10

General
History Print
Techniques of History Taking
The most difficult part of the examination is time maintenance. The examination must be
completed in 15 minutes. You must make the optimum use of your time. It is important that
you use appropriate transition sentences and ask openended questions as noted below.
Introduction and greeting:
"Hello Mr. XYZ. Good morning or good afternoon. I am Dr. XYZ. It's nice to meet you
(shake hand).
Technique one (HPI last method):
Starting with the past medical history first allows one to get the patient’s background history
and gives clues for what to focus on in the HPI.
Chief complaint: Start by asking the patient why they are here today.
“Can you please tell me what we can do for you today?”
Plan for interview:
"Before we continue, I would first like to get a little background information
about you so that I know what to focus on with your present problem.”
Start with past medical history
“What medical conditions has a doctor diagnosed you with in the past, such as
diabetes or high blood pressure?”
*Tip: It is best not to use medical words such as hypertension but simple
English, such as high blood pressure, to keep the interview as a fluid
conversation.
“Have you been hospitalized for any medical problems in the past?”
"Have you seen a psychiatrist before or been diagnosed with any psychiatric
conditions?”
Female patients
"How many pregnancies have you had?”
“How many children do you have?”
“Were they natural deliveries?”
“Were there any complications?”
Past Surgical History
“What operations have you had in the past?”
Medications
“What medications are you taking that a doctor has prescribed for you?”
“What vitamins or supplements are you taking overthecounter that a doctor has
not prescribed for you?”
Allergies
“What medications are you allergic to?”
“What allergic reaction does the medicine cause?”
“Are you allergic to anything in the environment or any food?
“What reaction do you get?”
Family history:
*Use transition sentences “I would like to ask you about your family’s medical
conditions.”
“How old is your father? What medical conditions does (or did) he have?”
“How old is your mother? What medical conditions does (or did) she have?”
"How many brothers do you have? Do any of them have any medical
conditions?”
"How many sisters do you have? Do any of them have any medical conditions?”
Social History:
*Transition sentence: “I would like to now ask you about your living situation.”
“Who do you live with at home?”
"What kind of work do you do?”
Tobacco use
“Do you smoke?”
If yes, “what age did you start smoking?”
“How much do you smoke and for how many years?”
Alcohol intake
“Do you drink alcohol or beer?”
If yes, “how many drinks do you have at one time when you drink?”
“What age did you start drinking?”
*Tip: Always keep in mind about the CAGE questionnaires for suspected
alcohol abuse cases (ex. upper GI bleeding, right upper quadrant pain,
epigastric pain).
"Have you ever tried to cut down on alcohol drinking?"
"Have you ever been annoyed by other people for your drinking?" or
"Have you ever annoyed other people by your drinking?"
"Have you ever had guilty feelings about your alcohol drinking?"
"Do you drink alcohol early in the morning?"
Illegal drug use
“Have you used any illegal drugs in the past?”
“What did you use?”
“When did you start?”
“When did you stop?”
“Have you had any blood transfusions? Have you had any tattoos?”
History of present illness (HPI)
*Transition sentence “Now that I have your background, l will now focus on
what brings you in today.”
After this, ask open ended questions: “Tell me more about the chest pain.”
Ask the following components of the chief complaint in the HPI
Location
“Show me where the problem is?”
“Point with one finger where it hurts.”
Onset and duration Always ask for the onset and duration of the problem so
you can know whether the problem is acute, subacute, or chronic.
“When did it first start?”
“How long does it last?”
Intensity One should always ask about the intensity or severity of the problem,
especially if the complaint is pain.
"On a scale of 110, with 1 being the least painful and 10 being the most
painful, which number would describe your pain?" or "How would you
grade your pain on a scale of 110?"
Quality
“Describe the pain.”
“What does it feel like?”
“Is it sharp?”
Frequency
“How many times a day are you having the symptom?”
“Is it constant or happening on and off?”
Radiation
“Does it move anywhere?”
Aggravating factors
“What makes it worse?”
Alleviating factors
“What makes it better?”
Associated symptoms
“I want to ask you about other symptoms that you may be having.”
*Tip: Ask the relevant associated symptoms with the chief complaint
General Review of Systems (ROS) brief overview
General:
“Do you have fever or chills?”
“Have you lost any weight?”
Skin:
“Have you had any rashes or changes in skin color?”
“Have you noticed any easy bruising?”
HEENT:
“Do you have any vision or hearing problems?”
“Do you have any headache or dizziness?”
“Do you have any nasal discharge or obstruction?”
“Do you have any difficulties swallowing?”
“Have you had any sore throat?”
Cardiac:
“Do you have any chest pain?”
“Do you feel that your heart races or goes fast?”
Pulmonary:
“Have you had any cough? If so, are you coughing anything up?”
“What color is the sputum? Is there any blood?”
“Have you had any shortness of breath?”
Gastrointestinal:
“Have you had any nausea or vomiting?”
“Have you had any constipation or diarrhea?”
“Have you had any abdominal pain?”
Genitourinary:
“Have you had to go to the bathroom more often?”
“Does it burn when you urinate?”
"Do you have blood in the urine?”
Musculoskeletal:
“Do you have any weakness in your legs or arms?”
“Do you have any pain in your joints?”
Neurologic:
“Do you have numbness or tingling?”
“Have you passed out at all?”
Technique 2 (HPI first method)
This is the same as above except starting with the HPI first and then proceeding with the past
medical history onwards. The Review of Systems would be performed at the end of the
history.
Summary and plan of action
In both techniques, always summarize the history with the patient. Standardized
patients are usually on the lookout for this.
Always list a plan of action. Standard patients many times will ask for this or look
for you to explain this.
“Let me make sure that I have the correct details. You were well until 5 days ago when
you started having fever, chills, cough with yellow sputum, and shortness of breath.
You started taking ibuprofen and Mucinex without relief. I am concerned about the
following things that could be going on pneumonia, bronchitis, etc… I would like to do
the following next steps to help figure out what could be going on.”
This copy of the material is licensed to Mohammed Mirza.
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Complete ROS Print
How to take history of complete Review of Systems
General:
“Do you have fever or chills?”
“Have you lost any weight?”
“Have you had any changes in your appetite?”
“Have you noticed any weakness in any part of the body?”
“Do you feel tired?”
“Have you had any sweats that drench your clothes or the sheets at night?”
“Have you been exposed to any radiation in the past?”
Skin:
“Have you had any rashes or changes in skin color?”
“Have you had increased itching in any part of the body?”
“Have you had bumps develop on your skin, known as hives?”
“Have you developed bruises more easily than usual?”
“Have you had eczema before?”
“Is your skin drier than usual?”
“Have you had any changes in your hair?”
“Have you had any changes in your nails?”
HEENT:
Head:
“Do you have headaches?”
“Do you have any dizziness?”
“Have you passed out?”
“Have you had any injury to your head, such as falls?”
Eyes:
“Do you have any vision problems, such as double vision or blurry vision?”
“Have you been having more watery eyes?”
“Do you have pain in your eyes?”
“Are your eyes more sensitive to light recently?”
“Have you had any redness or discharge from your eyes?”
“Have you had any injury to your eyes?”
Ears:
“Have you had any hearing loss or difficulties?”
“Do you have pain either inside or on the outside of the ear?”
“Have you had any discharge from your ears?”
“Do you have ringing in your ears or hear an unusual sound?”
Nose:
“Do you have any nasal discharge?”
“Are you having nosebleeds?”
“Do you have any nasal blockage?”
“Have you had any injury to your nose?”
“Do you have any history of sinus infections?”
Throat and mouth:
“Have you had bleeding from your gums?”
“Have you had any sore throat?”
“Do you have any changes in your voice?”
“Have you had drainage in your throat?”
“Do you have any difficulties swallowing?”
Neck:
“Have you noticed any lumps in your neck?”
“Do you have any neck pain when you move it?”
“Does your neck hurt when it is touched?”
Cardiac:
“Do you have any chest pain?”
“Do you feel that your heart races or goes fast?”
“Do you get short of breath when you walk? If so, how far can you walk before
becoming short of breath?”
“Do you get short of breath when you lay down to sleep?”
“Do you wake up in the night with shortness of breath that improves after you sit up for
1015 minutes?”
“Have you had rheumatic fever in the past?”
Pulmonary/Chest:
“Have you had any cough? If so, are you coughing anything up?”
“What color is the sputum?”
“Are you coughing up any blood? If so, how much blood are you coughing up?”
“How much are you coughing up?”
“Does it hurt in your chest when you take a deep breath?”
“Have you had any shortness of breath?”
“Have you been tested for TB before?”
“Have you had the BCG vaccine for TB?”
Vascular:
“Do you have pain in your legs, calves, or thighs while walking?”
“Have you had swelling in your legs?”
“Do you have varicose veins?”
“Have you had any blood clots in your legs before?”
“Do your arms or legs feel cooler than the rest of the body?”
“Have you had hair loss on your legs?”
“Have you had color changes in your arms or legs?”
“Have you had skin ulcers in your legs or arms before?”
Breasts:
“Have you noticed any lumps in either breast?”
“Have you had any discharge from the nipples?”
“Do you have pain in either breast?”
“Have you noticed any skin color changes?”
Gastrointestinal:
“Have you been more thirsty than usual?”
“Have you had any nausea or vomiting? If so, are you throwing up blood?”
“Have you had any constipation or diarrhea?”
“Have you had pain after eating meals or at night?”
“Have you had any belly pain?”
“Do you have any blood in your stool?”
“Has your stool become thinner recently?”
“Does your stool appear black?”
“Has your belly become bigger?”
“Have you had any pain with bowel movements?”
“Have you had yellow eyes or skin?”
Psychiatric:
“Have you had difficulty falling asleep or staying asleep at night?”
“Have you noticed a change in your mood recently? If so, do you think that it is more
depressed than usual?”
“Have you seen or heard things that others do not see or hear?”
Endocrine:
“Do you feel warm if everyone else in the room appears comfortable?”
“Do you feel cold if everyone else in the room appears comfortable?”
Immunology:
“Do you have any seasonal allergy symptoms to the environment?”
“Have you had any recent infections?”
Hematological/Lymphatic:
“Have you noticed any lumps or bumps anywhere on the body?”
“Have you been bleeding more easily than usual?”
Urinary:
“Have you had to go to the bathroom more often?”
“Do you feel like you have to go more often but do not urinate very much?”
“Does it burn when you urinate?”
“Do you have blood in the urine?”
“Do you have difficulty starting your urination?”
“Have you had difficulty controlling your urine such that you leak during the day or
night?”
“Do you have any pain in the side of your lower back?”
“Do you wake up from sleep to urinate at night? If so, how many times?”
“Are you unable to empty your urine?”
“Have you had kidney stones in the past?”
Male genitalia:
“Have you developed any sores on your penis? If so, are they painful?”
“Have you had any discharge from your penis?”
“Have you had any pain in the penis, scrotum, or testicles?”
“Have you had any prostate problems in the past?”
“Have you been treated for any sexually transmitted diseases in the past? If so, which
ones and what treatment did you receive?”
“Do you have any difficulty with sexual relations?”
“Have you had a hernia before?”
Female Genitalia:
“Have you had any sores or growths on the vaginal area?”
“Have you had any itching in the vaginal area?”
“Have you had any vaginal discharge?”
“Do you have any problems with sexual relations, such as pain?”
“What age did you start having periods?”
“How often are your periods?”
“How many days do your periods last?”
“How many pads or tampons do you use each day and on the heaviest day of your
periods?”
“When was your last period?”
“Have you had any bleeding between periods?”
“Have you had any irregular periods?”
“Have you had excessive bleeding than usual during your periods?”
“Do you have excessive pelvic pain during your periods or before your periods?”
Symptoms of menopause
“Have you stopped having periods? If so, when?”
“Do you have episodes when you feel hot but everyone else feels comfortable in
the room?”
“Have you or others around you noticed any changes in your mood?”
“Have you had any bleeding since your periods stopped?”
“Have you had pain with intercourse?”
“Do you have any vaginal dryness?”
Musculoskeletal:
“Do you have any weakness in your legs or arms?”
“Have you had any stiffness in your muscles?”
“Do you have any stiffness when moving any of your joints?”
“Do you have any pain in your joints?”
“Have you had any swelling in your joints?”
“Have you been diagnosed with arthritis?”
“Do you have any back pain? If so, where?”
“Do you have any muscle cramps?”
