNESS, FEVER, NICK
STIFFNESS, H/O TRAVEL OR ILL CONTACT, TEARING OR RHINNORREAH, TRAUMA, AURA, NAUSEA OR
VOMITING.
ROS:-VE EXCEPT AS ABOVE
PMH:-VE, ALLEGY:NKA, PSH:-VE, FH:DAD-KIDNEY DISEASE, SEXUAL HX:ACTIVE WITH GF ONLY,
CONSISTENT USE OF CONDOMS. SH:COCAINE 10 MIN BEFORE HAVING SEX, SNORT (FOR 2 YEARS).NO
SMOKING/ETOH
EX:
PT IS IN SEVERE PAIN
VS WNL EXCEPT HIGH BP
CVS: S1+S2+0, RRR, NO M/R/G, PMI NOT DISPLASED, +2 RADIAL PULSES
CNS: 5/5 POWER, INTACT SENSATION, +2 DTRS (B/L, THROUGHOUT)
-VE KERNIG'S & BRUDZINSKI

DDX:
*SUBARACHNOID HEMMORAHE
HEADACHE X 4 HOURS
SUDDENLY
CONSTANT, OCCIPITAL, 10/10, POUNDING, GETTING WORSE, WORSE BY LIGHT
NO NUMBNESS, WEAKNESS, FEVER, NICK STIFFNESS,
NO H/O TRAVEL OR ILL CONTACT, TEARING OR RHINNORREAH
NO TRAUMA, AURA, NAUSEA OR VOMITING.
FH OF KIDNEY DISEASE
COCAINE USE
HIGH BP
-VE KERNIG'S & BRUDZINSKI

*HYPERTENSIVE CRISIS
HEADACHE X 4 HOURS
SUDDENLY
CONSTANT, OCCIPITAL, 10/10, POUNDING, GETTING WORSE, WORSE BY LIGHT
NO NUMBNESS, WEAKNESS, FEVER, NICK STIFFNESS,
NO H/O TRAVEL OR ILL CONTACT, TEARING OR RHINNORREAH
NO TRAUMA, AURA, NAUSEA OR VOMITING.
COCAINE USE
HIGH BP
-VE KERNIG'S & BRUDZINSKI
WU:
CBC, ELECTROLYTE, U/S-KIDNEY
LP WITH CS ANALYSIS, URINE TOXOCOLOGY
NON CONTRAST CT HEAD
CASE 38:
HPI:
30 YO M, C/O LOC FOR FEW MIN WHILE HE WAS PLAYING BASKETBALL. PT REPORTS PALPITATION,
DIZZINESS & SWEATING BEFORE THE ATTACK. PT DENIES TRAUMA, SKIPING MEALS, TOUNGE BITING,
URINE/STOOL INCONTINANCE, SHAKING, ANY POST-ICTAL SLEEP, CONFUSION, SPEECH OR GAIT
DIFFICULTY, NUMBNESS, WEAKNESS, CHEST PAIN. NO PREVIOUS HX OF LOC.
ROS:-VE EXCEPT AS ABOVE
PMH: NONE ALLERGY: SEAFOOD (RASH) MEDS: -VE PSH:APPENDECTOMY
FH: DAD (HTN & DM), NO FH OF SUDDEN CARDIAC DEATH
SH: SEXUALLY ACTIVE WITH GF ONLY, INCONSISTANT USE OF CONDOMS, NO HX OF STD OR HIV TESTING,
NO SMOKING OR DRUG USE, DRINKS 3 BEERS/DAY, NO STRESS
EX:
PT IS NAD
VS WNL
CVS S1+S2+0, RRR, NO M,R,G
+2 RADIAL, DORASALIS PEDIS & PSTERIOR TIBIAL PULSES B/L
- JVD / CAROTID BRUIT
- PEDAL EDEMA
NEURO: 5/5 POWER, INTACT SENSATION & +2 DTRS THROUGHOUT
DDX:
*HOCM
LOC FOR FEW MIN
WHILE HE WAS PLAYING BASKETBALL
AGE
PALPITATIONS
NO PREVIOUS H/O LOC
NO SHAKING, TOUNG BITE, OR INCONTINANCE
NO WEAKNESS OR NUMBNESS

* CARDIAC ARRYTHMIA
LOC FOR FEW MIN
PALPITATIONS
SWEATING
DIZZINESSS
NO SHAKING, TOUNG BITE, OR INCONTINANCE
NO WEAKNESS OR NUMBNESS

WU:
CBC, ELECTROLYTE
SERUM GLUCOSE, EEG
ECG, ECHO, HOLTER MONITOR
CASE 39:
HPI:
34 YO M, C/O LOC YESTERDAY, FELL AT THE BUS STOP, WITNESSED TO HAVE TONIC-CLONIC SIEZURE
ASSOCIATED WITH TOUNGE BITING & URINE INCONTINANCE, PRECEEDED BY SWEATING &
LIGHTHEADEDNESS, NO AURA, HEAD TRAUMA, PALPITATION, SOB OR SKIPING MEALS. NO SUBSEQUENT
GAIT OR SPEECH ABNORMALITY, CONFUSION, WEAKNESS OR NUMBNESS, HEADACHE OR POST-ICTAL
SLEEP. 3 PREVIOUS EPISODES.
ROS:-VE EXCEPT AS ABOVE. PMH: TYPE1 DM ON INSULIN (NOT COMPLAINT), ALLERGY:-VE
PSH: -VE, FH: DAD-DM
SH: 1PPDX10Y, DRINKS 5-6 GLASSES OF WINE/DAY, NO DRUG USE, SEXUALLY ACTIVE, INCONSISTENT USE
OF CONDOMS, NO HX OF STD OR HIV TESTING, UNEMPLOYED
EX:
PT IS NAD
VS WNL
NEURO: POWER 5/5, SENSATION INATCT, +2 DTRS THROUGHOUT (UL & LL)B/L
CEREBELLER FUNCTION INTACT
INTACT GAIT

