KJ

Chest pain started <30 min while running to catch the bus. Nothing makes it better, and reports
it has got worsen, and is worse when lying down. Dull pain is felt on the left side of the chest,
with no radiation. Pt reports he is also short of breath, denies nausea and vomiting. Reports no
recent illnesses. Pt reports that he feels short of breath while playing football.

Meds: Vitamins, blood pressure meds, cholesterol meds

Medical: Hypertension, High cholesterol
Family: None
Social: current tobacco 15 pack hx, no etoh, methamampine ocassional use (yesterday)
Surgery: none
Diet:
Allergies: none

ROS:
Reports fever today, denies chills, cough, prior episode

PE:
Pt is in mild distress, with holding left side of chest, slightly over stated age, appropriately
dressed
Cardiac: normal S1 and S2, no S3, no murmurs, slight elevation in JVP, mild pitting edema
bilateral
Lungs: clear to auscultation
Vascular: normal

DDX:
Acute Coronary Syndrome
Percarditis

Dx:
Labs: CK-MB, Troponin, CBC
EKG- ST elevation V1-V3,
Imaging:
Meds: Aspirin, Nitrates, Oxygen, Morphine
Consult: Cath lab

Dx: anterior MI
Mallory

L.M. Male 6y/o with father.

Presents over the phone with persistent episodes of abdominal pain. The pain has been on/off
for a few months. He states his belly hurts on/off every morning. Stools have been more liquid
than solid, and only goes once a day. Patient describes the pain as dull and achy. Father denies
blood in the stool, light yellow and smells really bad. Father reports he soils his underwear
during the week and is worried that his friends will laugh.

Denies fever and chills.

Endorses a fever 4 months, when he felt sick to his stomach.
Med: none
Surgeries: none

Ddx:

Food allergy (lactose intolerance, celiac)

Constipation
Encopresis

Dx: Celiac

Amanda
N.C. 32 Y/O for trouble sleeping
Temp97.7, BP135/70, 90, R17
Hasn’t had a goodnight’s sleep in a year, stressed anxious talking very fast.
A lawyer just started a year ago a lot of stress from working. Has been working on sleep
hygiene. Has difficult falling asleep reports getting 5-6hrs a night. Drinks 6-7 cups of coffee and
drinks a energy drink after work.
Meds:
Psych: non psych
Family: mother has thyroid issue

ROS:
Chest feels tight, heart is racing
LMP: two weeks ago

PE:
Appears stated age, no
Cardiac: RRR
Lungs: clear
Vascular: Normal cap refill
Skin: normal
Hair: normal
Labs:
TSH:
GAD: 18
CBC:
Urine tox
Ddx: GAD, Depression, insomnia

DX: Generalized anxiety disorder

Houston
70 yr forgetfulness
Bp125/70, hr 70, R 18

Patient reports that this started two years ago. Daughter made her come, and states that
mother has always been forgetful, daughter states its getting worse. Patient reports that she
has been sleep less. Pt denies SOB, fever, chills. Patient reports she loses her keys a lot.

Diet: Healthy
Annual physical: More than a year
Meds:

ROS:
Endorses fatigue
Denies change in bowels

Pmhx: Hypertension
Meds: hydrochlorothiazide
Surg:
Family: father deceased in war, mother- pneumoniae died
Social: denies Etoh, tobacco, and illicit drug use

PE:
Neuro: normal, oriented alert, remote memory
MMI: pt missed things

Ddx:
New onset dementia

Labs: CBC, TSH,

Dx: dementia

Briana
Amanda M.
M.W.
98.6 bp 135/80, R 22, HR 80
Cough started seems to get worse. Worsened in the morning. Yellow film. No blood. Pt
Pmhx: high blood pressure 5 yrs ago
Meds: Lisinopril
Surg: C-section
Fam: father- died MI
Social: 2 pack for 35 yrs, works in supermarket