Neurologic:
“Do you have numbness or tingling in any part of the body?”
“Have you passed out at all?”
“Have you noticed a tremor in any part of your body?”
“Have you had any problems with your memory?”
“Do you have any difficulty with your speech?”
“Have you had problems with walking?”
“Has anyone noted any changes in your thinking or behavior?”
“Do you feel that you don’t know where you are or become lost?”
OBGyn History Print
Obstetric and Gynecology History: (for female patients and OB/Gyn complaints)
"When was your last menstrual period?"
"Are/Were your cycles regular?"
"How old were you when you had your first period?"
"Are your periods regular?"
"How many days does your period last?"
"Have you ever bled between cycles?"
"How many pads or tampons do you use each day and on the heavy days during your
period?"
"Do you have abdominal cramps/pain before or during your period?"
"Did you ever notice any bleeding after intercourse?"
"Have you been getting regular Pap smears? When was your last Pap smear?"
"Have you ever had any vaginal discharge?"
If YES, then ask "What is the color of the discharge?”
“Does the discharge have any bad odor?”
“Do you have any vaginal itching?"
"Have you had any sores or infections around the vagina?"
“How many pregnancies have you had?”
“How many children have you had?”
“Were they natural deliveries or Csections?”
“Were there any complications during the deliveries?”
Sexual History Print
Sexual History
This can be asked here as well as in special situations, if pertinent. Before taking the history,
let the patient know that you will be asking about her/his sexual history, so you will be posing
a transition question.
"Ok Mr. Brown, now I would like to ask a few questions about your sexual history.
Please understand that it will be kept confidential between you and me. Try to be as
honest as possible. Is that ok with you?" Continue as follows: "Are you sexually
active?"
If 'YES,'
"Who is your sexual partner?”
“Do you have any other sexual partners?"
"Do you have male, female, or both as partners?”
“Are you satisfied with your sexual life?"
If 'NO,' inquire the reason.
"Do you have any problems in your sexual life?”
“Any loss of interest in sex?”
“Are you able to reach an orgasm?"
"Do you use any means of contraception?"
If 'YES,' "What type of contraception do you use?”
“Do you use it regularly?”
For high risk groups, like patients who are not using barrier methods of contraception,
patients with multiple sexual partners, and patients with a homosexual history, continue
with the following questions: (Note: most of the time they have this history, so never
miss it.)
"Have you ever been tested/treated for sexually transmitted diseases?"
"Have you ever been tested for HIV?"
Psychiatry History Print
Ask what brings the patient in today.
Ask what the patient thinks the problem could be due to (This would give you a
concrete answer if the psychiatric manifestations were due to reactive causes. Be
prepared for a negative answer in most of the cases.)
Ask if the patient has anybody to talk to when she is in distress. (Support systems)
Ask if the patient has had any unusually traumatic episodes during the past few
months or in the remote past. (PTSD)
Ask about any changes in appetite.
Ask about any changes in sleep patterns, i e, problem falling asleep; problem
maintaining sleep; problem with early morning awakening; Ask also about
nightmares and dreams.
Ask about any weight loss/gain.
Ask about the daily routine of the patient. ("Could you describe to me a typical day
in your life?")
Ask about the patient's interests and hobbies. Ask if they give her the same kind
of pleasure that they gave her earlier.
Ask about her mood most of the day.
Ask about the duration of these symptoms.
Ask if the patient is frequently forgetting things or feels that she is losing her
memory
Ask the patient about her general attitude towards life. ("Do you tend to look at
things In a positive frame of mind or in a negative frame of mind?")
Ask about the patient's sexual life.
Ask if the patient has ever considered ending her life.
Ask if the patient has any plans regarding how to end her life.
Ask if there are pills or guns at home.
Ask about family life and the affinity of the patient towards her family members.
Ask about any excessive coffee intake.
Ask about drugs, alcohol, and recreational drugs. If yes then ask about the last
time that the patient took these drugs. (The psychiatric manifestation may be due
to a withdrawal syndrome.)
Ask about any delusions or hallucinations. ("Do you listen and see what others
can't? Have you heard voices talking to you only and nobody else around you
does?")
Ask about heat or cold intolerance and other thyroid manifestations.
Do a Mini Mental Status Examination. ( Look up the CNS history taking for the
MMSE )
Ask if the patient realizes that she has a problem.
Ask if the patient is willing to get help.
Challenging psychiatric situations
"The Silent Patient": If the patient is not answering you, stay silent for a minute;
establish eye contact. Put a hand on her shoulder and say, "I know that this is very
hard for you. Will you share it with me? I am here to help you. We can do it
together."
"The Over talkative Patient":If you are not able to get a word in edgeways, stop
the patient and firmly say, "I know that all these things bother you but my
number1 priority right now is you. So lets talk about you for now."
Sample documentation of a psychiatric patient note
Patient disheveled
Speech: scant, goal directed
Mood: dysthymic
Affect: mood congruent
Memory: Recent and remote: Intact
Delusions and hallucinations: none
MMSE results
Concentration:
Suicidal intent
Abstraction and Judgment
Insight
Duration of symptoms
Precipitating factors
Thyroid: not palpable
Special Situations Print
Special Situations
Angry patient:
"Mr. XYZ, you seem to be very angry. Could you please tell me why that is so? Is there
any way that I can help you?"
Uncooperative patient:
"Mr. XYZ, to properly understand your problem, I have to do this test. It won't take
more than a minute. I am here to assist you, ok?"
Pain in hand:
"Does your job involve repetitive hand movements like key board operation?" (carpal
tunnel syndrome).
Insect bite:
"Do you remember being bitten by any insects like ticks and/or mosquitoes?" (in any
rash case)
Trauma patient:
Sometimes you will see trauma patients with serious injuries, bruises, or gunshot
wounds. Avoid painful maneuvers while diagnosing their injuries. Also, be aware that
some severely injured patients without insurance will try to refuse expensive treatments.
For example, a trauma patient with significant injury to the chest who has signs and
symptoms of hemothorax may say he doesn't want to have a chest xray. In a case such
as this one, explain that, "We have a social worker. She will help with the financial
details. Right now we must take an xray in order to diagnose your condition.” Almost
every hospital in the US will have a social worker to deal with these kinds of problems.
Overtalkative patient:
Sometimes the patient may talk endlessly about irrelevant topics. If so, respond like
this, "Excuse me Mr. XYZ, sorry to interrupt you. I know these things have really been
bothering you. We will try to get back to this again. However, let me first focus on your
present problem."
Some patients will respond normally, but some patients will say, "Are you interrupting
me?" (Don't worry they have been told to act like that). Say the same thing again and
say sorry once again.
General:
If you have to say, "I don't know," say, "I don't know yet" or, "I don't know but I'll find
out and will let you know."
Note: This is a general way to take case histories. We have included questions for general
history taking, as well as questions for specific health issues. You do not need to ask all of
these questions for every case. Prioritize what you need to know and ask those questions. The
ability to prioritize becomes easier the more cases you practice.
Physical Examination Print
The aim here is to teach you how to examine a patient in the examination room.
Always wash your hands with soap before the physical examination. So as not to
lose time, while washing your hands, turn your head toward the patient and
continue your conversation.
Never examine through the gown. Always keep the patient's body covered or
draped as much as possible. Expose only the part being examined.
Don't hesitate to examine the heart in a female patient. Leaving the bra on, ask
her to lift her breast for PMI (Point of maximum impulse) and auscultation.
It is permissible to place the stethoscope down between the breasts to continue
listening. Don't do a breast examination.
The dictum is to inform the patient what you are doing during the examination.
Ex: Start like this:
You: "Ok, Mr. Samson now I would like to do a physical
examination on you. For that, I need to untie your gown. Is that
ok with you?"
SP: "Yes, it's ok"
You: "Thank you"
If the patient resists you, then you have to explain the importance of the
examination to understand the disease process. Something like this:
You: "Mr. Samson, I can understand your feelings but to clearly understand
the disease I have to do this examination. It won't take more than a minute.
Don't worry. I'm here to assist you. I will tell you whatever I'm going to do."
Some physical findings can be expressed on the SP's face (faked). So, be careful
and always observe SP's face while examining him. Sometimes, you may get a SP
with hypertrophic tonsils, as a case of a sore throat.
Always do a focused, relevant examination. You won't have time to do everything.
Prioritizing will come only with repeated practice.
Respiratory Examination:
Ideally, the patient should be sitting on the end of an exam table.
Inspection:
You: "Now, I would like to examine your chest. Is that OK with you?"
Observe the rate, rhythm, depth, and effort of breathing.
Listen for obvious abnormal sounds with breathing such as wheezes.
Observe for retractions and use of accessory muscles (sternocleidomastoids,
abdominals).
Observe the chest for asymmetry, deformity, or increased anteriorposterior (AP)
diameter.
Palpation:
You: "I would like to palpate your chest. Let me know if it hurt"
Look for tracheal deviation
Identify any areas of tenderness or deformity by palpating the ribs and sternum.
Assess expansion and symmetry of the chest by placing your hands on the patient's
back and thumbs together at the midline. Ask him to breathe deeply.
Check for tactile vocal fremitus.
Look for PMI (Point of Maximum Impulse).
Percussion:
You: "Now, I am going to tap on your lungs to look for any fluid or excess air"
Percuss both anterior and posterior chest from side to side then from top to bottom
Interpretations:
If dull Pleural effusion or Lobar pneumonia
Hyperresonant Pneumothorax or Emphysema
Auscultation:
You: "Now, I would like to listen to your lungs. Can you take some nice big deep breaths
for me?"
Use the diaphragm of the stethoscope.
Auscultate anterior, posterior and lateral sides of the chest from side to side then
from top to bottom.
Tactile Fremitus:
You: "Can you please say "ninetynine, ninetynine" repeatedly for me"
Palpate with your lateral border of palm.
Increased tactile fremitus suggests consolidation of lung.
Bronchophony:
You: "Can you please say "ninetynine, ninetynine" repeatedly for me?"
This time instead of palpation you do auscultation. Auscultate several symmetrical
areas over each lung.
The sounds you hear should be muffled and indistinct. Louder, clearer sounds are
called bronchophony (indicates consolidation).
Whispering pectoriloquy:
You: "Can you please whisper "ninetynine, ninetynine" repeatedly for me?"
Auscultate several symmetrical areas over each lung.
In normal people you should hear only faint sounds or nothing at all. If you hear
the sounds clearly this is referred to as whispering pectoriloquy (indicates
consolidation).
Special Points:
Never percuss or auscultate on scapula.
Let the patient fully exhale or inhale before auscultating (shifting to) the other
area.
For every case of the respiratory system, don't forget to auscultate the heart and
check for PMI.
Cardiovascular System:
Always examine from the patient's right side.
Always examine in 3 positions.
You: "OK Mr. Samson, now I would like to examine your heart. First, in a sitting
position, then lying down, and finally in a sitting position again."

While the patient is in sitting position:
You: "I need to check your pulse."
Note whether the pulse is regular or irregular.
Observe for carotid pulse.
Auscultate for carotid bruits (a sign of arterial narrowing and risk of a stroke) in
middle aged or elderly patients.
Check for dependent edema.
Don't measure the blood pressure unless otherwise asked (they usually give the
B.P).
Then ask the patient to lie down:
You: "I need to check your heart. Could you please lie down for me? I'll pull out the leg
extension to make it a little more comfortable for you"
Look for Jugular Venous Distention (JVD). Position the patient supine with the head
of the table elevated to 30 degrees.
Inspect for precordial movement.
Then palpate for precordial activity.
You may feel thrills or exaggerated ventricular impulses.
Palpate for the point of maximal impulse (PMI or apical pulse).
Note the location, size, and quality of the impulse.
Auscultation:
You: "Now, I would like listen to your heart."
Position the patient supine with the head of the table slightly elevated.
Record S1, S2, (S3), (S4), as well as the grade and configuration of any murmurs
("two over six" or "2/6", "pan systolic" or "crescendo").
Listen with the stethoscope diaphragm at the right 2nd intercostal space near the
sternum (aortic area).
Listen at the left 2nd intercostal space near the sternum (pulmonary area).
Listen at the left 3rd, 4th, and 5th inter costal spaces near the sternum (tricuspid
area).
Listen at the apex (mitral area). Next, ask the patient to turn on his left side and
then listen to the mitral area.
Record the rate, rhythm, and any extra sounds you hear.