DDX:
*SEIZURE DISORDER
LOC
SHAKING
BIT TOUNGE
INCONTINANCE
NO PALPITATION
NO SOB

*CARDIAC ARRYTHMIA
LOC
SWEATING
LIGHTHEADEDNESS
NO AURA
NORMAL NEURO EXAM

WU:
CBC, ELECTROLYTE, BLOOD GLOCOSE
ECG, HOLTER MONITOR, ECHO
EEG, BRAIN-MRI
URINE TOXOCOLOGY, ALCOHOL BLOOD LEVEL
CASE :
HPI:
48 YO M, C/O LOC X 2 MIN, HAPPENED YESTERDAY WHILE DOING GROCERY SHOPPING, NO PREVIOUS
EPISODE. PT REPORTS PRIOR TO LOC PALPITATION, CHEST PAIN & LIGHTHEADEDNESS, NO SOB,
SWEATING, SKIPPING MEALS, FAINITING OR AURA. DURING NO HEAD TRAUMA, SHAKING, BITING TOUNGE
OR LOSS OF INCONTINENCE. LOC FOLLWED BY SUBSEQUENT WEAKNESS ON BOTH ARMS & LEGS & GAIT
DISTURBANCE LASTING FOR 8 H,NO NUMBNESS, SPEECH VISION CHANGES, POST-ICTAL SLEEP OR
CONFUSION.
ROS:-VE EXCEPT AS ABOVE
PMH: MI 1 Y AGO, ALLERGY: PENICILLIN (RASH), MEDS:-VE
PSH:TONSILLECTOMY, FH: NO H/O STROKE OR OTHER CARDIAC DISEASES
SH: SEXUALLY ACTIVE WITH WIFE ONLY, 1PPDX30Y, DRINKS 2 BEERS EVERY OTHER DAY, NO DRUG USE.
EX:
PT IS NAD
VS WNL
CVS S1+S2+0, RRR, NO M/R/G
- JVD & CAROTID BRUIT
NO PEDAL EDEMA
+2 PULSES THROUGHOUT
NEURO: POWER 5/5, SENSATION, +2 DTRS THROUGHOUT

DDX:
*CARDIAC ARRYTHMIA
LOC SINCE 2 DAYS X 2 MIN
PALPITATION
 LIGHTHEADEADNESS
CHEST PAIN
MI LAST YEAR
NO AURA, SHAKING,
NO BITING TOUNGE OR LOSS OF BLADDE/STOOL CONTROL
NO POST-ICTAL SLEEP OR CONFUSION
LACK OF NEURO SIGNS

*TIA
LOC SINCE 2 DAYS X 2 MIN
LIMB WEAKNESS < 24 H
PALPITATIONS
GAIT DISTURBANCE
1 PPDX30 Y
MI LAST YEAR
MALE GENDER
NO SOB

WU:
CBC, ELECTROLYTE, SERUM GLU
HOLTER MONITOR, ECG, ECHO
BRAIN-MRI, CAROTID DOPPLER
CASE 41:
HPI:
45 YO M, C/O LOC 1 HOUR AGO. LASTED FOR 2 MIN, NO PREVIOUS EPISODE, PRIOR TO LOC, PT REPORTS
HE WAS GETTING THE MAIL. DENIES PALPITATION, CHEST PAIN, SOB, SKIPING MEALS, SWEATING,
TRAUMA, AURA. DURING THE LOC, PR DENIES HEAD TRAUMA, SHAKING , TONGUE BITING, LOSS OF
BLADDER/BOWEL CONTROL.AFTER LOC, PT DENIES ANY POST ICTAL SLEEP, CONFUSION, WEAKNESS,
NUMBNESS, GAIT/SPEECH ABNORMALTY, VISUAL CHANGES.
ROS:-VE EXCEPT AS ABOVE
PMH:MI 1 YEAR AGO, HYEPRLIPIDEMIA, HTN (X15 YEARS), MEDS:AMLODIPINE, ASA (COMPLAIENT).
ALLERGY:NKA, PSH:-VE, FH: NOT RELEVENT, SEXUAL HX: HOMOSEXUAL, ACTIVE WITH HIS PARTNER FOR
30 YEARS, NO H/O STD OR HIV TESTING. SH: NO SMOKING/ETOH/ILLICIT DRUGS

EX:
PT IS IN NAD
VS WNL
CVS:S1+S2+0, RRR, NO M/R/G, PMI NOT DISPLACED,NO CAROTID BRUIT, +2 RADIAL PULSES B/L
NEURO: POWER 5/5, INTACT SENSATION, +DTRS (THROUGHOUT B/L)
CN 2-12 INTACT
GAIT INTACT

DDX:
*CARDIAC ARRYTHMIA
LOC 1 HOUR AGO
MI 1 YEAR AGO, HYEPRLIPIDEMIA, HTN (X15 YEARS)
DURING THE LOC, PT DENIES HEAD TRAUMA, SHAKING , TONGUE BITING, LOSS OF
BLADDER/BOWEL CONTROL
NO SKIPING MEALS, SWEATING, TRAUMA

*TIA
LOC 1 HOUR AGO
MI 1 YEAR AGO, HYEPRLIPIDEMIA, HTN (X15 YEARS)
DURING THE LOC, PT DENIES HEAD TRAUMA, SHAKING , TONGUE BITING, LOSS OF
BLADDER/BOWEL CONTROL
 NO SKIPING MEALS, SWEATING, TRAUMA, AURA

WU:
CBC, ELECTROLYTE, GLU, LDL, HDL, CHOLESTEROL, TRIGLYCRIDE
ECG, ECHO, HOLTER MONITOR
CAROTID DOPPLER, MRI-BRAIN, CT-HEAD
CASE 42:
HPI:

EX:

DDX:
*AORTIC DISSECTION
WU:
CBC,
CASE 43:
HPI:
32 YO F, C/O FATIGUE FOR 8 MONTHS, THE SAME THROUGHOUT THE DAY. PT REPORTS SLEEPING MORE
THAN USUAL, UNINTENTIONAL WEIGHT GAIN 35IBS & CAN'T LOSE THEM, THINING HAIR, COLD
INTOLERANCE, SNORING & DAY SKIN. PT DENIES FEVER, NIGHT SWAETS, STESS, SOB,
PALPITATIONS,FEELING DEPRESSED, ANHYDONIA, NO URINARY CHANGES OR BOWEL HABIT CHANGES,
NO CHANGE IN APPETITE OR DIET
OB: LMP 5 MONTHS AGO, REGULAR, G2P2+0, NORMAL SVD, SHE HAD BLEEDING AFTER HER LAST
DELIVERY, REQUIRED 2 UNITS OF BLOOD, SHE CAN'T LACTATE.
ROS:-VE
PMH: -VE
MEDS: GENSING
ALLEGY:-VE
FH: MOM HAS SLE
SH: SEXUALLY ACTIVE WITH HUSBAND ONLY, - SMOKING, DRNKNIG, DRUG USE
EX:
NO CONJUNCTIVAL PLALOR
THIN HAIR & DRY SKIN
THYROID WNL,- LAD
DTR +2 THROUGHOUT
+2 PULSSES THROUGHOUT
NO PEDAL EDEMA
DDX:
*SHEEHANS SYNDROME
NO LACTATION
AMMENORRHEA
POSTPARTUM BLEEDING
SLEEP MORE, FATIGUE
WT GAIN
COLD INTOLERANCE
DRY SKIN
THIN HAIR

