CLINICAL SKILLS EVALUATION

PATIENT NOTE

HISTORY: Describe the history you just obtained from this patient. Include only information
(pertinent positives and negatives) relevant to this patient's problem(s).
Adam Davidson is a 8 yo M child who came in for the evaluation of bed enuresis. He has been having
enuresis for several years, occurring 2-3x a week at bedtime, wetting his bed all over, urine
characterized as yellow, minimal amount, odorless and non-bloody, with associated dysuria, however
with no associated hesitancy, bladder intolerance, fever, abdominal pain, lank pain and body aches.
He is not able now to go to sleep overs because of this complaint. However, his mother noted that
there were no major stress happening in school nor at home. His mother is now having some worries
about the severity of the condition. Bed wetting alarms never worked.
ROS: none except above
PMH: no UTI and psych disorder
Meds: none
Allergy: nka
FH: father bed wetting full control only at 10 yo
Birth hx: nsvd, term, uncomplicated
Devt hx: wt, ht and devt milestones are normal
Diet: healthy

PHYSICAL EXAMINATION: Describe any positive and negative findings relevant to this patient's
problem(s). Be careful to include only those parts of examination you performed in this encounter.
none

DATA INTERPRETATION: Based on what you have learned from the history and the physical
examination , list up to 3 diagnoses that might explain this patient's complaint(s). List your diagnoses
from most to least likely. For some cases, fewer than 3 diagnoses will be appropriate. Then, enter the
positive or negative findings from the history and the physical examination (if present) that support
each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis
(e.g. restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc.)

Diagnosis #1: Monosymptomatic nocturnal enuresis

History Finding(s) Physical Exam Finding(s)

bed enuresis none
2- 3 x a week
no other PMH

Diagnosis #2: UTI

History Finding(s) Physical Exam Finding(s)

fever none
nocturia
dysuria

Diagnosis #3: Diabetes Insipidus

History Finding(s) Physical Exam Finding(s)

nocturia none
enuresis
2-3x a week

Diagnostic Study/Studies
UA with Urine culture
BMP (BUN and crea; glu and electrolytes)
U/S KUB