PE: Health phy

Cardio: RRR,
Lungs: sounds appear distant, no wheezing rales or rhonci
Pitting edema bilateral lower legs, cap refill normal,

Ddx: COPD, Lung cancer, Med sde effect, CHF

Test: CBC, CMP, BMP, Pulmonary function tests normal TLC, increase residual reserve, Chest
xray: blackened lung fills

Dx: COPD
Txt: Ipratropum

Brittany
Shawn P. 42y male, altered sensation in legs and feet
Tep 97.7 110/80, HR 64 R 15
Sensation started 3 mo ago. Tingling and stinging over feet, feels different after stroking legs
and feet with hands. The feeling doesn’t radiate anywhere else. Reports nothing makes it
better, and it is worse at night. Pain 7/10. Feels like feet are on fire. Never experienced this
before. No recent travel or illnesses.

Pmx: chronic pancreatitis

Surg: none
Sexual: yes
Meds:
Allergies:
Social: 30 pack tobacco, alcohol occasionally
Trauma: none
Family: mother and father diabetes

ROS
No fever
Weak, Calf cramps,
Sensation: weak from knees down
Motor: Strength is normal, refluxes normal
Gait: Insteady
Romberg +
Impaired ??

Test: LMP, EMG

Dx: Guillain Barre

Holly O.
Past 2 days, Patient denies dysuria, no abdominal pain, back pain for the past 3 days, flank pain
with no radiation
Patient denies fever, fever 3 weeks ago with cold. Blood in urination.

Trauma: none
Pmhx: none
Family hx: none
Social: not sexual active, no STD
Ros: small amount of urination, no penile discharge, hemtauria
PE:
Not in acute distress
Cardiac: RRR, clear
Lung: clear auscultation
Abdominal: non-tender, normal
CVA: mild CVA tenderness
GU: normal
Extremities: 1+ pitting edema bilateral
Vascular: cap refill good
Skin: normal

Ddx: Kidney stones, Plyneprhotis, Prostatic, Cancer, Streptococcal Kidney, Nephrotic Syndrome
Test: KUB,
Labs: CK, Anti-Strep Anti-lysin

C.K.
E.G. 60yr female, trouble swallowing
HR 62, R 15, 120/80
Trouble swallowing 6 mo ago, occasionally with swallowing eating bigger amounts of food. No
regurgitation or aspiration. Inability is getting worse with liquid and solid foods. Have to eat
very slowly and chew very carefully. Patient endorses chest pain, in the middle around the
breast bone.

Pmhx: GERD for 18yrs

Travel: Vietnam 3 wks ago
Social: No tobacco ½ pack for 30 years
Family: Mother-diverticulosis

ROS
Loss 8Ilbs
Fatigue- 2 mo
Appetite normal, no recent illness, no changes in voice, no n/v

PE:
No signs of distress
Cardiac: RRR
Lungs: clear to auscultation
Mouth: Normal mucosa, moisture
Neck: No
Abdomen: Normal bowel sounds, non tender to palpation
Skin: No rashes

Ddx: Achalasia, Esogopheal cancer, Ring, Esophagitis

Test: EKG, Upper Endoscopy, Manometry, Barium Swallow

Dom

M.B 65 Y male, hearing loss, 97.7 120/80 HR 62, R 15

Onset 5 years ago. Hering higher tones less, and having a hard time hearing granddaughter.
Don’t know why or how it started.