*HYPOTHYROID
WT GAIN
COLD INTOLERANCE
DRY SKIN
THIN HAIR
AMMENORRHEA
FH OF SLE
 POSTPARTUM BLEEDING
SLEEP MORE, FATIGUE
WU:
TSH, T4 & T3
LH/FSH, PROLACTIN LEVEL
CBC, IRON STUDIES, BRAIN-MRI

CASE 44:
HPI:
35 YO M, C/O FATIGUE X 3 MONTHS, THE SAME THROUGHT THE DAY, PT REPORTS UNINTINTIONAL WT
LOSS 10IBS/1 MONTH, LOSS OF APPETITIE, FEVER, NIGHT SWEATS, DRY SKIN, STRESS (WORK). PT DENIES
SOB, COUGH PALPITATION, ANHYDONIA, FEELING DEPRESSED, URINARY CHANGES, BOWEL HABIT
CHANGES, COLD INTOLERANCE, HAIR LOSS, ILL CONTACT.
ROS:-VE
PMH:-VE
MEDS:MULTIVITAMIN
ALLERGY:-VE
PSH: APPENDECTOMY
FH:NOT RELEVENT
SH: SEXUALY ACTIVE WITH GF ONLY, INCONSISTENT WITH CONDOM USE, NO HX OF STD OR HIV
TESTING.1PPD X 5 YRS, 1BEER/DAY,NO DRUG USE. HE WORKS AT A HOSPITAL IN IT DEPARTMENT
EX:
PT IS NAD
VS WNL EXCEPT LOW GRADE FEVER
THYROID NL, - LAD
+2 DTRS KNEES
+2 PREPHERAL PULSES
CHEST CTA&P
DDX:
*LYMPHOMA
NIGHT SWEATS, FEVER
WT LOSS
LOSS OF APPETITIE
AGE
FATIGUE
NO BOWEL HABIT CHANGES OR COLD INTOLERANCE

*TB
OCCUPATION
NIGHT SWEATS, FEVER
WT LOSS
LOSS OF APPETITIE
FATIGUE
WU:
CBC WITH DIFF
CXR, PPD, QUANTYFERON GOLD
TSH, T3 & T4
CASE 45:
HPI:
16 YO F, C/O FATIGUE X 3 MONTHS, THE SAME THROUGHTOUT THE DAY. PT REPORTS FEELING DOWN,
PROBLEMS SLEEPING(FALLING ASLEEP, EARLY AWEAKINING), ANHYDONIA, FEELING OF GUILT,
DECRESED ENERGY & NOT FEELING REFERESHED, DIFFICULTY CONCENTRATING & WT GAIN. PT DENIES
SOB, PALPITATIONS, URINARY CHANGES. APPETITE CHANGES, SUICIDAL THOUGHTS,SKIN/HAIR CHANGES,
BOWEL HABIT CHANGES, VOICE CHANGES, FEVER.FEELING STRESSED & HASN'T BEEN DOING WELL IN
SCHOOL.
ROS: -VE PMH: -VE MEDS: -VE ALLERGY: -VE PSH:-VE FH: -VE
OB: LMP 3 WKS AGO, REGULER, USES 3-4 TAMPONS/DAY, LAST PERIOD IS LIGHTER
SH: SEXUALLY ACTIVE WITH BF ONLY OVER THE PAST 1 YEAR, CONSISTENT USE OF CONDOMS, - H/O STD
EX:
PT IS NAD
VS WNL
A&O X3, GOOD MEMORY & CONCENTRATION
NL THYROID - LAD
NO CONJUNCTIVAL PALLOR
+2 KNEES DTRS

DDX:
*MAJOR DEPRESSION
FATIGUE X 3 MONTHS
FEELING DOWN
PROBLEMS SLEEPING(FALLING ASLEEP, EARLY AWEAKINING)
ANHYDONIA, FEELING OF GUILT
DECREASED ENERGY
DIFFICULTY CONCENTRATING
NO SKIN/HAIR CHANGES

*STRESS INDUCED FATIGUE

FATIGUE X 3 MONTHS
DECREASED ENERGY
DIFFICULTY CONCENTRATING & WT GAIN
OLIGOMENORREAH

*HYPOTHYROIDISM
FATIGUE X 3 MONTHS
BRADYCARDIA
WT GAIN
OLIGOMENORREAH

WU:
BECK DEPRESSION INVENTORY
CBC, ELECTROLYTE
TSH, T4 & T3
URINE TOXOCOLOGY
CASE 46:
HPI:
30 YO M, C/O FATIGUE X 1 MONTH. THE SAME THROUGHOUT THE DAY. PT REPORTS H/O FEELING SAD,
ANHYDONIA, FEELING OF GUILT, DECRESED ENERGY, DECRESESD CONCENTRATION, UNINTENTIONAL WT
LOSS (UNDOCUMENTED). PT DENIES SUICIDAL THOUGHTS, COLD INTOLERANCE, BOWEL HABIT CHANGES,
HAIR OR SKIN CHANGES,RECENT FLU LIKE SYMPTOMS, POLYURIA OR PILYDEPSIA, APPETITE OR DIET
CHANGES.
ROS: -VE PMH: -VE MEDS: -VE ALLERG: -VE PSH:-VE
FH: MOM HAS THYROID DISEASE
SH: HE'S HOMOSEXUAL WITH MANY PARTNERS, INCONSISITENT USE OF CONDOMS, NO H/O STD, NO HIV
TESTING. 1PPD X 10 YEARS, 1-2 BEERS/WEEK, HERION DRUG ABUSE (IV), LAST USE 1 M AGO
EX:
PT FEEL SAD, NAD
VS WNL EXCEPT FOR LOW GRADE FEVER
MMS: A&O X3, INTACT MEMORY & CONCENTRATION
- THYROID & LAD
+2 RADIAL PULSES B/L
+2 DTRS KNEES
DDX:
*MAJOR DEPRESSION
FATIGUE X 1 MONTH
FEELING SAD
ANHYDONIA,
DECRESED ENERGY,
UNINTENTIONAL WT LOSS
DECRESESD CONCENTRATION
FEELING OF GUILT