Ask the patient to sit up again .
Again auscultate all the 4 areas.
Ask him to lean forward and listen at the base of heart.
Examination of the Abdomen:
The patient should be lying supine on the exam table and appropriately draped.
Watch the patient's face for signs of discomfort during the examination.
Consider the inguinal/rectal examination in males and pelvic/rectal examination in
females.
Don't do these examinations but tell the SP that you want to do them later.
Inspection:
You: "I am looking at your belly for any gross abnormalities".
Look for scars, swellings, and hernias.
Look for any visible peristalsis or pulsations.
Note the abdominal contour (Flat, scaphoid, or any abdominal distention).
Auscultation:
You: " Now, I would like to listen to your bowel sounds"
It is very important to auscultate prior to palpation
1. Listen for bowel sounds.
2. Listen for bruits over the renal arteries, iliac arteries, and aorta.
Percussion:
You: "Now, I would like to tap on your belly."
Percuss all four quadrants.
Percuss the liver span
1. Percuss downward from the chest in the right midclavicular line until
you detect the top edge of liver dullness.
2. Percuss upward from the abdomen in the same line until you detect the
bottom edge of liver dullness.
3. The distance between the points is the liver span.
Check for splenic dullness
1. Percuss the lowest costal interspace in the left anterior axillary line.
This area is normally tympanic.
2. Ask the patient to take a deep breath and percuss this area again.
Dullness in this area may be a sign of splenic enlargement.
Palpation:
You: "Now, I would like to press on your belly first lightly then deeply. Please let me
know if it hurts"
Start with light (superficial) palpation. This is to look for any areas of tenderness.
Look at the patient's face not at the abdomen. The most sensitive indicator of
tenderness is the patient's facial expression. Also look for guarding (Voluntary or
involuntary).
Proceed to deep palpation after light palpation.
Palpate the Liver: Place your fingers just below the right costal margin and press
firmly. Ask the patient to take a deep breath.
Palpate the aorta: If you suspect any aneurysms
Palpate the spleen:
Special Tests:
Rebound Tenderness:
This is a test for peritoneal irritation.
Tell the patient what you are about to do. "Now, I would like to press in and
release. Please let me know if it hurts when I press in or let go."
Press deeply on the abdomen with your hand. After a moment, quickly release
pressure.
If it hurts more when you release, the patient has rebound tenderness.
Costovertebral angle (CVA) Tenderness:
CVA tenderness is often associated with renal disease.
Tell the patient what you are about to do. "Now, I would like to give few thumps on
your back. Please let me know if it hurts."
1. Ask the patient to sit up.
2. Use the heel of your closed fist to strike the patient firmly over the
costovertebral angles.
3. Compare the left and right sides.
Shifting dullness:
Can be done for fluid in the abdomen.
Psoas sign:
This is a test for appendicitis. First ask the patient to turn onto his left side. Then
extend the patient's right leg. This will cause stretching of the psoas muscle and
will cause pain if it is irritated by inflamed appendix. (SP can act exactly like a real
patient, so watch his face.)
Obturator sign:
This is also a test for appendicitis.
1. Raise the patient's right leg with the knee flexed.
2. Rotate the leg internally at the hip.
3. Increased abdominal pain indicates a positive obturator sign.
Murphy's sign:
You: "Now, I would like to press on your belly. Please take a deep breath and let me
know if it hurts."
This is for suspected cholecystitis. Hook the finger of your right hand underneath
the right costal margin at the point where the lateral border of the rectus muscle
intersects with the costal margin. Then ask the patient to take a deep breath. If he
complains of pain then the test is +ve.
Neurologic Examination:
Always consider left to right symmetry.
Organize your thinking into seven categories:
1. Mental Status
2. Cranial Nerves
3. Motor system
4. Coordination and Gait
5. Reflexes
6. Sensory system
7. Special Tests
Mental Status:
Level of Consciousness: You: "Hello Mr. Swanson. Can you hear me? If you hear
me, can you smile for me?"
Orientation in time, place and person: You: "Where are we? What is the date
today? Can you please tell me your full name?"
Assess Judgment: You: "What would you do if you found a selfaddressed
envelope on the street?"
You have to test for memory of recent, remote, and registration.
Test memory: Recent remote registration. You: "Mr. Swanson, I'm going to say
three words. I want you to say them after me. I will ask you to repeat the same
words again after 5 minutes. Do you understand? Say, "pen, car, and chair". Ask
again at the end of the mental status. For longterm memory you can ask
something like, "What happened on September 11th?"
Abstraction: You: "Can you please spell the word, "WORLD" backwards for me?"
Three Object Command: "Mr. Swanson, I am going to write a sentence. Please
read the sentence and do as it says. Ok?" You write, 'Close your eyes' on a piece of
paper. (Some people do the serial '7's test, but it is time consuming. We don't
advise that. If you do the above six things, that is more than sufficient for this
exam.)
Cranial nerves:
Observe for any gross abnormalities like
Ptosis (III).
Facial droop (or) asymmetry (VII).
Abnormal articulation of words (V, VII, X, XII).
Abnormal eye position (III, IV, VI).
Abnormal or asymmetrical Pupils (II, III).
Olfactory:
Usually not tested for this exam.
Optic:
You: "Now, I need to examine your eyes. Can you please count my fingers?"
Examine the optic fundi.
Test visual acuity by using Snellen's chart or simply by using your fingers.
Screen visual fields by confrontation.
Stand two feet in front of the patient and have them look into your eyes. Hold your
hands about one foot away from the patient's ears, and wiggle a finger on one
hand. Ask the patient to indicate which side they see the finger move. Repeat two
or three times to test both temporal fields. If an abnormality is suspected, test the
four quadrants of each eye while covering the other with the patient's hand.
Test pupillary reactions to Light.
1. Dim the room lights as necessary.
2. Ask the patient to look into the distance.
3. Shine a bright light obliquely into each pupil in turn.
4. Look for both the direct (same eye) and consensual (other eye)
reactions.
5. Record pupil size and any asymmetry or irregularity.
Oculomotor:
Observe for ptosis.
Test extra ocular movements.
Ask the patient to follow your finger with their eyes without moving their
head.
Check gaze in the six cardinal directions using a cross or "H" pattern.
Pause during upward and lateral gaze to check for nystagmus.
Check convergence by moving your finger toward the bridge of the patient's
nose.
Test pupillary reactions to light.
Trochlear:
Test extra ocular movements (Inward and downward movement).
Trigeminal:
Test motor strength.
Ask the patient to clench his/her teeth.
Palpate the temporal and masseter muscles as they do this.
Test the 3 divisions for pain sensation.
Explain what you intend to do.
Use a suitable sharp object to test the forehead, cheeks, and jaw on both
sides.
Substitute a blunt object occasionally and ask the patient to report "sharp" or
"dull."
Test the corneal reflex (Not required for this exam).
Abducens:
Test extra ocular movements (Lateral movement).
Facial:
Observe for any facial droop.
Ask patient to do the following, note any lag, weakness, or asymmetry:
Raise eyebrows ("Can you please raise your eyebrows for me?").
Close both eyes to resistance ("I will try to open your eyes, don't let me
open.").
Smile ( "Can you please smile for me?").
Frown ("Can you please frown for me?").
Show teeth ("Can you please show me your teeth?").
Test the 'corneal reflex' (Not required for this examination).
Acoustic:
Screen hearing
Test hearing by making simple noise with fingers.
If abnormal, then do Weber and Rinne tests.
Test for lateralization (Weber)
Use a 512 Hz tuning fork.
Place the base of the vibrating tuning fork firmly on top of the patient's head.
Ask the patient where the sound appears to be coming from (normally in the
midline).
Compare air and bone conduction (Rinne)
Use a 512 Hz tuning fork.
Place the base of the vibrating tuning fork against the mastoid bone behind
the ear.
When the patient no longer hears the sound, hold the end of the fork near the
patient's ear (air conduction is normally greater than bone conduction).
Vestibular function is not normally tested.
Glossopharyngeal:
Not required for this examination.
Vagus:
Listen to the patient's voice, is it hoarse or nasal?
Ask the patient to swallow.
Ask the patient to say "Ah".
Watch the movements of the soft palate and the pharynx.
Test 'gag reflex' (unconscious/uncooperative patient). (Not required for this
examination.)
Accessory:
From behind, look for atrophy or asymmetry of the trapezius muscles.
Ask the patient to shrug his shoulders against resistance ("Can you please shrug
your shoulders for me?").
Ask the patient to turn his head against resistance. Watch and palpate the
sternomastoid muscle on the opposite side.
Hypoglossal:
Listen to the articulation of the patient's words.
Ask patient to stick out his tongue. Ask him to move his tongue from side to side.
("Can you please stick out your tongue? Move it from side to side.")
Motor :
Observation:
Involuntary movements
Muscle symmetry and atrophy. Always compare both (right and left) sides. Check if
there is any difference between the proximal and distal muscle groups.
Gait
Muscle tone:
You: "I would like to check your muscle tone. Please relax your muscles. OK?"
Flex and extend the patient's fingers, wrist, and elbow.
Flex and extend patient's ankle and knee.
There is normally a small, continuous resistance to passive movement.
Observe for decreased (flaccid) or increased (rigid/spastic) tone.
Muscle Strength:
You: "Now I would like to check your muscle strength/power".
Test strength by having the patient move against your resistance.
Always compare one side to the other.
Grade strength on a scale from 0 to 5 "out of five":
0/5 No muscle movement at all
1/5 Just flicker of movement.
Movement at the joint, but not
2/5
against gravity
Movement against gravity, but
3/5
not against added resistance
Movement against resistance,
4/5
but less than normal
5/5 Normal strength

Test the following:
Spine:
"I would like to check the flexibility of your spine. Please lean over at the waist,
and try to touch your toes."
Upper limb:
Flexion at the elbow ("Can you please pull in?")
Extension at the elbow ("Can you please push out?")
Flexion and Extension at the wrist. ("Can you please pull up and push down?")
Squeeze two of your fingers as hard as possible. ("Can you please squeeze my
finger as tightly as you can?")
Finger abduction (ulnar nerve) ("Can you please spread your fingers out?")
Opposition of the thumb (median nerve).
Lower limb:
Flexion at the hip (iliopsoas): ("Can you please pull in?")
Adduction at the hips (adductors): ("Can you pull your thighs together?")
Abduction at the hips (gluteus medius and minimus): ("Can you please push your
thighs apart?")
Extension at the hips (gluteus maximus): ("Can you please push your thighs out?")
Extension at the knee (quadriceps): ("Can you please kick out?")
Flexion at the knee (hamstrings): (" Can you please pull in?")
Dorsiflexion at the ankle: ("Can you please pull in?")
Plantar flexion (S1): ("Can you please push down?")
Coordination and gait:
Cerebellar Function Tests:
You: "Now I would like to check your balance and movements"
Rapid alternating movements i.e. ask him to do rapid supination and pronation of
hands.
PointtoPoint Movements: "Can you please touch your finger to my finger and then
to your nose". Ask the patient to touch your index finger and their nose alternately
several times. Move your finger about as the patient performs this task.
Ask the patient to place one heel on the opposite knee and run it down his shin to
his big toe. Repeat with the patient's eyes closed. (If you do the above test you
don't need to do this one.)
Romberg's' test:
You: "Can you please stand up with your feet together? Close your eyes. Don't worry, I
won't let you fall".
Be prepared to catch the patient if they are unstable.
Ask the patient to stand with his feet together and eyes closed for 510 seconds
without support.
The test is said to be positive if the patient becomes unstable. (It's a test for
sensory ataxia not for cerebellar ataxia.)
Gait:
You: "Can you please walk a few steps for me?"
Ask the patient to rise from a sitting position, walk across the room, turn, and
come back. ('Get Up and Go Test')
Ask the patient to walk in a straight line: "Can you please walk in a straight line for
me?"
Reflexes:
You: "Miss CSA, I would like to check your jerks. First, let me begin with your arms.
Then, let me check your legs. Please relax your muscles."
Deep Tendon Reflexes:
The patient must be relaxed and positioned properly.
Reflexes can be reinforced by asking the patient to perform isometric contraction
of other muscles (clenched teeth): ("Can you please clench your teeth").
Reflexes should be graded on a 0 to 4 "plus" scale:
0 Absent
Hypoactive
1+ (diminished)
2+ "Normal"
Exaggerated
3+
without clonus
Exaggerated with
4+
clonus
Biceps (C5, C6).