PMhx: bladder cancer, chronic shoulder pain

Meds: Asprin- 6mo daily 1 500mg tab
Surger: Bladder prostate removed
Family- dad heartattack at 52
Social: 40 pack year, 1 beer occasionally, no illict drug use, works in steel plant

ROS
General: No fever, chills, n/v, no bowel changes
Neuro: decreased hearing bilaterally

PE:
Everything normal
Decreased hearing
Ddx: tumor, tympanic membrane rupture, noise reduced hearing loss, bladder cancer chemo-
cause hearing loss, Aspirin
Dx: age related hearing loss (Presbycusis)
Laura
C.H. 30 y female at urgent care after fall
98.0, 122/69, HR 95, R 13

Pt reports she fell last night, and has bruises to face and arms. Pt reports that she fell
downstairs at home, left arm and right side of face has big bruises that hurt. Patient reports she
did not pass out, and reports the bruising is getting bigger. Pt reports she doesn’t fall easily but
does bruise easily. Denies headaches, but her face hurts. Denies dizziness.

Ros
Pt reports that she bleeds easily, prior cut and loss
No fatigue, no joint pain
Pmhx: none
Med: ocp
Allergies: none
Surg: none
Family hx:
Social: no etoh, illicit drug use, tobacco
Social: Reports husband gets mad and takes out his angry on her.

PE:
2-4cm bruise on right cheek
5cmx5cm hematoma on left arm
Multiple tender hematomas and multiple stages on right lower arm
Neuro: intact

Labs: cbc. Pt, PTT

Ddx: domestic violence, Von Willebrand disease, immune thrombocytopenia
Tests: factor 8, VwF- von Willebrand factory assay

Cast
A.S. 47y female pain in right knee
Temp 104, 115/80, HR 68, R 16, BMI 32
Patient reports entire R knee hurts. The pain is better with non movement and ibuprofen,
moving and walking makes it worse. Pt reports the pain is getting worse over the 3 days. 6/10
pain level.

ROS:
No similar symptoms
No n/v

Pmhx: No STD
Surg:
Social: wine occasionally, tobacco use 20yrs, no illicit drug use
PE: Hurts with flexing ankle, swollen, difficult bending it

PE:
Edema to right lower leg above knee, calf tender to palpation, decreased ROM right knee,
bruise over patella
Drawer/Valgus, Vargus- normal

Test: BHcg- neg, Knee x-ray- no acute issues, edema- of the joint
Considered MRI
US-

Ben
29y male urgent care due to headache
97.9 120/70, hr 70, r18
This morning 2 hrs ago. Pt reports occasionally headaches in the past, but not ever this bad. Pt
reports the pain is 7/10. He reports that ibuprofen for headache, but it didn’t help. Pt reports
moving around and bright lights in the room makes it worse. Pt reports lying down in a dark
room makes it better. Pt says that the right side and above the eye hurts.

Social: Construction company, jobless.

ROS:
Eye: normal
HEENT: normal
Neuro: normal

Test: CT
Dx: Cluster Headache, Migraines

04/09

Sibu
L..W 28 yo female fatigue
95 110/65 HR 50 RR 15

Pt reports she started feeling tired 5 mo ago. She reports it happens all the time, no makes it
better. When her sons cry a lot it makes the fatigue worse, because she can’t get enough sleep.
She also reports that she feels more cold lately, and wears a sweater when no else is. Pt reports
she is having trouble breastfeeding.

Ros
No change in weight
Dry hair

Family: bipolar

General: tired looking female of stated age

Hair: brittle
Cardiac: RRR
Lungs: clear to auscultation
Abdomen:

DDX: Prolactinoma, Hypothyroidism/Hyperthyroidism, Sheenan’s Syndrome,

Labs: CBC, Cortisol, TSH
Test: MRI

Joseph
S.C. 45y male, gaining weight
Started two months ago. Pt has noticed 7-10 pounds of weight gain. Pt reports wife left him a
few months ago. He reports not being interested in his usual fun activities. Pt reports he wakes
up early in the morning, but doesn’t feel refreshed. He reports having a hard time at work.
Endorses suicidal ideation, but no plan.