*ACUTE HIV SYNDROME

FATIGUE X 1 MONTH
MANY PARTNERS
HOMOSEXUAL
INCONSISITENT USE OF CONDOMS
IV DRUG ABUSER
LOW GRADE FEVER
WU:
BECK DEPRESSION INVENTORY
CBC, ELECTROLYTE
HIV PCR & VIRAL LOAD, WETREN BLOT
CASE 47:
HPI:
75 YO M, C/O MEMORRY LOSS X 4 M. HE LOST HIS WAY BACK HOME LAST MONTH & FORGOT HIS INSULIN
DOSE COUPLE OF MONTHS EARLIER. PRGRESSIVE, HE HAS NO DIFFICULTY IN DAILY ACTIVITY LIVING. PT
DENIES ANHYDONIA, LOSS OF CONCENTRATION, LACK OF ENERGY, SLEEP DIFFICULTY, CHANGE IN VOICE,
HAIR/SKIN CHANGES, CONSTIPATION, COLD INTOLERANCE, ATAXIA & URINARY INCONTENANCE,
FALL/HEAD TRAUMA.
ROS:-VE EXCEPT AS ABOVE
PMH:DMX30Y, LAST CHECKUP ^ M AGO(NL), MEDS: INSULIN (COMPLAINT), ALLERGY:NKA, PSH:-VE, FH:NO
H/O STROKE, THRYROID DISEASE.
SEXUAL HX:ACTIVE WITH WIFE ONLY
SH:NO SMOKING/ETOH/ILLICIT DRUG, WELL SUPPORTED, NO STRESS, HEALTHY DIET

EX:
PT IS NO NAD
VS WNL
THYROID WNL, NO SKIN/HAIR CHAMGES
MMS: A&OX3, INTACT MEMORY & CONCENTRATION
CNS: 5/5 POWER, INTACT SENSATION, +2 DTRS (THROUGHOUT B/L)
CN 2-12 INTACT, GAIT WNL
CVS: S1+S2+0, RR, NO M/R/G, +2 RADIAL PULSES

DDX:
*ALZAHIMER DISEASE
MEMORRY LOSS X 4 M
PRGRESSIVE
LOST HIS WAY HOME,
MISSED INSULIN DOSE
AGE
DENIES ANHYDONIA, LOSS OF CONCENTRATION, LACK OF ENERGY, SLEEP DIFFICULTY, CHANGE IN
VOICE, HAIR/SKIN CHANGES, CONSTIPATION, COLD INTOLERANCE, ATAXIA & URINARY
INCONTENANCE, FALL/HEAD TRAUMA.
*MULTIINFARCT VASCULAR DEMENTIA
MEMORRY LOSS X 4 M
PRGRESSIVE
LOST HIS WAY HOME,
MISSED INSULIN DOSE
H/O DM X 30 Y
DENIES ANHYDONIA, LOSS OF CONCENTRATION, LACK OF ENERGY, SLEEP DIFFICULTY, CHANGE IN
VOICE, HAIR/SKIN CHANGES, CONSTIPATION, COLD INTOLERANCE, ATAXIA & URINARY
INCONTENANCE, FALL/HEAD TRAUMA.

WU:
CBC, ELECTROLYTE
CT- HEAD, MRI- BRAIN
TSH, SERUM B-12
CASE 48:
HPI:
20 YO COLLAGE STUDENT F, C/O FEELING ANXIOUS X 1 MONTH, PT REPORTS DIFFICULTY FALLING
ASLEEP & EARLY AWEAKINING, PALPITATIONS, WEIGHT LOSS 3IBS/1 M, DIFFICULTY
CONCENTRATING.COFFEE INTAKE 5-6 CUPS/DAY, SNORING. TOTAL HOURS OF SLEEP IS REDUCED FROM 8
TO 4 H/DAY.PT DENIES NAPS DURING THE DAY, ANHYDONIA OR DECREASED ENERGY. NO DIARRHEA,
MENSTRUAL IRRIGULARITY, TREMOR, APPETITE CHANGES. PT ADMITS TAKING ADDERAL GIVEN BY HER
BOYFRIEND TO KEEP HER ALERT, SHE'S STRESSED ABOUT HER SCHOOL PERFORMANCE.
ROS:-VE EXCEPT AS ABOVE
PMH:-VE, ALLERGY:ASA(RASH), PSH:TONSILLECTOMY
FH:MOM (THYROID DISEASE), OB: LMP 2 WEEKS AGO, REGULER, 3PADS/DAY
SH:SEXUALLY ACTIVE WITH BF ONLY, CONSISTENT CONDOM USE, NO SMOKING/DRUGS. DRINKS 2 CUPS
AT SOCIAL EVENTS, SHE EXCERSICE (YOGA)-NOT BEFORE BED

EX:
PT IS NAD
VS WNL EXCEPT FOR TACHYCARDIA
EYE: PERRLA, FUNDOSCOPY WNL
THYROID: WNL, NO TREMORS, +2 DTRS THROUGHOUT
CVS: S1+S2+0, RRR, NO M/R/G, PMI NOT DISPLACED, +2 PLUSES THROUGHOUT

DDX:
*CAFFIENE INDUCED INSOMNIA
FEELING ANXIOUS X 1 MONTH
DIFFICULTY FALLING ASLEEP & EARLY AWEAKINING,
DIFFICULTY CONCENTRATING
INTAKE 5-6 CUPS/DAY
STRESSED OUT OBOUT SCHOOL PERFORMANCE
PALPITATIONS,
WEIGHT LOSS 3IBS/1 M
NO DIARREAH, NO MENSTRUAL IRRIGULARITY, TREMOR, APPETITE CHANGES

*AMPHETAMINE INDUCED INSOMNIA

FEELING ANXIOUS X 1 MONTH
DIFFICULTY FALLING ASLEEP & EARLY AWEAKINING,
DIFFICULTY CONCENTRATING
PALPITATIONS,
WEIGHT LOSS 3IBS/1 M

WU:
CBC, ELECTROLYTE
 TSH, T4, T3
URINE TOXOCOLOGY
CASE 49:
HPI:
22 YO F, C/O JAW PAIN, AT THE RT TMJ, 7/10, CONSTANT, ACHING, GRADUAL ONSET, GETTING WORSE,
NON RADIATING, WOSRE BY MOVING THE JAW & BETTER BY REST, NO NUMBNESS, WEAKNESS. PT
REPORTS BEING HIT BY HER BOYFRIEND, DOESNT FEEL SAFE, AFRAID, HAS NO EMERGENCY PLAN, NO
GUNS AT HOME, HE'S HEAVY DRINKER, SISTER KNOWS ABOUT IT, STRESSFUL RELATIONSHIP. FEELS
DEPRESSED, FEELING OF GUILT, LACK OF ENERGY, CAN'T CONCENTRATE, IRRITATED, ANOREXIA. NO
ANHYDONIA, PROBLEM SLEEPING, OR SUICIDAL THOUGHTS.
ROS:-VE EXCEPT AS ABOVE
PMH: -VE, MEDS:-VE, ALLERGY:NKA, PSH:-VE, FH:NOT RELEVENT, OB:LMP 2 WEEKS AGO, REGULLER,
3TAMPONS/DAY.
SH:SEXUALLY ACTIVE WITH BF ONLY, INCONSISTENT USE OF CONDOMS, NO H/O STD OR HIV TESTING. NO
SMOKING/ETOH/DRUGS.
EX:
PT IS NAD
VS WNL
JAW: NO SKIN CHANGES, TENDER, INTACT SENSATION, LIMITED ROM DUE TO PAIN