Triceps (C6, C7).
Brachioradialis (C5, C6).
Abdominal (T8, T9, T10, T11, T12).
Knee (L2, L3, L4).
Ankle (S1, S2) .
Clonus:
If the reflexes are exaggerated, test for ankle clonus.
Plantar response (Babinski) : Stroke with a blunt object along the lateral border of
the feet. Extension of the big toe with fanning of fingers is abnormal. This is
referred to as a positive Babinski.
Sensory:
You: "Now I would like to check your sensory perception in different areas of your body."
General:
Explain each test before you do it.
Patient's eyes should be closed during the testing.
Compare symmetrical areas on the right and left side.
Also compare distal verses proximal.
Vibration:
Use a lowpitched tuning fork (128Hz).
Test with a nonvibrating tuning fork first to ensure that the patient is responding
to the correct stimulus.
Place the stem of the fork over the distal interphalangeal joint of the patient's index
fingers and big toes.
Ask the patient to tell you if he feels the vibrations.
If vibration sense is impaired proceed proximally
1. Upper limb: From wrists, elbows etc:
2. Lower limb: From medial malleoli, patella, anterior superior iliac spine.
Position Sense:
Grasp the patient's big toe and show the patient "up" and "down."
With the patient's eyes closed ask the patient to identify the direction you move his
toe.
If position sense is impaired move proximally to test other joints.
Test the fingers in a similar fashion.
If vibration, position sense, and subjective light touch are normal in the fingers and
toes you may assume the rest of this exam will be normal.
Pain:
You: "Please understand, this is sharp and this is dull. Now, close your eyes and tell me
know which is which"
Use a suitable object to test "sharp" and "dull" sensations.
Test the following areas:
Shoulders (C4).
Inner and outer aspects of the forearms (C6 and T1).
Thumbs and little fingers (C6 and C8).
Front of both thighs (L2).
Medial and lateral aspect of both calves (L4 and L5).
Little toes (S1).
Temperature:
Often omitted if pain sensation is normal.
Light touch:
Use a fine wisp of cotton or your fingers to touch the skin lightly.
Ask the patient to respond whenever he feels something touching him.
Test the following areas:
Shoulders (C4)
Inner and outer aspects of the forearms (C6 and T1)
Thumbs and little fingers (C6 and C8)
Front of both thighs (L2)
Medial and lateral aspect of both calves (L4 and L5)
Little toes (S1)
Discrimination:
Since these tests are dependent on touch and position sense, they cannot be performed
when the tests above are clearly abnormal.
Two point discrimination Using two sharp pins, touch the pad of the patient's finger in
two places simultaneously. Alternate with a onepoint touch. The distance between the
two points should be <5 mm on the finger pads.

Special tests:
Kerning's Sign: Here the patient lies on his back. Flex both knee and hip then try to
extend the knee only. In meningitis, patient will complain of pain or resistance to
knee extension.
Brudzinski's Sign: When you flex the neck, there may be a flexion of the patient
hips and knees. This is also seen in meningitis patients.
Neck stiffness: Have the patient lie on his back. Place your hand behind his neck
and flex it until his chin touches his sternum. (In meningitis he will complain of
neck pain and you will notice resistance to motion.)
Examination of the Head and Neck:
Head:
Look for scars, lumps, rashes, hair loss, or other lesions
Look for facial asymmetry, involuntary movements, or edema.
Palpate to identify any areas of tenderness or deformity.
Eyes:
You: "Now, I need to examine your eyes".
Test the visual acuity by using the Snellen's chart.
Inspection:
Ask the patient to look up and pull down both lower eyelids to inspect
the conjunctiva and sclera. Note any discoloration, redness, discharge,
or lesions. Note any deformity/lesions of the iris and cornea.
Extra ocular muscles: "I'm going to check your eyes. Please look at
that object while I shine this light in your eyes."
Corneal Reflections:
Shine a light from directly in front of the patient.
The corneal reflections should be centered over the pupils.
Asymmetry suggests extra ocular muscle pathology.
Test for extra ocular movements.
Test visual fields.
Look pupillary reactions to light.
Ophthalmoscopic exam:
Darken the room as much as possible.
Adjust the ophthalmoscope so that the light is no brighter than
necessary.
Use your left hand and left eye to examine the patient's left eye. Use
your right hand and right eye to examine the patient's right eye.
Ask the patient to look at a point on the wall.
Examine retina and fundus and note any abnormalities.
Ears:
Inspect the auricles and move them around gently. Ask the patient if this is painful.
Palpate the mastoid process for tenderness.
Hold the otoscope then pull the ear upwards and backwards to straighten the canal.
Insert the otoscope. Inspect the ear canal and middle ear structure. Note any
redness, drainage, or deformity.
Nose:
Inspect the nose
Tilt the patient's head back slightly.
Insert the otoscope into the nostril. Try to avoid contact with the septum. Inspect
the visible nasal structures and note any swelling, redness, drainage, or deformity.
Throat:
You: "I need to look inside your mouth for any ulcers or dental problems."
Ask the patient to open his mouth.
Note any ulcers, white patches (leucoplakia), or other lesions.
Inspect the posterior oropharynx by depressing the tongue with tongue depressor
and asking the patient to say, 'Ah'. Note any tonsillar enlargement, redness, or
discharge.
Neck:
Inspect the neck for asymmetry, scars, or other lesions.
Palpate the neck to detect areas of tenderness, deformity, or masses.
Lymph Nodes:
You: "I would like to check for swollen glands. Let me press on this area."
Systematically palpate the various lymph node groups.
Check superficial cervical, supra clavicular, and the deep cervical lymph nodes. The
deep cervical chain of lymph nodes lies below the sternomastoid and cannot be
palpated without getting underneath the muscle. Inform the patient that this
procedure will cause some discomfort. Hook your fingers under the edge of the
sternomastoid muscle. Ask the patient to bend their neck toward the side you are
examining. Move the muscle backward and palpate for the deep nodes underneath.
Note the size and location of any palpable nodes and whether they were soft or
hard, nontender or tender, and mobile or fixed.
Thyroid gland:
You: "Let me check your thyroid, I am going to press very gently gently on this area"
Inspect the neck looking for the thyroid gland.
Note the size, symmetry, and position of the lobes, as well as the presence of any
nodules. The normal gland is often not palpable.
Special Tests:
Facial tenderness:
You: "I would like to check your sinuses. I'm going to press on your forehead and
sinuses. Please let me know if it hurts."
Ask the patient to tell you if these maneuvers cause excessive discomfort or pain.
Press upward under both eyebrows with your thumbs.
Press upward under both maxillas with your thumbs.
Excessive discomfort on one side or significant pain suggests sinusitis.
Sinus transillumination:
Darken the room as much as possible.
Place a bright point light source on the maxilla.
Ask the patient to open his mouth and look for an orange glow on the hard palate.
A decreased or absent glow suggests that the sinus is filled with something other
than air.
Temporomandibular joint:
You: "I need to examine your jaw joint."
Place the tips of your index fingers directly in front of the tragus of each ear. Ask

the patient to open and close his mouth.
Note any decreased range of motion, tenderness, or swelling.
Musculoskeletal System:
Inspection:
Inspect the area.
Always compare with the opposite area.
Always compare other joints for any signs of abnormality.
Palpation:
Palpate the area for warmth, and look for any swelling.
Palpate for tenderness and crepitus .
Check range of motion.
Always check the neurological status (motor, sensory, reflexes.) and vascular
status of that area.
Special situations:
Knee:
Always do the Drawers test and Mc.Murray's test if patient has a H/O
trauma to the knee.
Shoulders:
Range of motion is crucial. Ask him to touch the opposite shoulder.
Wrist:
Check the neurological (dermatomes) status.
Spine:
Check the flexibility, gait, and reflexes
Leg:
Homan's sign this is usually done for suspected deep vein thrombosis.
Forceful dorsiflexion of the foot will cause pain in the calf.
Communication Skills Print
Communication Skills
The following are points to keep in mind during your encounter with the SP.
Introduction
Always knock before entering the room.
When you enter the room, introduce yourself by name and greet the SP warmly.
Always use the SP’s name to address him/her.
Maintain good eye contact. This demonstrates selfconfidence and creates a sense
of trust and credibility.
During abdominal palpation, for example, observe the patient’s face for any
signs of pain or discomfort and maintain eye contact.
History
Start with openended questions before specific questions, as this is the best way
to elicit a patient’s history.
“What caused you to come in today?”
“Could you please tell me more about what’s going on?”
Ask 1 question at a time and do not ask leading questions.
Ask a question, pause, and wait for the answer before proceeding to the next
question.
For example, “Does anyone in your family have high blood pressure?” (Pause
and wait for the answer).
“Diabetes?” (Pause and wait for the answer).
Always pay attention and listen without interrupting.
Try to acknowledge the SP’s emotions.
Use layman’s language.
Try not to use medical terms, such as hypertension for high blood pressure.
Use appropriate transitional sentences.
Physical examination
Wash your hands before starting the physical examination.
Tell the SP what you are going to do (one step at a time, not the entire procedure).
Do not examine through the gown.
Ask the SP’s permission before untying the gown.
Use appropriate draping techniques.
The general rule is that as little of the body should be exposed as necessary
for a set of maneuvers to be performed.
To auscultate the heart or lungs, do NOT raise the gown up from the waist,
exposing the entire torso.
Rather, the SP should lower the gown from the top, exposing only the upper
chest and shoulders.
Offer to help the SP on and off the table during the examination.
Never repeat painful maneuvers and always apologize immediately for any pain
they caused.
Express empathy.
Try to make the SP comfortable during the examination.
Extend the leg rest when the SP lies back and push it in when the SP sits up.
If the SP is in pain, ask if there is anything you can do to help him/her feel
more comfortable.
Conclusion
Summarize the history and explain the physical examination findings.
Make appropriate reassurances but do not give false reassurances.
Never forget to ask “Do you have any questions or concerns?”
Closing the encounter Print
Closing the Encounter
“All right, Mr. XYZ, thank you so much for your cooperation. Now, I’d like to let
you know what I think so far. First, let me summarize.”
“You just told me that __ and __. Also, you said that __ and __. Is that
right?”
“According to the information I got from you and the examination, I am considering
a couple of possibilities.”
“It may be __ (your probable diagnosis) or possibly __(differential
diagnosis).”
“I need to run some tests to find out exactly what the problem is.”
“As soon as I get the results, we can meet again to go over everything.”
“At that time, I’ll explain the details and we will talk about your options for
treatment. Does this sound OK?”
If this is a psychiatric case involving depression, grief, anxiety, or dementia, ask
the following question:
“Ms. XYZ, would you be willing to talk to a counselor or go to a support
group?”
If Mr./Ms. XYZ smokes, drinks alcohol, eats fatty food, does not exercise, uses
recreational drugs, has multiple sexual partners, does not use condoms, etc., give
the following suggestions:
“Mr./Ms. XYZ, I have noticed that you__ (address the problem).”
“Are you willing to quit? If you need any more help from me, just let me
know. I’ll be glad to help.”
“Ms. XYZ, do you have any concerns or questions you’d like to ask before I go?”
“OK then, I’m glad that I was able to work with you. We will try to make you feel
better.”
“Thanks for your cooperation and have a good day.”
Documentation of Case Print
Documentation of History
History of present illness
Write present history and positive/negative symptoms
(HPI)
Review of systems
Include pertinent positive/negative associated symptoms
(ROS)
Include past medical conditions diagnosed by doctor and
Past medical history psychiatric conditions
(PMH) Include ob/gyn history in women
Include birth and developmental history in children
Past surgical history
Include previous operations (including cesarean sections)
(PSH)
Medications Include overthecounter and prescription medications
Allergies Include drug allergies and the patient's reaction
Family history Include parents and siblings (if pertinent)
Include occupation (if pertinent) and support system (who
patient lives with)
Social history Include smoking, alcohol, and illicit drug use history
Outside stressors that may be causing symptoms (eg, work,
relationship)
Documentation of Physical Examination
Always write vital signs first.
Give a brief comment about patient's general appearance.
General tips
Then focus on main systemic examination noting abnormal
and relevant positive/negative findings.
Always write the most specific tests first.
List tests in order of priority.
Write all related tests in a single line (eg, CBC, ESR).
Investigations Do not write referrals or consultations.
Do not write prescriptions.