Pmhx: GERD,
Surg: none
Social: Beer or wine before bed, 3-4x drinks a week, denies tobacco and illicit drug use
Exercise: none
Meds: stool softener
Family: Obesity
PE: normal vitals

ROS
Denies fever, chills, night sweats, rashes, skin or nail changes, headaches, swelling,
nausea/vomiting, hematochezia, joint pain/stiffness, urinary symptoms,
Endorses: trouble concentrating, constipation, anorexia, cold intolerance

Ddx: sleep apnea, insomnia

Tests: Sleep Study, PHQ,
Labs: TSH
Follow up: In 6-8 weeks to see if SSRI works, will have pt to follow up in 1-2 weeks due to
suicidal thoughts

Savannah
L.P. 18y female, fatigue
Vitals: normal
Noticed the fatigue 2 weeks ago. Denies other symptoms with the fatigue. Patient reports 2
weeks ago she had a sore throat and fever, that went away after taking ibuprofen for it.

Pmhx: none
Meds: none
Social: no recent travel
LMP: 2 wks ago

ROS
Denies: SOB, skin/hair changes, weight changes, cough, STD, muscle weakness, leg cramping,
sore throat

PE:
Eyes: normal
HEENT: normal
Lymph: no swelling
Cardio: RRR
Lungs: clear to auscultation
Abdominal: normal bowel sounds, hepatosplenomegaly

Dddx: Mono, Iron deficiency anemia, hypothyroidism

Test: TSH, Monospot, CMP, CBC

Anthony

A.S. 19y male, sore throat

102, R 15, HR 70
Reports sore throat started last night. Pt reports he is having trouble swallowing with solid and
liquid, and woke up with a really hoarse voice this morning. Denies emesis, and rates pain 7/10.
Pt reports he had something like this in past as a child. He reports cold drinks makes it better.
Endorses hoarseness.

Pmhx: none
Meds: none
Allergies: none
Social: lives in the dorm on campus, roommate, girlfriend had sore throat past couple weeks,
non tobacco, sexually active- girlfriend
Work: College student, criminal justice, playing football

ROS: denies headaches, vomiting, chest pain,

Endorse: nausea, fatigue, chills, fever
Abdominal: belly hurts
Throat: erythema
Eyes: normal
Lymph: tenderness to anterior cervical lymph nodes

Ddx: Strep, Mono, Phargyngitis

Tests: Strep w /culture,

Kavita

A.R. 58y male, presented to ER for cough

98.6, 135/80 HR 80 RR 18
Patient reports cough started 4 weeks ago, that is productive with dark brownish-red phlegm.
Patient reports varying fever over the past four weeks with chills. Pt reports he uses his
albuterol and ipratorum inhalers 3x a day. Pt reports smokers cough in the morning for the past
3 years.

Endorses: SOB with activity, right sided chest pain, wheezing, breathing deep makes it worse
Denies: swelling, palpitations, abdominal pain

PHMx: Chronic bronchitis

Trauma: none
Social: 60 pack year, currently, no alcohol use
Allergies: None
Surg: none
Meds: albuterol and ipratorum

PE:
General: appears older than stated age, smoke smell, leathry skin, nail clubbing
HEENT: normal
Cardiac
Lungs: distance hearts sounds, diminished sounds on the middle area
Abdomen: soft, non-tender

Ddx: Pneumonia, Costochondritis, Exacerbation Bronchitis, CHF, Cancer, TB

Test: Chest xray, sputum culture, EKG, Chest CT w/ contrast

Labs: Troponin, CBC, Cardiac enzymes, ABG

Jacob
E.W. 17yo female, genital lesion, vitals normal
Patient reports she first noticed the lesions 5 days ago. Patient reports she is sexually active
with multiple male partners. Patient reports her last encounter was last night. Pt reports it is a
open lesion on the mucosa. Denies pain, but dysuria. Patient denies applying any creams to the
area. Denies having anything similar to this. Reports UTI in the past couple of days.