DDX:
*DOMESTIC VIOLENCE
JAW PAIN, AT THE TMJ
REPORTS BEING HIT BY HER BOYFRIEND
DOESNT FEEL SAFE,
FEELS DEPRESSED
ABUSE ALCOHOL
STRESSFUL RELATIONSHIP
TENDERNESS
RESTRICTID ROM

*DEPRESSION
FEELS DEPRESSED,
LACK OF ENERGY,
FEELING OF GUILT,
CAN'T CONCENTRATE,
IRRITATED
ANOREXIA

*MANDIBLE/TMJ FRACTURE
TRAUMA
PAIN
WORSE BY MOVEMENT & BETTER WITH REST
NO SLEEP PROBLEMS, ANHYDONIA OR SUICIDAL THOUGHTS
TENDERNESS
RESTRICTID ROM

WU:
HEAD X-RAY & MRI
CBC, ELECTROLYTE
BECK'S DEPRESSION INVENTORY
CASE 50:
HPI:
57 YO F, C/O INSOMNIA X 3 WEEKS, SINCE THE DEATH OF HER SON, PT REPORTS DIFFICULTY FALLING
ASLEEP & EARLY AWEAKENING, HALLOCINATION(AUDIORY/VISIUAL), REDUCED TOTAL SLEEP TIME
FROM 6 TO 4 HOURS/DAY, CAN'T CONCENTRATE, ANOREXIA, IRRITABILITY & LACK OF ENERGY. PT
DENIES ANY CAFFIENE INTAKE, ANHYDONIA, SUICIDAL THOUGHTS,NIGHT TIME EXERCISE, TREMOR,
DIARREAH OR WEIGHT LOSS.
ROS:-VE EXCEOT AS ABOVE
PMH: DM(METFORMIN)-COMPLAINT, ALLERGY:-VE MEDS: ZOLPIDEM-5 PILLS
PSH:-VE OB: LMP 25 Y BACK, LAST PAP SMEAR WAS LAST YEAR (NL)
FH:NOT RELEVENT
SH: SMOKE 1/2 PPD/10 YEARS, 3 GLASSES OF WINE/DAY (CAGE 3/4 EXCEPT EYE OPENER), NO DRUGS
EX:
PT IS TEARFUL & SAD
VS WNL
MMS: A&OX3, INTACT MEMORY & CONCENTRATIN
THYROID WNL, +2 DTRS TROUGHOUT, NO TREMORS OR SWEATY PALMS

DDX:
*NORMAL GRIEF
INSOMNIA X 3 WEEKS
DEATH OF HER SON
DIFFICULTY FALLING ASLEEP & EARLY AWEAKENING,
HALLOCINATION
CAN'T CONCENTRATE, ANOREXIA, IRRITABILITY
LACK OF ENERGY
DENIES ANY CAFFIENE INTAKE, ANHYDONIA, SUICIDAL THOUGHTS

*ADJUSTMENT DISORDER WITH DEPRESSED MOOD

INSOMNIA X 3 WEEKS
DEATH OF HER SON
DIFFICULTY FALLING ASLEEP & EARLY AWEAKENING,
CAN'T CONCENTRATE, ANOREXIA, IRRITABILITY
LACK OF ENERGY
DENIES ANY CAFFIENE INTAKE, ANHYDONIA, SUICIDAL THOUGHTS

*MDD
INSOMNIA X 3 WEEKS
DIFFICULTY FALLING ASLEEP & EARLY AWEAKENING,
DEATH OF HER SON
CAN'T CONCENTRATE, ANOREXIA, IRRITABILITY
FEELING SAD
DENIES ANY CAFFIENE INTAKE

WU:
CBC, ELECTROLYTE
BECKS DEPRESSION INVENTORY
MENTAL STATUS EXAM
TSH
CASE 51:
HPI:
22 YO F, C/O INSOMINA X 2 WEEKS. NO PREVIOUS EPISODE, PT REPORTS EARLY AWAKENING, DECREASED
TOTAL HOURS OF SLEEP FROM 8-4 HOURS/DAY, GAINED WEIGHT 12IBS/2 MONTHS, FEELING FATIGUE,
SNORING, FEELS SAD. TAKES NAPS DURING THE DAY. PT DENIES ANY CAFFIENE INTAKE, STRESSORS,
ANHYDONIA,SUICIDAL THOUGHTS, FEELING DEPRESSED, BOWEL HABIT CHANGES, HAIR/SKIN CHANGES,
CHANGE IN APPETITE OR TREMORS. NO NIGHT TIME EXERSICE.
ROS: -VE EXCEPT AS ABOVE
PMH:-VE ALLERGY:SEAFOOD (RASH), MEDS:-VE, PSH:-VE, FH:NOT RELEVENT, OB: LMP 3 WEEKS, REGULAR,
INCREASE IN FLOW (PADS # DOUBLE TO 6), NO OCP.
SH: NOT SEXUALLY ACTIVE, NO SMOKING/DRUG USE. DRINKS 1 GLASS OF WINE/DAY. LIVES ALONE.
EX:
PT IS NAD
VS WNL
PT IS A&OX3, INTACT MEMORY & CONCENTRATION
THYROID WNL, +2 DTRS THROUGHOUT, NO SKIN CHANGES/TREMORS
DDX:
*DEPRESSION
INSOMINA X 2 WEEKS
FEELING SAD
FATIGUE
NO NIGHT TIME EXCERCISE
NO CAFFIENE INTAKE
NO HAIR/SKIN CHANGES
NORMAL THHYROID EXAM
NORMAL REFLEXES