Recommend breast, renal, pelvic, or genital examinations
(if needed).
Vital signs Temperature, blood pressure, pulse, and respiratory rate
Head
Normocephalic and atraumatic (NCAT)
Eyes
Pupils equally round and reactive to light (PERRLA)
Visual acuity 20/20 with intact visual fields
Extraocular muscles intact (EOMI)
Fundi without papilledema, lesions, or exudates
Conjunctiva without erythema
No icterus
Ears
Pinnae without inflammation or tenderness
HEENT Tympanic membranes intact without erythema or effusion
Weber midline, Rinne with air conduction > bone conduction
(AC > BC)
Hearing grossly intact bilaterally
Nose
Septum midline with patent nares
No nasal polyps or lesions
No sinus tenderness to palpation
Throat
Oropharynx clear without tonsillar erythema or exudates
Uvula midline
Normal dentition and gums without ulcers or lesions
Supple without lymphadenopathy or thyromegaly
Neck Carotid pulse 2+ without jugular venous distention (JVD)
Trachea midline without accessory muscle use
No chest wall lesions, scars, or tenderness to palpation
Fremitus symmetrical
Lungs/chest Resonant to percussion bilaterally
Clear to auscultation bilaterally with vesicular breath sounds
No wheezes, crackles, or rhonchi
No visible heaves or lifts
Heart Point of maximal impulse (PMI) at 5th intercostal space in left mid
clavicular line
Normal S1 and S2 without murmurs, gallops, or rubs
Nondistended without scars, bruises, or visible pulsations
Normoactive bowel sounds throughout without bruits
Tympanic to percussion in all 4 quadrants
Abdomen
Soft and nontender with no rebound tenderness or peritoneal signs
No hepatosplenomegaly
No costovertebral angle (CVA) tenderness
No cyanosis, clubbing, or edema
Extremities
Pulses 2+ bilaterally throughout
Patient is alert and oriented to person, place, and time
Cranial nerves (CN) IIXII intact
Motor 5/5 bilaterally in all muscle groups
Neurologic Sensory grossly intact bilaterally
Deeptendon reflexes (DTR) 2+ bilaterally, downgoing toes bilaterally
Gait normal without dysmetria or dysdiadochokinesia
Normal Romberg test
No pain or tenderness to palpation in all joints
Musculoskeletal Normal range of motion (ROM) in all joints
No abnormalities in spine or paraspinal tenderness to palpation
Case Investigation Print
These are the common investigations that you should keep in mind while writing Pt
notes.

HEENT
Xray, CT, MRI of head
Eye Snellen's chart, Visual acuity
Ear Complete audiometry and tympanometry, Culture/Sensitivity for any discharge
Routine CBC with diff, ESR
CNS
Xray, CT, MRI
Lumbar puncture
Carotid Doppler study
EEG
Electromyography and Nerve conduction studies
Echocardiogram for suspected embolic phenomena
Musculoskeletal
Xray
Joint aspiration for culture/ sensitive, cytology, crystals
Rheumatic factor, HLAB27,
Serum uric acid levels
Antinuclear antibodies, anti dsDNA
Muscle biopsy
CVS
EKG and echocardiogram
Cardiac enzymes (CPKMB, Troponin, LDH)
Chest Xray
Lipid profile
Thyroid screen
Serum electrolytes
Respiratory
Chest Xray
Sputum studies (culture/sensitivity, gram stain, AFB)
Pulmonary function tests and spirometry
PPD
ABG and pulse oximetry
Abdominal
Abdominal Xray
Ultrasound of abdomen
LFTs
CT abdomen/pelvis
Upper GI seriesBarium swallow, endoscopy, ERCP
Lower GI series enema, Colonoscopy
Test for fecal occult blood/rectal examination
Pancreatic enzymes (amylase, lipase)
Renal function tests
Endocrine
Blood sugar
Serum electrolytes
Serum calcium
Thyroid screen T4/T3/TSH
24hr urinary catecholamines and metabolites
Urine for ketones and sugar
Psychiatry
CBC and ESR
CT and MRI of brain
Thyroid screen
Electrolytes
Urine analysis
Drug screen / HIV
Challenging Qs Print
Challenging Questions
During your patient encounter, you may be asked some questions that catch you off
guard. These questions may be about the patient's fears and concerns or may simply
reflect the patient's curiosity. Such questions are intentionally included to assess your
communication and counseling skills, as well as your concern for the patient.
The scenarios and challenging questions below can provide a good idea of the kinds of
questions you may encounter in the examination. Keep in mind that although these cases
are similar to those in the examination, you may be asked about a different case with a
different challenging question. Your objective is to be familiar with these kinds of cases
and questions rather than to simply memorize them.
Using the examples below as a guideline and not as a script will give you an idea of how
to respond to such questions.
General tips
Expect the unexpected and adapt to the best of your ability.
Keep your composure and do not panic if you do not know the answer.
To give yourself more time to think about a question (translation: stalling
tactic), you can start by saying, “That's a very good question,” and analyze
the question as you speak.
Always look confident and speak with conviction.
Once you have answered the question to the best of your knowledge, make
sure that the patient is satisfied with your reply.
Ask, “Did I address that particular concern or question of yours?” or
“Do you have any more questions?”
Patients who want a diagnosis or medical opinion
Some patients may ask for a diagnosis or your “expert opinion” during the encounter.
Just answer the question to the best of your knowledge.
Explain why one diagnosis is more likely than others. If you are not sure about the
diagnosis, don't panic.
Calmly explain that there are several causes that could be responsible for symptoms
and that further investigation is required.
Make sure the patient has an adequate support system before giving a definite life
altering diagnosis.
Patient: “Do I have Alzheimer's disease?”
Response
“Alzheimer's disease is certainly a possibility. However, there
Demented
are also other conditions that can cause memory difficulties,
patient
such as thyroid problems or vitamin deficiencies.”
“We need to first do some blood tests and then I can give you a
better idea of what may be going on.”
Patient: “Do you think I have HIV?”
Patient with
Response
suspected HIV
(eg, fever, "You do have some risk factors for HIV, which can cause some
chronic of your symptoms."
diarrhea, weight "However, there are other treatable conditions that may cause
loss) these symptoms."
"We need to do some blood tests, including an HIV test, before
meeting again to discuss the results."
Patient: “Am I having a heart attack? Am I going to die?”
Response
Chest pain “Your symptoms and physical examination findings don't
patient with suggest a heart attack.”
suspected “Your symptoms are more consistent with inflammation of the
pericarditis heart membranes.”
“We need to do some blood tests, an ECG, and possibly an
echocardiogram.”
Patient: “Do you think I've had a stroke?”
Response
Patient with “At this point, I don't know the exact cause of your symptoms.”
weakness or “A stroke is a possibility, but there could also be other causes
numbness such as a pinched nerve, infection, spinal injury, etc.”
“I need to order some blood work and imaging studies before I
can tell you for sure.”
Patient: “Do you think this is colon cancer?” or “Do you think I'll
get colon cancer too?”
Elderly patient
Response
with
“Your family history does increase your chance of colon cancer,
constipation and
but constipation can also be due to medication side effects,
significant
thyroid problems, etc.”
family history of
“I want to do a very thorough investigation with blood work and
colon cancer
imaging studies before discussing diagnosis and treatment
options.”
Patient: “Do you think I'm just getting old?”
Response
“Age could play an important role in decreased sexual
Elderly patient function.”
with erectile “However, there are also certain reversible causes that could
dysfunction be causing your problem such as medications, diabetes, and
high blood pressure.”
“I would first like to do some blood tests to rule these out and
then discuss treatment options with you.”
Patient: “Do you think I need surgery?”
Response
“I understand you might be anxious or scared about possible
Acute
surgery, just like most patients.”
appendicitis
“I cannot be sure yet that you will need surgery.”
patient
“I would first like to order some blood tests and imaging
studies to evaluate you further and we can then discuss
treatment options.”
Patient: “Do you think I need surgery?”
Response
“I'll need to order some imaging tests first to see what is
Chronic back
causing your back pain.”
pain patient
“If it can be treated using medication, we will give you pain
medication first.”
“Otherwise, surgery may be an option.”
Patient: “Do you think I'm going to lose my baby?”
Response
Pregnant
“Losing your baby can cause bleeding, but there are many
patient with
causes of vaginal bleeding in a pregnant patient.”
vaginal bleeding
“I will need to do some blood tests and imaging to see what is
causing the bleeding.”
Patient: “What's causing this? Is it my thyroid?”
Patient with
Response
palpitations and
“Thyroid problems can cause palpitations in addition to other
a family history
conditions such as heart disease.”
of thyroid
“I'll need to run some tests first before discussing your
problems
diagnosis and treatment options.”
Sensitive issues
Some patients may have concerns that prevent access to adequate health care such as
financial constraints, confidentiality issues, personal fears, etc.
Express empathy for the patient regardless of how trivial the issue may seem.
Healthcare promotion is more effective with adequate doctor and patient satisfaction.
Patient: “Should I tell my wife? I'm scared.”
Response
“It can be very uncomfortable and difficult to discuss your
medical condition.”
HIV patient
“It's usually better to tell the truth since your wife may also be
infected with HIV and needs testing.”
“If you'd like, I can help you with the process of informing and
testing her.”
Patient: “I don't have insurance and can't afford an operation.
Do I really need surgery? Are there other options?”
Acute Response
appendicitis “I understand your concerns, but surgery is really the best
patient option for your condition.”
“The hospital has a social worker who can see what financial
assistance the hospital can offer you.”
Patient: “Do you think my insurance will cover these
Patient needing
expenses?”
extensive
Response
laboratory
“I'm not sure if it will or not since I don't have that information
workup or
right now.”
diagnostic
“However, our social worker can help evaluate your situation.”
procedures
“I can also write a letter to your insurance company describing
the procedure and its importance to your health to see if it will
cover the costs.”
Patient: “Do you think my partner is cheating on me?”
Response
“Since the disease is transmitted sexually, the most likely
STD patient with
possibility is from your sexual partner.”
a single sexual
“It's a possibility that your partner obtained it from somebody
partner
else. It would be best if you both discuss this further.”
“I would like your partner to also get treated to prevent
reinfection.”
Patient: “Will I ever get better?”
Response
Patient with
“Your problem could be due to many causes such as a thyroid
chronic fatigue
problem, anemia, etc.”
and nonspecific
“I need to first investigate with blood work to rule out possible
pain
causes before going over treatment options.”
“We will then see how you do from there.”
Medication issues
Standardized patients sometimes ask about medications, their proper use, and side
effects.
It is important that you answer these questions confidently and with conviction.
If you are not sure, inform patients that you will look up the information and let them
know.
Patient: “I'm tired of this medication. I want to switch to an
herbal medication.”
Response
Elderly patient
“Chronic pain can be very frustrating, and I understand that you
with chronic
are not happy with your current treatment.”
osteoarthritis of
“Herbal medications may help some people, but the studies are
the knee
somewhat limited.”
“I will look at some of these studies and get back to you after
reviewing them.”
Menopausal
Patient: “Can I go on hormone replacement therapy?”
patient with hot
Response
flashes and
“You're certainly a candidate for hormone replacement therapy,
strong family
since HRT is indicated for the treatment of hot flashes.”
history of breast
“However, HRT may increase your risk of breast cancer.”
cancer
Patient: “I've had this before. Can't you just give me
antibiotics?”
Response
Patients with “Your symptoms and examination are more consistent with a
apparent viral likely viral infection.”
upper “Antibiotics treat bacterial infections and are not effective
respiratory tract against viruses.”
infection “Giving antibiotics repeatedly for viral infections may lead to
increased resistance to the drugs in the future.”
“Antibiotics can also cause side effects such as diarrhea and
nausea.”
Explaining medical jargon
It is best to avoid using medical jargon while talking to the patient.
Medical jargon creates a feeling of alienation or unfamiliarity and can distance you from
the patient.
If you accidentally use a medical word, explain it in simple terms.
Patient: “A colonoscopy? What's that?”
Response
“A colonoscopy involves placing a tube with a camera from
Patient in need
below (in the rectum) to take a look at the whole intestine on a
of colonoscopy
television screen.”
“If there are any growths, called polyps, they can be cut out
and examined under a microscope.”
Difficult patients
These patients may be angry, demanding, or very impatient and prevent you from
having an effective and meaningful interaction.
Do not disregard these statements/questions even though they may be annoying.