Pmhx: none
Surg: appendectomy
Meds: OCP
Social: etoh use bidaily, no illcit drug use, 60pck history, not current smoker
LMP: one week ago
Female: no OB/GYN, OCP use, no condome use, never had a pap smear
Vaccines: HPV

Ros:
Denies fever, chills, headaches, bowel changes, pelvic pain
Endorses UTI 4 mo ago, genital itching

Ddx: Trichomonas, HPV, Syphilis,

Test: Swab, UA, Treponemal test, RVR

Exam: pelvic, abdominal, rectal

PE:

Maceala
C.M. 55y female, headache
101.7, 145/95, HR 100, R19
Patient reports a headache two weeks ago. Patient reports the headache started after she was
walking her dog and fell 2 hours ago. Husband reported she was unconsioness for two seconds.
Patient reports she vomited on the way to the ER. Patient reports headache is 10/10. Denies
vision loss or blurry vision. Pt reports 2 weeks ago she had the same pain.

Pmhx: hypertension
Meds: prior bp meds, none
Surg: none
Allergies: none
Family: mom- migraines, father- hypertension
Social: 60 pack history, non-smoker, denies etoh, illicit drugs.
Travel: none, up to date on vaccinations

ROS: neck stiffness, vomiting, headache,

PE:
HEENT: Swelling in nasal cavity, normal
Neck: non-tender, decreased ROM with flexion
Neurology: alert to person, place, not time. Neural rigidity, photophobia, Kernig- pos, Romberg-
neg, gait unsteady

ddX: Meningitis, Migraine, Subachronoid hemorrhage, Stroke

Labs: CBC, CSF
Test: CT- non-contrast

Ginger
E.G. 66y male, urgent care due to loss of vision
143/94 HR 70, R 17
Pt reports vision loss started 2 hours ago in left eye. Patient denies any type of trauma before
vision loss. Patient reports it started like a veil coming over the eye, which it got darker and
darker. Nothing makes it better or worse. Patient reports the same occurrence happened over
the past 6 months, that got better each time. Patient reports headache in the frontal region,
that is squeezing. Denies eye pain. Pt reports on/off headaches for the past 8 months.

Pmhx: headaches, hypertension, diabetes

Meds: Metformin, ibuprofen, hydrochlorothiazide
Surg: appendectomy
Family: dad- lung cancer
Social: smoke, occasional etoh use

ROS
Denies fever, n/v, chills, chest pain, recent illness, dizziness, syncope, numbness, tingling
Endorses: SOB with activity, morning cough, right hand weakness

PE:
General: right sided droop
Eyes: fundoscopic normal, left side <220
Carotid: right bruit
Cardiac: RRR
Lungs: clear to auscultation
Neuro: motor aphasia, muscle strength 1/5 right hand and lower arm

Test: CT noncontrast, MRI

Labs: PT, PTT, CBC

Sarah M.

J.G. 54y female, heartburn

98F, BP 145/85. HR90, RR 20
Pt reports heartburn started over 10 years ago, but has been getting worse. She takes
Omeprazole for the pain, for the past 8 years. Pt reports it usually helps but for the past 3
weeks it has been getting worse. Reports it got worse when the medication raned out. She
reports she gets it worse at night, but now during the day. Pt reports nausea and chest pain,
denies difficulty swallowing, vomiting. Pt reports it gets worse during activity, and it gets better
once she rests. Pain 2/10.

ROS
Denies bowel changes, hematuria, radiation of pain to stomach, fever, weight loss, cough,
regurgitation, constipation/diarrhea
Endorses shortness of breath with activity, chest tightness

Pmhx: Hypertension, GERD

Family- dad- heart attack, mom-dementia
Social: 60pack tobacco hx, Etoh occasionally, no illicit drug use
Allergies: none

PE:

Pitting edema

DDx- GERD, Hiatal hernia, Angina

Labs: Troponin, EKG- (ST depression),
Test: Endoscopy, Stress Test

Jessica

E.M. 4 day old, skin

Temp 98.4 80/50, HR 140, R40
Mother reports infant skins looks yellow. She reports that she first noticed it this morning, and
that she looked fine two days ago after leaving hospital. Birth 39 wks, normal vaginal delivery
no complications. Mother notices yellowing on face and eyes. Mother reports that she is barely
sleeping. Denies abnormal movement.