*HYPOTHYROIDISM
INSOMINA X 2 WEEKS
FATIGUE
NO CAFFIENE INTAKE
NO ANHYDONIA
NO SUICIDAL THOUGHTS

*OSA
DAYTIME SLEEPENESS & NAPS
FATIGUE
INSOMNIA
SNORING
OBSEITY

WU:
CBC, ELECTROLYTE, URINE TOXOCOLOGY
BECKS DEPRESSION INVENTORY
MENTAL STATUS EXAM
CASE 52:
HPI:
65 YO M, C/O UNINTENTIONAL WT LOSS 15IBS/3M, NO CHANGE IN DIET.PT REPORTS FATIGUE, POLYURIA,
NOCTURIA, POLYDEPSIA & POLYOPHAGIA. PT DENIES DYSURIA, CHANGE IN BOWEL HABITS, SKIN/HAIR
CHANGES, TREMOR, FEVER & NIGHT SWEATS, FEELING DEPRESSED, ANHYDONIA OR LOSS OF
CONCENTRATION. LAST COLONOSCOPY 15 YRS BACK (NL).
ROS:-VE PMH: DYSPEPSIA (ATACIDS) ALLERGY:-VE PSH: -VE
FH: NOT RELEVENT
SH SEXUALLY ACTIVE WITH WIFE ONLY, 1PPD X 15 YRS, DRINKS ON THE WEEKENDS, NO DRUG USE. HE'S
WELL SUPPORTED BY HIS WIFE & HAS NO STRESSORS.
EX:
PT IS NAD.
VS WNL
- CONJUNCTIVAL PALLOR OR PAPILLEDEMA
NL THYROID, - LAD
INTACT SENSATION THROUGHOUT ( DULL, SHARP, VIBRATION, PROPERIOCEPTION)
NO SIGNS OF INFECTIONS BETWEEK TOES
DDX:
*DM
POLYURIA
 NOCTURIA
POLYPHAGIA
POLYDEPSIA
WT LOSS
FATIGUE

*COLON CA
WT LOSS
LAST COLONOSCOPY 15 YRS BACK
AGE
FATIGUE
WU:
CBC, ELECTROLYTE, UA, URINE MICROALBUMENURIA
RECTAL EXAM WITH OCCULT BLOOD TEST
CEA, COLONOSCOPY, HBA1C, FASTING GLOCOSE

CASE 53:
HPI:
60 YO M, C/O UNINTENTIONAL WT LOSS 18IBS/8 MONTHS. DECREASED APPETITIE, BUT NO CHANGE IN
DIET. PT REPORTS FEVER, SOB ON EXERTION, ORTHOPNIA (2 PILLOWS). PT DENIES BING DEPRESSED,
ANHYDONAI, SKIN/HAIR CHANGES, HEAT INTOLERANCE, POLYURIA OR PLYDEPSIA, NO ABD PAIN,
CHANGE IN STOOL COLOR OR CALIBER, NO BLOOD. NO CHEST PAIN OR LEG SWELLING, NO COUGH OR
HYMOPTYSIS.
ROS:-VE EXCEPT AS ABOVE
PMH: HTN X 20 YRS-CONTROLLED ALLERGY: NKA MEDS:ASPRIN, CAPTOPRIL
PSH:AORTIC VALVE REPLACEMET. FH:DAD STROKE & HTN
SH: NOT SEXUALLY ACTIVE-WIFE PASSED AWAY 8 M AGO. 11/2PPD X 35 YEARS, 1-2 BEERS ON
THWEEKENDS, NO DRUG USE. LIVES ALONE, NO SOCIAL SUPPORT SYSTEM, LST TIME HE DID
COLONOSCOPY WAS 5 YEARS AGO.
EX:
PT IS NAD
VS WNL
CVS:S1+S2+0, RRR, NO M,R,G
EXT:
2+ RADIAL PULSES B/L
2+ DTRS KNEES
NO PEDAL EDEMA
NECK: NL THRYROID, - LAD

DDX:
*COLON CA
SOB, PALPIATION (ANEMIA)
WT LOSS
NIGHT SWEATS
DECREACED APPETITE
FEVER
AGE
NO COUGH OR HYMOPTYSIS

*LUNG CA
SMOKER 11/2 PPD X 35 YEARS
SOB
WT LOSS
LOSS OF APPETITE
FEVER
 NIGHT SWEATS

*CHF
SOB
PALPITATION
ORTHOPNIA
HTN X 20 YRS
AGE

WU:
ECG, BNP, ECHO
CXR & CT-CHEST, BRONCOSCOPY
COLONOSCOPY, RECTAL EXAM & OCCULT BLOOD TEST, CEA, CBC, IRON STUDIE
CASE 54:
HPI:

EX:

DDX:
*AORTIC DISSECTION
WU:
CBC,
CASE 55:
HPI:
22 YO M, C/O CHEST PAIN X2 DAYS.ITS GRADUAL, INTERMITTENT, DIFFUSE, 6/10, SHARP, NON
RADIATING, NO PREVIOUS EPISODE, AGGREV BY INSPIRATION, NO RELIEV FACTORS. PT REPORTS
PRODUCTIVE COUGH WITH SCANTY ANOUBT OF YELLOWISH SPUTUM, NO BLOOD, H/O COLD 3 DAYS AGO,
SUBJECTIVE FEVER. PT DENIES ILL CONTACT, PALPITATION, CHILLS, NIGHT SWEATS,TRAUMA,
IMMOBILIZATION, NO RELATION TO FOOD OR EXERTIONS. NOT RELIVED BY LEANING FORWARD.
ROS:-VE EXCEPT AS ABOVE
PMH: PNEUMONIA 6 MONTHS GO, ALLERGY:NKA, PSH:-VE, FH:NOT RELEVENT, SEXUAL HX: HOMOSEXUAL,
ACTIVE WITH BF ONLY, NO H/O STD, TESTED FOR HIV 6 MONTHS AGO (-VE)
SH: NO SMOKING/ETOH/ILLICIT DRUGS

EX:
PT IS IN NAD
VS WNL EXCEPT RR 20
CHEST: NL APPERANCE, TVF & CHEST EXPANSION WNL
CTA&P, NO ADDED SOUNDS
CVS: S1+S2+0, RRR, NO M/R/G, PMI NOT DISPLACED, +2 RADIAL PULSES B/L

DDX:
*PNEUMONIA
CHEST PAINX2 DAYS.
DIFFUSE
AGGREV BY BREATHING
SPUTUM SCANTY ANOUBT OF YELLOWISH SPUTUM, NO BLOOD
H/O COLD 3 DAYS AGO, SUBJECTIVE FEVER.
DENIES ILL CONTACT, PALPITATION, CHILLS, NIGHT SWEATS,
NO RELATION TO FOOD OR EXERTIONS. NOT RELIVED BY LEANING FORWARD

*PLEURISY
CHEST PAINX2 DAYS.
DIFFUSE
AGGREV BY BREATHING
 H/O COLD 3 DAYS AGO, SUBJECTIVE FEVER.
DENIES ILL CONTACT, PALPITATION, CHILLS, NIGHT SWEATS,
NO RELATION TO FOOD OR EXERTIONS. NOT RELIVED BY LEANING FORWARD