Always try to resolve the situation first (ie, calm the patient down) in order to
effectively discuss the medical problem.
Patient: “Stop asking me these stupid questions. I'm in pain, so
just give me pain medications.”
Patient with Response
acute abdominal “I understand that you're in a lot of pain right now.”
pain “However, I need to ask you a few questions first and quickly
examine you to get a better idea of what is going on.”
“I can then decide which therapy is best to decrease your pain.”
Patient: “I've been waiting for a long time. What took you so
long?”
Response
Demanding “I'm very sorry that you had to wait so long.”
patient “I had some complications with my other patients that took
longer than expected to treat.”
“Let's discuss what is going on and I'll try to help you as much
as I can.”
List of Cases Print
Practice Cases
Contents
Case 1: 30year
History taking old female
complaining of
Physical Examination Abdominal Pain
Physical Exam Videos Case 2: 27year
old female
Closing the encounter complaining of
rash
Documentation of Case
Case 3: 65year
Case Investigation old female
complaining of
Psychiatry History taking arm and leg
weakness
Pt Notes
Case 4: 29year
Abbreviations old female known
sickle cell
Miscellaneous anemia pt c/o
chest pain
Key to Success
Case 5: 35year
Communication Skills old male with
recent onset
Guidance for better cough
practice
Case 6: 50year
On the Day of Exam old
male complaining
CSA FAQ of fatigue and
loss of weight
Sample Cases
Case 7: 35year
Alcoholism old male with
acute onset
Back pain diarrhea
Confusion Case 8: 25year
old female
Chest Pain complains of
sore throat
Chronic Cough
Case 9: 56year
Chronic Diarrhea old male for BP
check and refill
Dark urine of the
medications
Depression
Case 10: 66
Diabetic Drug Refill yearold male
complaining of
Dizziness constipation
Case 11: 50
Domestic Violence yearold male
complaining of
Enuresis impotence
Forgetfulness/Alzheimer's Case 12: Mother
of 1 Yr. O/Baby
Headache With Fever
Heel pain Case 13: 45
yearold female
Hemoptysis c/o acute, right
upper quadrant
Insomnia abdominal pain
Menopause Case 14: 24
yearold female
Night sweats came for prenatal
visit for the first
Obesity time
Preemployment checkup Case 15: 60
yearold male
Shoulder pain complaining of
acute shortness
of breath
Spells
Case 16: 40
Vaginal Bleeding
yearold female
with increased
Vomiting
urination
Terminal cancer
Case 17: 35
yearold female
Telephone Encounter for evaluation of
jaundice
Other
Case 18: 35
Palpitations yearold female
complaining of
Counseling Chest Pain
Other imp Cases Case 19: 45
yearold male
complaining of Rt
lower abdominal
pain
Case 20: 55
yearold male
with bilateral leg
pain
Case 21: 40
yearold male
with vomiting of
blood
Case 22: 55
yearold male
complaining of
Chest Pain
Case 23: 70
yearold male
complaining of
Frequent Falls
Case 24: 35
yearold male
complaining of
cough and chest
pain
Case 25: 60
yearold male
complaining of
lower abdominal
pain
Case 26: 35
yearold male
complains of
fatigue
Case 27: 65
yearold female
complaining of
loss of hearing
Case 28: 53
yearold male
with right knee
pain and swelling
Case 29: 50
yearold male
with blurred
vision
Case 30: 32
yearold female
with multiple
bruises
Case 31: 20
yearold female
with burning
urination
Case 32: 50
yearold male
with difficulty
swallowing
Case 33: 30
yearold male for
HIV drug refill
Case 34: 16
yearold female
with amenorrhea
Case 35: 35
yearold female
with acute right
lumbar and lower
abdominal pain
Case 36: 70
yearold male
with insomnia
Case 37: 65
yearold male
patient with
difficulty
urinating
Case38: 45year
old female
complains of
breathlessness
and anxiety
Case 39: 53
yearold male
with a long
history of
epigastric pain
Case 40: 45
yearold male
complaining of
bloody vomiting
Case 41: 60
yearold male
complains of
dizziness
Case 42: 30
yearold male
with new onset of
seizure
Case 43: 23
yearold male
with rectal
bleeding
Alcoholism Case Print
Doorway information about patient
The patient is a 55yearold man brought in by his wife to
discuss ways for him to stop drinking alcohol.
Vital signs
Temperature, 98.0 F (36.7 C)
Blood pressure, 110/70 mm Hg
Heart rate, 80/min
Respiratory rate, 14/min
History
When did you start drinking alcohol?
On average, how many drinks do you have a day?
On average, how many days a week do you drink?
Have you ever tried to cut down on your drinking?
Has anyone ever criticized your drinking?
Have you ever felt bad or guilty about drinking?
HPI Have you ever had a drink first thing in the morning?
How do you feel about yourself?
Have you had any mood changes?
Do you get anxious over small things?
Have you ever had seizures or fits?
If you don’t drink for 23 days do you get any shakes (tremors)?
Do you have any other complaints?
Do you have any other medical problems (eg, diabetes mellitus,
Past medical
peptic ulcer disease)?
history
Have you ever been admitted to a hospital?
Do you take any medications (prescription and overthecounter)?
Medications/
Are you allergic to any medications?
allergies
If so, what reaction do you have?
How old are your father and mother?
Family history
Do they have any medical conditions?
Who do you live with?
What kind of work do you do?
Do you have any marital or sexual problems?
Social history Have you had any family problems?
Do you have any financial problems?
Do you smoke?
Do you use recreational drugs (IV drugs)?
Wash your hands.
General Perform proper draping techniques.
Examine without the gown, not through the gown.
Skin Look for evidence of cirrhosis (eg, telangiectasia, jaundice).
Examine the conjunctiva for pallor and jaundice.
HEENT
Examine the oral cavity and dentition.
Auscultate lungs for adventitious sounds and heart for murmurs or
Lung/heart
gallops.
Inspect for ascites or signs of cirrhosis (eg, caput medusae).
Auscultate for bowel sounds.
Abdomen Percuss the abdomen looking for shifting dullness if ascites present.
Check for hepatomegaly.
Palpate abdomen and for hepatic tenderness.
Extremities Check for cyanosis, clubbing, or edema.
Conclusion
Summarize history and findings.
Counsel patient on the following:
Review the quantity and frequency of current
drinking.
Explain the risks associated with alcoholism.
Explain patient's responsibility to reduce or stop
drinking.
Set up a drinking diary.
Motivate the patient by discussing available
resources/support groups.
Schedule a followup appointment.
Investigations
CBC
Liver function tests
Gammaglutamyl transpeptidase (GGT)
Backpain Case Print
The patient is a 60yearold woman who comes to the clinic
complaining of 2 months of back pain.
Vital signs
Heart rate, 90/min
History
When did the pain start?
Can you show me exactly where the pain is?
What were you doing when the pain began?
On a scale of 1 to 10, how severe is the pain?
Please describe the pain (eg, sharp, burning, crushing, heavy).
Does this pain wake you up at night?
Does anything make the pain better?
Does anything make the pain worse?
HPI Does it move anywhere, such as your legs?
Do you have any numbness or tingling in your legs?
Do you have any weakness in your legs?
Are you able to control your urine or have you had any accidents?
Are you able to control your stool or have you had any accidents?
Have you had a fever?
Have you had any trauma to your back?
How is your appetite?
Have you lost any weight?
Have you had a similar problem before?
When was it diagnosed and treated?
Have you had any bone fractures?
Do you have any other medical problems (especially cancer or recent
Past medical
infection)?
history
Do you have pain in any other joints?
Are you in menopause?
Have you had any hormone replacement therapy?
Have you used any steroid medications?
Medications/
allergies
Family history
How old are your brothers and sisters?
Do you smoke? At what age did you start and how much do you
Social history
smoke?
Do you drink alcohol, including beer? How much and how often?
Wash your hands.
Test motor strength of lower extremity.
Evaluate sensory function of lower extremity.
Neurologic Test lowerextremity reflexes.
Perform straightleg test.
Evaluate patient's gait.
Palpate back for spinal or paraspinal tenderness.
Musculoskeletal
Evaluate range of motion of lumbar spine.
Extremities Check lowerextremity pulses.
Conclusion
Explain physical examination findings.
Explain differential diagnosis.
Explain the next steps in workup.
Suggest rangeof motion exercises for back.
Set up followup appointment.
Investigations
Back xrays.
Consider MRI of back.
ESR.
Chest Pain Case Print
The patient is a 65yearold man who comes to clinic with 1
day of episodic chest pain.
Vital signs
Heart rate, 90/min
History
When did the chest pain begin this time?
Do you still have the chest pain or has it resolved?
For active chest pain
What were you doing when the pain began?
Can you think of anything that may have caused the pain?
For resolved or intermittent chest pain
How long ago did the chest pain episodes begin?
How often do the episodes occur?
How long do the episodes last?
What brings on the pain (eg, walking, exertion)?
How far can you walk before you develop chest pain or
shortness of breath?
Point with 1 finger to your chest to show me where the pain is.
HPI
Does it move anywhere else?
On a scale of 1 to 10, how severe is the pain?
Describe the pain (eg, sharp, burning, crushing, heavy).
Does anything make the pain worse?
Do you have any other symptoms associated with the pain (eg,
shortness of breath, palpitations, nausea, vomiting, sweating,
lightheadedness)?
Have you had a fever?
Have you had a cough?
Have you had any recent chest trauma?
Do you have any swelling in the legs?
Do you have leg pain while walking?
Past medical
Have you been diagnosed with any other medical conditions by a
history
doctor (eg, high blood pressure, diabetes, heart problems, high
cholesterol)?
Medications/
allergies
Family history How old are your brothers and sisters?
Social history
smoke?
Wash your hands.
HEENT Examine the conjunctiva for pallor.
Assess jugular venous pressure.
Palpate PMI and note location.
Cardiac
Auscultate for murmurs, rubs, or gallops.
Listen to neck for carotid bruits.
Lungs Auscultate lungs.
Check peripheral pulses.
Extremities
Examine lower extremities for edema.
Conclusion
Explain possible admission to the hospital.
Differential diagnosis
Acute coronary syndrome
Pericarditis
Aortic dissection
Pulmonary embolism
GERD
Costochondritis
Anxiety
Investigations
EKG
Cardiac enzymes
Chest xray
ECHO
Fasting lipid panel
Blood pressure in both arms
ABG (if patient has dyspnea)
V/Q scan if high suspicion for PE
Chronic Cough Print
The patient is a 35yearold man who comes to the clinic
complaining of episodes of coughing for 3 months.
Vital signs
Heart rate, 90/min
History
When did the cough start (acute cough < 3 weeks, chronic cough > 3
weeks)?
Is it a dry cough or does it bring up some sputum?
What color is the sputum?
Has there been blood in the sputum at any time?
Is there anything that makes your cough worse?
Is there anything that makes your cough better?
Have you noticed any dripping sensation in your throat or the
frequent need to clear your throat (postnasal drip)?
Do you have any facial pain or tooth pain (sinusitis)?
HPI Do you get short of breath?
Have you noticed any wheezing? Any nighttime wheezing?
Have you had frequent heartburn, regurgitation, or sour taste
(GERD)?
Do you have any chest pain?
Do you have any pets?
Did you buy any new furniture recently?
Does your cough get worse when you are at your workplace?
Have you had a fever? Chills? Night sweats?
Have you lost any weight? How is your appetite?
Have you been exposed to anyone who has tuberculosis?
Past medical When was it diagnosed and treated?
history Have you been diagnosed with any other medical conditions by a
doctor (eg, allergies, asthma, frequent sinus infections)?
Medications/ Look for ACE inhibitors specifically.
allergies Are you allergic to any medications?
Family history
Social history
smoke?
Wash your hands.
Examine oropharynx for any lesions.
Examine nasal passages for inflammation, masses, or polyps.
HEENT/ neck
Palpate sinuses to assess for tenderness.
Palpate for enlarged cervical lymph nodes.
Cardiac Auscultate for murmurs, rubs, or gallops.
Palpate to assess for symmetrical fremitus.
Lungs Percuss to assess resonance.
Auscultate lungs.