5 wet diapers/ no bowel movements in last 24hrs. No abnormal urine color/smell.

Mother reports she has only fed 6 times in the last 24hrs from breastfeeding.

ROS:
No vomiting, sob, fever, vomiting, dehydration
Endorses: yellow skin, eye,

Ddx: Physiologic Neonatal jaundice

PE:
General: sleeping
Skin: yellow tinge
Abdomen: soft, non-tender
Fontanelles: soft smooth, non-depressed

Labs: bilibrubin,

Follow them, lactating ability

Dx: Breastfeeding Jaundice

Jeff

H.D. 83y male, 6 mo fu, stagmina not what it use to be, more forgetful
Temp 7.4 R 22, bp 128/84 BMI 26.9
Patient a little less energy, but is still walking a mile a day. Pt reports stagmina has been
decreasing over the past several years. Pt reports forgetfulness has been occurring over the
past several months. He reports not feeling anything like this before. He reports 6-7hrs of sleep
nightly, and feels rested.

Pmhx: DM II, A-fib, 1-Tubular adenoma, cataract

Surg: cataract bilateral removal- 10yrs
Social: etoh use
Meds: Rivoxban, linsonpril, Metroprol, aspirin, marlax, tamuoslin,

ROS:
No pain, numbness or tingling, fever, chills, rashes

Labs: WBC 8.2, Hem 11.9, Plat 221, everything else is normal, Fasting glucose 116, CK 1.01
Alkaline phosphate slightly elevated, Uric acid 6.3, A1C 7.2%, UA- neg, Cholestrol 220, LDL 141
Trig 188, HDL 41.

Chest xray- clear of infiltrates, pulmonary vasculature normal, cardiac size normal

PE:

DDX:
LABS: TSH, B12

Jorge
P.L. 81y, incontence
140/74, R 18
Patient reports incontinence started 1 yr ago. She feels urgency, and by the time she goes her
diaper is wet. She voids a lot of urine. She occasionally loses her urine when she coughs and lifts
things up. She has a history of 2-3 UTIs per year. Denies pain with urination, hematuria, and
change in color. Patient reports that she has to go and urinate every hour, and if she doesn’t
she’ll urinate on herself.

Allergies: NKDA
Meds: Trimadol, Linospril 10mg, Lipitor 10mg, Vitmain C,
PMHx: TIA-15ys ago, hypetension, hyperlipidemia, breast bipsy-bening, cataract surgery,
degenerative joint disease, hysterectomy with bilateral
Meds:
Family- MOTHER- lung cancer, bladder cancer, daughter- mild hypertension

Refer to urologist

Madison

F.C. 32y male for yearly visit, head congestion

99.6, R 72, R 16, 126/82
Pt reports the head congestion started two years ago. He reports a headache that just started,
and blowing out yellow mucus. Tylenol makes the headache go away. He reports taking
medicine that makes it

No fever, no change in weight, no seasonal allergies, no sneezing

Dry cough, cant smell food, mild pain with swallowing

PE: erythematous throat

Lymph: submaxillary lymph nodes enlargement,
Tenderness of frontal sinuses, TM not red, landmarks not visible

Ddx: allergic rhinitis, sinusitis,

Labs:
Tests:

Fu: Histamine,

Ashley
20wks female girl, well child, concerns about constipation
Parents reports 2 wks ago she was constipated, switched her to a low iron formula, mixed with
prune juice that has helped her. Infant feeds twice during the night for feedings, and every 4-5
hrs during the day. Her bowel movments are once daily, and sometimes every other day. Two
soft brown bowel movments day. Parents report organe juice seems to fix the constipation.
Started on similac and started on low iron similac. No cereal of solid foods.