WU:
CBC WITH DIFF, ELECTROLYTE,
CXR, ECG, TROPONIN, CPK-MB, CT-CHEST
SPTUM CULTURE/GRAM STAIN

CASE 56:
HPI:
40 YO M, C/O CHEST PAIN X 4 H, SUDDEN, CONSTANT, LT SIDED, 8/10, STAPPING, GETTING WORSE, NO
PREVIOUS EPISODE, NONRADIATING, WORSE WITH COUGING & DEEP BREATHING, NOTHING RELIEVES IT.
PT REPORTS SOB AT REST, DRY COUGH, FEVER, URI 1 WEEK AGO. PT DENIES PALPITATION, SWEATING,
NUASEA, TRAUMA, ILL CONTACT, OR LONG DISTENCE TRAVEL(IMMOBILIZATION).
ROS:-VE EXCEPT AS ABOVE
PMH:-VE, MEDS:-VE, ALLERGY:NKA, PSH:-VE, FH:-VE, SH:HOMOSEXUAL, SEXUALLY ACTIVE WITH BF,
CONSISTENT USE OF CONDOMS, SMOKES 1PPDX15 YEARS, NO ETOH/ILLICIT DRUGS, NO EXERCISE. WORK
AS A BUS DRIVER
EX:
PT IS IN PAIN
VS WNL EXCEPT RR22
CVS:NO COSTAL CARTILAGE TENDERNESS, S1+S2+0, RRR, NO M/R/G, PMI NOT DISPLACED, -JVD/CAROTID
BRUIT,-PEDAL EDAMA, +2 PULSES THROUGHOUT
CHEST: NL APPERANCE, CTA&P, TVF & CHEST EXPANTION WNL, NO ADDED SOUNDS
DDX:

*MI
CHEST PAIN X 4 H, SUDDEN
STAPPING, CONSTANT, LT SIDED,
WORSE WITH COUGHING & DEEP BREATHING
SOB AT REST, SMOKES 1PPDX15 YEARS
NO TRAUMA, ILL CONTACT, OR TRAVEL.
NO EXERCISE
NO COSTAL CARTILAGE TENDERNESS

*PNEUMONIA
CHEST PAIN X 4 H, SUDDENT
CONSTANT, LT SIDED,
WORSE WITH COUGING & DEEP BREATHING
SOB AT REST, DRY COUGH
FEVER, URI 1 WEEK AGO
NO TRAUMA, OR TRAVEL.
NO COSTAL CARTILAGE TENDERNESS

WU:
TROPONIN, CK-MB, ECG
CBC WITH DIFF, ELECTROLYTE, CXR
CASE 57:
HPI:
40 YO F, C/O CHEST PAIN X 1 HOUR. ITS SUDDENT, CONSTANT, LT SIDED, 8/10, SHARP, RADIATED TO LT
SHOULDER, BETTER WITH LEANING FORWARD, WORSE WITH LAYING FLAT, NO PREVIOUS EPISODE. PT
REPORTS H/O OCP USE X 2 YEARS, SMOKER(1PPDX10Y), IMMOBILIZATION, FH OF MI (DAD). PT DENIES
ANY RALATION TO FOOD, SOB, PALPITATION, URI, TRAUMA, COUGH & SPUTUM, FEVER, N/V, SWEATING,
LEG PAIN/SWEALLING.
ROS:-CE EXCEPT AS ABOVE
PMH:-VE, ALLERGY:NKA, PSH:-VE, FH:AS MENTIONED, OB:LMP 2 WEEKS AGO, REGULAR, 3 TAMPON/DAY.
SEXUALH HX: SEXUALLY ACTIVE WITH HUSBAND ONLY. SH: AS MENTIONED, NO ETOH/ILLICIT DRUGS.
WORKS OFFICE WORK

EX:
PT IS IN ACUTE DISTRESS
VS WNL EXCEPT RR 22, HR 110
CHEST: NL APPERANCE, TVF &CHEST EXPANTION WNL, CTA&P, NO ADDEDE SOUNDS
CVS: S1+S2+0, RRR, NO M/R/G, PMI NOT DISPLACED
EXT: +2 PULSES B/L THROUGHOUT

DDX:
*MI
CHEST PAIN X 1 HOUR
SUDDENT, CONSTANT, LT SIDED
RADIATED TO LT SHOULDER
FH OF MI (DAD)
SMOKER (1PPDX10Y),
DENIES ANY RALATION TO FOOD, SOB, PALPITATION, URI, TRAUMA, COUGH & SPUTUM, FEVER.
RR 22
HR 110

*PE
CHEST PAIN X 1 HOUR
SUDDENT, CONSTANT, LT SIDED
H/O OCP USE X 2 YEARS, SMOKER (1PPDX10Y), IMMOBILIZATION,
DENIES ANY RALATION TO FOOD, SOB, PALPITATION, URI, TRAUMA, COUGH & SPUTUM, FEVER
RR 22
HR 110

WU:
ECG, TROPONINX3, CPK-MB, CXR
CBC, ELECTROLYTE, D-DIMER, FIBRINOGEN
SPIRAL CT, LEG U/S DOPPLER

CASE 58:
HPI:

EX:

DDX:
*AORTIC DISSECTION
WU:
CBC,
CASE 59:
HPI:

EX:

DDX:
*AORTIC DISSECTION
WU:
CBC,
CASE 60:
HPI:
45 YO F, C/O CHRONIC COUGH X 3 MONTHS. ITS GRADUAL,DRY, LST WEEK GOT WORSE, NO SPECIFIC
PATTERN, WORSE AT NIGHT, AGGREV BY LAYING FLAT, NOTHING MAKES IT BETTER. PT REPORTS THE
URGE TO CLEAR THROAT ALL THE TIME. PT DENIES FEVER, URI, SPUTUM, HEADACHE, NASAL DISCHARGE,
HEARTBURN, N/V,REGURGITATION, NO RELATION TO FOOD, WHEEZING, NO ORTHOPNIA, PND OR SOB, NO
EXPOSURE TO SMOKES.
ROS:-VE EXCEPT AS ABOVE
PMH: ASTHMA AS A CHILD, POST NASAL DRIP FOR THE LAST YEAR WITH STIFFY NOSE.
ALLERGY:ALLERGIC RHINITIS. PSH:-VE, FH:NON CONTREBUTERY, OB:LMP 2 WEEKS AGO, REGULLAR, 3
TAMPONS/DAY. SEXUAL HX:SEXUALLY ACTIVE WITH HUSBAND ONLY. SH:NO SMOKING/ILLICIT DRUGS,
DRINKS 1 GLASS OF WINE/WEEK