Abdomen Look for hepatomegaly
Extremities Look for peripheral edema
Conclusion
Postnasal drip syndrome and sinusitis
Asthma
GERD
Chronic bronchitis
Bronchiectasis
Cough secondary to ACE inhibitors
Malignancy
Cough secondary to occupational exposure
Tuberculosis
Investigations
CBC with differential
Chest xray
Sputum Gram stain/AFB and culture, as needed
Pulmonary function tests, as needed
Highresolution CT scan, as needed
Confusion Case Print
The patient is a 65yearold man who is brought to the clinic
by his wife for 23 months of confusion.
Vital signs
Heart rate, 80/min
History
Your wife is concerned about your being confused. Does this happen
all the time?
Are there any specific times or situations that cause this confusion?
Do you notice any problems with your memory?
Has your wife noticed any problems with your memory?
Have you had any weakness in your arms or legs?
Have you had tingling or numbness in your arms or legs?
Have you had any episodes of dizziness?
Have you ever had any jerky hand movements or seizures?
Do you have any history of head trauma?
Have you had any fever?
HPI
Do you have headaches?
Have you ever passed out?
Have you had diarrhea or constipation?
Have you had problems with urination?
Are you able to do your daily activities such as dressing, eating,
walking, and personal hygiene (eg, bathing)?
Are you able to go shopping?
Are you able to do any housework?
Are you able to drive?
Are you able to cook or prepare food?
Please describe a typical day.
Past medical
history
doctor (eg, diabetes, HTN)?
Have you had any surgeries?
Medications/
allergies
Family history
Social history
smoke?
Have you use recreational drugs (IV drugs)?
Wash your hands.
HEENT Palpate for lymphadenopathy or thyroid enalrgement.
Adomen Palpate for masses and tenderness.
Perform mini mental status examination.
Examine cranial nerves relatively quickly.
Neurologic
Test gait and reflexes.
Evaluate muscle strength and conduct gross sensory examination.
Conclusion
Trasnient ischemic attack
Multiinfarct dementia
Electrolyte abnormalities
Medications
Alzheimer's dementia
Investigations
Urinalysis
Basic metabolic panel, TSH
ECG
CT scan of the head
Carotid Doppler
Chest xray
Dark urine Print
complaining of dark urine for 5 days.
Vital signs
Heart rate, 74/min
History
Describe what you mean by dark urine.
When did you first notice the dark urine?
Is/was there any blood in the urine?
Is it consistently the same color throughout the day?
Have you noticed a decrease or increase in the quantity of urine each
day?
Do you have any pain associated with urination?
Have you had any abdominal pain or back pain?
HPI Have you had any fever or chills?
Do you have any nausea or vomiting?
Do you have any diarrhea?
Have you eaten anything (eg, berries, colored candy, or beets) that
could cause this change in color?
Have you had any recent injury/trauma?
Do you do heavy exercise?
Have you had any recent infections, such as a sore throat?
Have you had any previous urinary or kidney problems?
Past medical
history
Medications/
allergies
Family history
Social history Do you smoke? At what age did you start and how much do you
smoke?
Have you used recreational drugs (IV drugs)?
Wash your hands.
HEENT Examine the oropharynx.
Abdomen Palpate both superficially and deeply.
Examine for CVA tenderness.
Conclusion
Glomerulonephritis
Benign familial hematuria
Exerciseinduced
Kidney or bladder stones
Urinary tract infections
Tumors of the kidney and bladder
Acute tubular necrosis
Rhabdomyolysis
Medicationinduced
Foodinduced
Investigations
Urinalysis
Creatinine phosphokinase
Basic metabolic panel
Cystoscopy depending on above results
CT scan of the abdomen depending on above
results
Depression Case Print
stating that she feels “down.”
Vital signs
Heart rate, 90/min
During the entire patient encounter, the SP will be in a disinterested mood and talk in a feeble
voice. The doctor should always make eye contact with the patient. The bored responses
from the patient should not frustrate the doctor.
History
What brings you in today?
How long have you been feeling this way?
Is there anything in particular that has brought this on?
Do you have anybody to talk to you when you feel down?
How's your appetite?
Have you lost or gained any weight recently?
Are you having any trouble falling asleep or staying asleep?
Do you feel guilty about anything?
Do you feel abnormally tired?
Tell me about your daily routine.
What are your hobbies and interests?
Do you have trouble concentrating?
Do you find yourself forgetting things?
HPI
What's your favorite thing to do?
Are you still feeling that way?
Have you ever felt like life wasn't worth living?
Have you ever thought about hurting yourself?
Do you ever think about how you would do it?
Do you have guns or pills at home?
Do you feel cold if everyone else appears comfortable in the room?
Are you losing any hair?
Are your bowel movements regular?
Have you had any shortness of breath?
Do you hear or see things that other people don't?
Are you willing to get help from a counselor?
Would you talk with a counselor if I set it up?
Past medical
history
Medications/
allergies
Family history
Social history
smoke?
Do you drink alcohol or beer? How much and how often?
Wash your hands.
Neck Examine the thyroid.
Lungs Auscultate for breath sounds.
Abdomen Palpate for any masses and tenderness.
Check reflexes, noting any delayed relaxation phase.
Neurologic
Perform MMSE (mini mental status examination) in elderly.
Conclusion
Depression
Hypothyroidism
Anemia
Investigations
Serum TSH
Comprehensive metabolic panel (CMP)
Diabetic Drug Refill Print
The patient is a 50yearold man who comes to the clinic for
refill of his diabetes medications.
Vital signs
Heart rate, 74/min
History
When were you diagnosed with diabetes?
Are you currently taking any medications for diabetes?
Are you taking your medications regularly?
Do you think that your medicine is effectively controlling your
diabetes?
Have you ever taken insulin?
Do you check your blood sugar regularly?
What is the usual range of your blood sugar?
Do you have any problems that you would like to talk about?
Have there been any changes in your vision?
When was your last eye examination?
HPI
Do you feel any abnormal sensations in your legs (pins or needle
prick sensations, tingling, or numbness)?
Have you ever had any chest pain?
Do you have any breathing problems?
Are you sexually active?
Do you have any problems during sexual intercourse?
Do you have regular bowel movements?
Do you have any problems with urination?
Have you lost or gained any weight lately?
Have you had your urine tested for protein?
Past medical
doctor (eg, HTN)?
history
Have you had any surgeries before?
Do you take any other medications (prescription and overthe
Medications/ counter)?
allergies Are you allergic to any medications?
Family history
Social history
smoke?
Wash your hands.
HEENT Examine the fundi for retinopathy.
Neck Auscultate for carotid bruits.
Palpate for PMI.
Cardiac
Auscultate for murmurs, rubs, or gallops.
Conduct sensory examination on both feet (ask SP to remove shoes
Neurologic/
and socks if they are on).
extremities
Check distal pulses in at least 2 places in lower extremities.
Conclusion
Explain preventive diabetes care.
Investigations
CBC with differential count
Spot urine protein, creatinine ratio
HbA1C
BUN and serum creatinine
Lipid profile
Chronic Diarrhea Print
complaining of 4 weeks of diarrhea.
Vital signs
Heart rate, 86/min
History
Please explain what you mean by diarrhea.
How many times a day are you going?
Do you have a large volume or small volume?
When did the diarrhea start (differentiate between acute and
chronic)?
What is the pattern of diarrhea? Do you have episodes of normal
bowel movement in between (continuous or intermittent)?
How often do you have diarrhea?
Does the stool have blood?
Is there pus or mucus in the stool?
Is the diarrhea greasy with fat on top?
HPI
Do you have abdominal pain (inflammatory bowel disease and
irritable bowel syndrome)?
Have you lost weight (malabsorption or malignancy)?
Is the diarrhea triggered by anything you are eating (eg, milk
products for lactose intolerance)?
Have you had increased stress recently?
Does anything make your diarrhea worse?
Does anything make your diarrhea better?
Do you have a history of recent travel?
Do you have any sick contacts?
Have you had fever or chills?
Past medical Have you been diagnosed with any other medical conditions by a
history doctor (eg, diabetes, HTN)?
Have you been exposed to any radiation in the past?
Medications/
allergies
Social history
smoke?
Wash your hands.
Examine oropharynx for any lesions.
HEENT/
Palpate neck for enlarged cervical lymph nodes, thyromegaly, and
Neck
masses.
Adomen Percuss for bowel gas pattern.
Palpate abdomen both superficially and deeply.
Conclusion
Secretory diarrhea (bacterial toxins, ileal bile
acid malabsorption, endocrine diarrhea)
Osmotic diarrhea (osmotic laxatives,
carbohydrate malabsorption)
Inflammatory diarrhea (inflammatory bowel
disease, infectious diseases Giardia)
Fatty diarrhea (celiac disease, short bowel
syndrome)
Investigations
FOBT
Comprehensive metabolic panel
Serum TSH
Stool studies (eg, WBC, O+P)
Dizziness Case Print
complaining of episodes of dizziness.
Vital signs
Heart rate, 90/min
In real life (as well as in the Step 2 CS), evaluating a patient with dizziness can be challenging
and frustrating for the clinician. “Dizziness” is a nonspecific term. Patients complaining of
dizziness may be experiencing vertigo, nonspecific “dizziness,” disequilibrium, presyncope, or
nearsyncope. It is therefore very important to obtain an extensive history to narrow down the
differential diagnosis.
History
How long have you had these dizzy spells?
Describe an episode and what you mean by dizziness.
Do you feel that the room is spinning?
How long does the episode last?
How often are you having episodes?
What brings on an episode?
What makes the symptoms better?
What makes the dizziness worse once it starts?
When did the dizziness first occur?
Do you have any warning signs that the episode is about to start?
Does it occur at any particular time of the day or night?
Do changes in position (eg, getting up out of a chair) make you
dizzy?
When you get dizzy, do you have a tendency to fall? To which side?
HPI
Have you ever lost consciousness?
Do you have loss of balance when walking?
Have you had any headaches when you get dizzy?
Have you had any nausea or vomiting when you get dizzy?
Have you had a feeling of your heart racing when you get dizzy?
Have you had shortness of breath?
Have you had feelings of panic when you get dizzy?
Have you noticed any difficulty with your hearing?
Do you hear any ringing or buzzing noise in your ears?
Do you have any problems with double or blurry vision?
Have you ever noticed any weakness in your arms or legs?
Do you have any numbness in your face, arms, or legs?
Do you have any problems with your bowel movements?
Do you have any problems with urination?
Have you had similar a problem before?
Past medical When was it diagnosed and treated?
history Have you been diagnosed with any other medical conditions by a
Medications/
allergies
Family history
Social history
smoke?
Do you drink alcohol or beer? How much and how often?
Wash your hands.
Vital signs Check for orthostatic hypotension.
Gross hearing test (if history of hearing loss), Rinne, Weber
HEENT
Otoscopic examination (if history of tinnitus or ear discharge)
Examine the thyroid.
Neck
Auscultate for carotid bruits.
Check for nystagmus while doing DixHallpike maneuver.
Neurologic Check gait and Romberg.
Check dysmetria and dysdiadochokinesia (cerebellar tests).
People with dizziness are often reluctant to move because of the fear of falling although they
are able to walk. Before you check the gait or perform a Romberg test, say “I can imagine
how uncomfortable it is, but I am here to assist you. I will help you in every aspect of the
examination. This won't take more than a couple of minutes.”
Conclusion
Benign positional vertigo
TIA
Stroke
Postural hypotension/orthostatic hypotension
Arrhythmias
CNS tumors/Meniere's disease
Druginduced/polypharmacy
Nonspecific dizziness
Peripheral neuropathy
Thyroid abnormalities
Anemia
Metabolic disturbances (eg, hypoglycemia)
Investigations
Serum electrolytes
Thyroid function tests
Carotid Doppler if there is a relevant history for
stroke/TIA
MRI of brain for suspected acoustic neuroma or
any CNS tumor
24hour Holter monitoring in patients with
history of palpitations and cardiac disease
Domestic Violence Print
complaining of bruises on her arms and face after falling
down.
Vital signs
Heart rate, 90/min
There are many ways to ask direct questions about domestic violence or an abusive
relationship. However, it is very important to be sensitive and supportive. No single question
is right or wrong, as long as you are sensitive and supportive. In real life, many battered
women are hesitant to initiate information about abuse but are relieved to answer when
someone asks. For this reason, you are expected to recognize these kinds of cases during the
Step 2 CS examination.
History
How did you fall down?
I noticed that you have a number of bruises. Did someone do this to
you? (If the answer is yes, ask the following questions.)
Can you please tell me what happened to you?
Are you currently in a relationship where you are physically hurt,
threatened, or feel afraid?