PE: Posterior closed, anterior-palpale soft and flat,

Eyes: red reflux
Ears: normal
Cardio: RRR
LUNGS: clear
Neuro: no head lag, pulls up to elbows, tracks objects to eyes, blabs, holds head erect, she
makes it clear when shes happy/not, reaches for objects, pulls up to elbows.

Vaccines: vaccines

Marianna

OCP gaining weight question. Pt concern that she will gain weight from OCP injection. Patient
being sexually active with boyfriend for the past use, with condom use.

Vaccines: started HPV series, never finished the rest

PMHX: none
Surgy: none
Social- occasional beer, denies illicit drug use
Fam: dad- hypertension, high cholesterol mom

ROS:
Denies: chest pain, seizures, abdominal pain, urinary symptoms,

Alex
MS 24yr male, abdominal bloating

Pt reports that he is consistently bloated, and has to defect frequently. He states that he has a
hard time participating in his college work. He also reports he has a hard time evacuating his
bowels completing. 3-5 loose to semi loose bowel movements a day. Cramping gets better with
lying down, and defecation makes it better. One year ago pt was diagnosed with Giardia, but
stool cultures were negative. He was treated with metronidazole but didn’t approve. He has
tired loperamide and Pepto but doesn’t help.

Ros: lower abdominal cramping, GERD- 2-3 x a week

Med: none, infrequent abx use, loperamide and pepto
Social: etoh 3-6packs beer on the weekend, current occasional use. Denies smoking or illict drug
use. grad student, previously worked n cruise ship, sexually active-girlfriend
Family: none

PE:
HEENT: normal, normal mucosa
Abdomen: diffuse tenderness to lower abdomen
Rectal: no masses lesion, fistulas, hemorrhoids, palpable non-tender stools
Cardiac: RRR
Lungs: clear
Skin: No rashes

Ddx: Inflammatory Bowel

FU: diet change, if doesn’t work will fu with

Ashley
O. 54y female, urinary incontinence,
Pt been using her urine for a few months when she laughs and when she sneezes. Pt reports
that she gets a uncontrolled urge to urinate. Nothing seems to make it better.

Surg:
Pmhx
LMP: none

ROS: No fever or chills, no abdominal pain or pressure

Everything is negative.

Test: Kelgel exercises, UA

Mckenzie

J.M. 81yr, memory problems, accompanied w/ daughter

Daughter feels like her mom is getting my forgetful, she states that she did not notice any
sudden change. Patient had prior cataract surgery and reports vision has improved. She has
been more confused over the past 2 months, and has been unable to found her room within
the house

Meds: Thiazide, bendryl, tums 3x day, multi vitamin, asprin

Pmhx: hypertension
Social- reitred
Famhx: husband- MI

ROS:
Neuro- normal
Everything normal
MMSE- didn’t do

FU: Get her admitted, she needs assistance

Scott

I.A 39y, annual gyn visit, last seen a year ago

Pt states that she likes visiting the clinic, feels like she has a abusive partner, that has
demonstrated domestic violence towards her. She reports that this has been going for 1 ½.
Patient denies sexual abuse.

Surgies: dental surgery, mammoplasty

Pmhx: none
Meds: none
Social: excessive etoh use, 3-4 drinks a day.

ROS: denies urination symptoms, dyspareunia,

PE: appears well, no obvious bruises

Vital: 98, 74 R, R 16, 140/90
Skin: back- different stages of healing, upper legs
Pelvic exam- clear mucous, no lesions, uterus anti-verted, adexnal non-tender
Cardiac: RRR
Lungs: clear
Abdomon: soft non-tender, no masses

Labs: AST- 58, ALT- normal 30, CMP, CBC, bHCG- neg
FU- want to get her on birth control, get her some support, ask if she would like to report (call
the police)