45 YO F, C/O COUGH X 1 MONTH. ITS DRY, GRADUAL ONSET, WORSE AT NIGHT & WHEN LAYING FLAT,
NOTHING MAKES IT BETTER. NO SPECIFIC PATTERN, NO PREVIOUS EPISIDE. PT REPORTS HEARTBURN &
THE URGE TO CLEAR THROAT. PT DENIES, RELATION TO FOOD, EXPOSURE TO PETS, SMOKE, EXERSICE OR
COLD AIR, NO FEVER.
ROS:-VE EXCEPT AS ABOVE
PMH: ASTHMA AS A CHILD & H/O POST NASAL DRIP X 1 YEAR, ALLERGY:ALLERGIC RHINITIS, PSH:-VE, FH:
NO H/O ALLERGY/ASTHMA. OB: LMP 2 WEEKS AGO/REGULLAR. SH: SEXUALLY ACTIVE WITH HUSBAND
ONLY. NO SEMOKING OR ILLICIT DRUG USE. DRINKS OCC (1 BEER ON THE WEEKENDS). LIVES WITH
HUSBAND, WORKS AS A SCHOOL TEACHER

EX:
PT IS IN NAD
VS WNL
CHEST: NL APPEARANCE, NT, TVF & CHEST EXPANTION WNL, CTA&P, NO ADDED SOUNDS
HEENT: NO TENDER SINUSIS, NASAL TURBUNATE NOT CONGESTED
DDX:
*ASTNMA
COUGH X 3 MONTHS
CHRONIC, DRY, WORSE AT NIGHT
H/O ASTHMA AS A CHILD
H/O ALLERGIC RHINITIS
DENIES FEVER, URI, SPUTUM, HEARTBURN, NO RELATION TO FOOD, NO ORTHOPNIA, PND OR SOB.

*POST NASAL DRIP

COUGH X 3 MONTHS
CHRONIC, DRY
POST NASAL DRIP FOR THE LAST YEAR WITH STIFFY NOSE
ALLERGIC RHINITIS
DENIES FEVER, URI, SPUTUM, HEADACHE, NASAL DISCHARGE, HEARTBURN, N/V,
REGURGITATION, NO RELATION TO FOOD, WHEEZING, NO ORTHOPNIA, PND OR SOB, NO
EXPOSURE TO SMOKES

WU:
CBC, ELECTROLYTE
CXR, PFT, PEAK FLOW METER, METHACHOLINE CHALLENGE TEST
ESOPHEAGEAL PH MONITORING

CASE 61:
HPI:
55 YO F, C/O COUGH X 3 M, PRODUCTIVE, SCANTY AMOUNT OF YELLOWISH SPUTUM, NO BLOOD,
GRADUAL, GETTING WORSE, NO PREVIOUS EPISODE, NO SPECIFIC PATTERN, NOTHING MAKES IT WORSE
OR BETTER. PT REPORTS SOB ON EXERTION, ANOREXIA & FATIGUE. DENIES ORTHOPNIA, PND, LEG
SWELLING, WHEEZING, FEVER, CHANGE IN WEIGHT, ILL CONTACT.
ROS:-VE EXCEPT AS ABOVE
PMH: BREAST CA 3 Y AGO, MEDS:-VE, ALLERGY:NKA, PSH:MASTECTOMY, FH:NOT RELEVENT, OB:LMP 20 Y
AGO, LAST PAP SMEAR WAS LAST Y(NL) SH: SMOKES 1PPDX38Y, DRINKS WINE 4-5 GLASSES/DAY (CAGE
3/4 EXCEPT EYE OPENER), NO ILLICIT DRUGS. WELL SUPPORTED, NO STRESS
EX:
PT IS IN NAD
VS WNL
EXT: NO CLUBBING/CYANOSIS
CHEST: NL APPEARNCE, TVF, CHEST EXPANSION WNL, CTA&P, NO ADDED SOUNDS

DDX:
*LUNG CA
COUGH X 3 M
SPUTUM
GRADUAL, GETTING WORSE,
SOB ON EXERTION
ANOREXIA & FATIGUE
SMOKES 1PPDX38Y
DENIES ORTHOPNIA, PND, LEG SWELLING, FEVER, ILL CONTACT.

*COPD
COUGH X 3 M
SPUTUM
GRADUAL, GETTING WORSE,
SOB ON EXERTION
ANOREXIA & FATIGUE
SMOKES 1PPDX38Y
DENIES ORTHOPNIA, PND, LEG SWELLING, WHEEZING, FEVER, ILL CONTACT.

WU:
CXR-AP & LATERAL, CT-CHEST
SPUTUM CULTURE/GRAM STAIN
CBC, ELECTROLYTE, PFTS
BRONCHOSCOPY
CASE 62:
HPI:

EX:

DDX:
*
WU:
CBC,
CASE 63:
HPI:
60 YO M, C/O SOB X 2 M, WITH EXERTION(WALKING SHORT DISTANCES), GRADUAL, CONSTANT. NO
AGGREVATING FACTORS, , GETTING WORSE, ASSOCIATED WITH ORTHOPNIA (SLEEPING ON 2 PILLOWS),
LEG SWELLING & DRY COUGH. PT DENIES CHEST PAIN, PALPITATIONS, PND, CONSTITUTIONAL
SYMPTOMS, NO GI SYMPTOMS, NO SPUTUM/HEMOPTYSIS, NO LEG PAIN.
ROS:-VE EXCEPT AS ABOVE
PMH:HTN X 30 Y, LLAST CHECKUP WAS 20 Y AGO - ON LISINOPRIL (COMPLAINT)
ALLERGY:NKA,PSH:-VE, FH:NOT RELEVENT, SH:SEXUALLY ACTIVE WITH WIFE, SMOKES 1PPDX40 Y, NO
ETOH/ILLICIT DRUGS, LIVING WITH HIS WIFE, NO STRESS,WELL SUPPORTED, LAST COLONOSCOPY 20
YEARS BACK
EX:
PT IS IN NAD
VS WNL EXCEPT HIGH BP
S1+S2+0, RRR, NO M/R/G, PMI NOT DISPLACED
-JVD/CAROTID BRUIT, +2 PULSES THROUGHTOUT, -PEDAL EDEMA
CHEST NL APPEARANCE, TVF & CHEST EXPANTION WNL, CTA&P, BO ADDED SOUNDS
DDX:
*CHF
SOB X 2 M
LEG SWELLING
ORTHOPNIA
UPON EXERTION
NO CONSTITUTIONAL SYMPTOMS
HTN X 30 Y
NO SPUTUM/HEMOPTYSIS

*LUNG CA
SOB X 2 M
SMOKES 1PPDX40 Y
NO PND, NO PALPITATIONS
COUGH
NO LEG PAIN

WU:
CBC, ELECTROLYTE, BUN/CR, BNP
ECG, ECHO, COLONOSCOPY, FOB
CXR, CHES-CT