If so, have you ever been attacked with a weapon?
How long have you been in this abusive relationship?
Has this happened before?
Are you afraid it will happen again?
Has your partner ever made you have sex when you didn’t want to?
You mentioned that your partner loses his temper with you. How are
things between him and your children?
HPI
Does this person you live with use alcohol or drugs?
Have you ever left home? When?
If not, have you ever wished you could leave? What has prevented
it?
Are you planning to leave/divorce your partner?
Has your partner ever threatened or tried to commit suicide?
Do you think of suicide as a way out of the relationship? If the
answer is yes, ask, Do you have a plan or method by which you
would kill yourself or your partner?
Do you have an emergency plan?
Are your friends or family aware of your situation?
During the encounter, tell her repeatedly that she does not deserve
to be beaten. Battering is against the law.
Past medical
history doctor (eg, diabetes, HTN)?
Medications/
allergies
Family history
Social history smoke?
Wash your hands.
Lungs Auscultate for breath sounds.
Abdomen
Palpate for tenderness.
Examine affected body part(s) for bruises.
Skin/extremities
Palpate for any tenderness.
Conclusion
Counsel the patient on the following (a major part of the examination in any abuse
case):
Assure the patient you will do everything possible to maintain her safety.
Assure the patient that her medical condition will be treated appropriately
without forcing her to do anything against her will.
Tell her that her children (if present) will be cared for and kept safe.
Assure confidentiality by explaining that only with her signed consent will
her medical records be released to any other source.
Tell her that violence never ends on its own and that it almost always
escalates in severity and frequency over time.
Explain that the only way to end the abuse is to get away from the abuser.
Always be respectful and nonjudgmental by saying, “I believe you. It’s not your
fault. You’re not crazy and you are not alone. Help is available.”
Before you leave, ask, “Do you think it’s safe to go home? Do you have a safe
place to stay? Would you like to speak with a domestic violence counselor?”
Enuresis Case Print
You will be speaking with the mother of a 5yearold boy
who frequently wets his bed.
History
What brought you in today?
Tell me more about it. Has your son ever been dry at night or has he
started wetting his bed after being dry for a long time?
Does he have any daytime bedwetting?
On average, how many nights a week does your child wet his bed?
How many episodes of bedwetting does he have each night?
How much urine does he void during each episode?
Is there a particular time when these episodes occur?
How much fluid does he take in during the day?
Does he drink a lot of fluid before going to bed?
HPI
Does he ever have to run to the bathroom?
How many times during the day does he urinate?
How much does he urinate each time he goes?
Does he have any difficulty in initiating or stopping the stream?
Does he ever complain of dribbling or burning while urinating?
Does he complain of feeling like he did not completely empty his
bladder?
Does he have any problems associated with bowel movements?
Has this problem affected you and your family?
Is there anything you've tried so far to deal with this problem?
Has he been diagnosed with any other medical conditions such as
diabetes or sickle cell disease?
Past medical Has he had urinary tract infections?
history Has he had any surgeries or injury to his nervous system?
Did he have any problems at birth?
Were there any complications during pregnancy or delivery?
Does he take any medications (prescription and overthecounter)?
Medications/
Is he allergic to any medications?
allergies
If so, what reaction does he have?
Do you or his father have any medical conditions?
Family history How old are his brothers and sisters?
Who does he live with?
Children often wet the bed as a result of some stressful event in their
Social history lives. Are you aware of any incident that could be causing these
symptoms in your son?
Would you describe your son as playful and social or shy and quiet?
Conclusion
Emphasize that bedwetting is a common problem, especially in boys. They usually
do not have any control over it.
Bedwetting does not indicate mental problems, but it can be extremely stressful
and embarrassing for children if they continue to wet the bed beyond the age of 3.
As a result, they may lose self confidence and avoid social situations like
sleepovers at their friends' houses.
Your role as a parent is to be supportive and help your child deal with the
problem.
Here's what you can do:
Monitor your child's fluid intake during the day.
Limit the amount of fluid intake 2 hours before bedtime (ideally it should not
be more than 2 ounces).
Encourage your child to go to the bathroom before going to bed.
Have your child change his pajamas and the bed sheets if he wets them at
night. It is also helpful to have rubberflannel sheets handy to keep the bed
dry.
Another helpful step is to set an alarm clock and have him wake up 23
hours after going to bed. He can then get up and go to the bathroom.
Bedwetting alarms are excellent options for children more than 5 years old.
An alarm is attached to the child's underwear and is triggered by the first
drop of urine.
The child then wakes up and goes to the bathroom to finish urinating.
With time, the child learns to wake up to go to the bathroom when his
bladder is full.
Motivate your child to be involved and reward him when he's “successful.”
Primary enuresis
Secondary enuresis
Investigations
Urinalysis
Urine culture
Forgetfulness Case Print
complaining of episodes of forgetfulness.
Vital signs
Heart rate, 76/min
History
Please tell me more about your memory problems?
Do you have any problems sleeping?
Do you have any trouble eating or preparing meals for yourself?
Do you have difficulty walking?
Are you able to bathe yourself without help?
Do have any problems getting your shopping and housekeeping done?
Are you able to find your way through your house?
HPI Do you have any problems driving to the grocery store?
Do you have any difficulty managing your accounts?
Have you felt sad or lonely?
Do you have any dizzy spells or falls?
Do you feel cold if everyone else in the room feels comfortable?
Do you have any problems urinating?
Have you had any diarrhea or constipation?
Have you noticed any recent weight loss?
Past medical
history
Medications/
allergies
Family history
Who do you live with? Do you have someone to take care of you in
case of an emergency?
smoke?
Wash your hands.
HEENT Examine fundi.
Pulmonary Auscultate for breath sounds.
Perform mini mental status examination.
Do the “get up and go” test.
Neurologic
Check for power and reflexes.
Check for sensations in legs (position and vibration).
Conclusion
Discuss Alzheimer's disease if you suspect it.
Stress the importance of a structured home
environment and precautions for avoiding falls.
Explain the necessity of taking medications
regularly.
Ask about social support and offer help if needed.
Alzheimer's disease
Vascular dementia
Normalpressure hydrocephalus
Vitamin B12 deficiency
Hypothyroidism
Masked depression
Chronic subdural hematoma
Investigations
CT scan of the head
Serum TSH and Vitamin B12 level
Basic metabolic panel (Na, K, Cl, CO2, BUN,
creatinine, calcium)
Syphilis serology (Serum RPR)
Headache Case Print
complaining of episodic headaches.
Vital signs
Temperature, 98.6 F (37 C)
Heart rate, 80/min
History
Please describe what your headache feels like.
How long have you had the headache?
Did the headache come on gradually or suddenly?
Is the headache constant or intermittent?
Please show me exactly where the pain is.
Does it hurt anywhere else, such as your jaw or the back of your
neck?
What were you doing when the headache started?
On a scale of 1 to 10, with 10 being the worst headache of your life,
which number best describes your pain?
Does anything relieve the pain?
Does anything make the headache worse?
Do you have nausea or vomiting?
HPI
Have you ever had this type of pain before? If so, how long did it
last?
Do you have any warning signs (eg, blurry vision, double vision, or
flashes) before the headache starts?
How are these headaches affecting your daily life?
Do you have any fever or chills?
Have you had neck stiffness?
Have you had a runny nose, watery eyes, or scratchy throat?
Have you noticed any ear discharge?
Have you had any head trauma?
Have you had any weakness in your arms or legs?
Have you had any tingling or numbness in your hands or legs?
Have you lost or gained weight recently?
Past medical
history
Medications/
allergies
Wash your hands.
Examine fundi.
HEENT Palpate scalp.
Examine ears to visualize tympanic membrane.
Musculoskeletal Palpate muscles in neck, cervical spine, and shoulder for tenderness.
Examine cranial nerve function.
Evaluate motor and sensory function in arms and legs.
Neurologic Perform Romberg test.
Check dysmetria and dysdiadochokinesia (cerebellar tests).
Assess gait.
Conclusion
Migraine
Tension headache
Cluster headache
Sinus headache
Brain tumor
Subarachnoid hemorrhage/CVA
Meningitis/encephalitis/infections
Temporal arteritis (in elderly patients)
Medications/drugs
Investigations
Sinus xray
CT head without contrast
Heel pain Case Print
complaining of 1 week of left heel pain.
Vital signs
Heart rate, 80/min
History
Please tell me more about your pain?
Where exactly do you feel the pain?
On a scale of 1 to 10, with 10 being the worst, how would you rate
the severity of your pain?
How would you describe the quality of the pain?
When did this pain begin?
When you have the heel/foot pain, do you feel pain in any other part
of your body?
What makes the pain worse?
How long does an episode last and how often do episodes occur?
HPI Have you had any accidents/trauma involving your foot/heel?
Do you stand for long periods during the day?
Do you walk a lot during the day?
Do you have fever?
Do you have joint pain? Where?
Do you have any joint/back stiffness in the morning that improves as
the day goes on?
Have you had diarrhea or other recent illness (for possible reactive
arthritis)?
Have you had any discharge from your penis?
Have you had any eye problems lately?
Have you had any rashes (for psoriatic arthritis)?
Past medical
history
Medications/
allergies
Wash your hands.
HEENT Examine conjunctiva.
Examine entire foot.
Palpate foot for any tenderness.
Evaluate range of motion and have patient dorsiflex and plantar flex.
Musculoskeletal
Palpate tendons during flexion to evaluate for tendinitis.
Examine spine also for range of motion and any tenderness in
sacroiliac joints.
Conclusion
Can recommend the following:
Rest foot for 23 days.
Apply ice to area for 30 minutes 34
times/day.
Use soft heel pads or padded foot splint.
Avoid excess weight on heel.
Try overthecounter ibuprofen for pain
relief.
Plantar fasciitis
Calcaneal periostitis
Calcaneal spurs
Painful heel pad syndrome
Bone tumors
Reactive arthritis and other spondyloarthritides
Investigations
ESR
Xray of foot and ankle, 3 views (if needed)
Hemoptysis Case Print
complaining of cough with blood in his sputum.
Vital signs
Heart rate, 80/min
History
When did you first start coughing up blood?
How often are you coughing up blood?
Was it brightred blood or streaked with sputum? Or rustcolored
sputum?
Are you coughing up a lot or a small amount of sputum?
Is the sputum foulsmelling?
HPI Have you had any chest pain?
Have you had fevers or chills?
Have you had sweats at night that soak your clothes?
Have you been exposed to anyone with tuberculosis?
Have you traveled recently within the US or outside the country?
Have you had any other sick contacts recently?
Past medical
history
Medications/
allergies
Family history
Wash your hands.
HEENT Examine oropharynx.
Neck Examine for cervical lymphadenopathy.
Palpate for symmetrical fremitus.
Lungs Percuss to evaluate for dullness.
Auscultate for breath sounds and adventitious sounds.
Heart Auscultate for murmurs, gallops, and rubs.
Examine for clubbing and cyanosis.
Extremities
Examine extremities for rashes.
Conclusion
Bronchiectasis
Acute or chronic bronchitis
Pneumonia
Bronchogenic carcinoma
Lung abscess
Tuberculosis
Connective tissue diseases (GPA, Goodpasture's
disease, lupus)
Pulmonary embolism
Pseudohemoptysis (hematemesis)
Investigations
Sputum for AFB and Gram stain
Chest xray
Urinalysis
CT of the chest pending above results
Insomnia Case Print
complaining of insomnia.
Vital signs
Heart rate, 80/min
Insomnia is a very common problem with numerous and often concurrent etiologies such as
medical conditions, medications, psychiatric disorders, sleep apnea, and poor sleep hygiene.
The evaluation usually requires a detailed history to narrow down the differential diagnosis.
History
Please tell me more about your sleeping problem.
How long have you been having problems with sleep?
Do you have problems falling asleep?
Do you have any problem staying asleep?
Do you feel tired in the morning when you wake up?
Do you fall asleep during the day?
When do you usually go to bed?
How much time does it take you to fall asleep?
What do you do before you go to bed (eg, exercise)?
Do you drink caffeine before going to bed?
HPI Do you watch television while lying in bed?
Do you wake up with shortness of breath during the night?
Do you wake up at night to urinate?
Do you have any cough at night?
Have you been under more stress recently?
Has there been any recent traumatic event such as a death in the
family?
How is your mood? (If the SP appears depressed, you have to ask
all questions regarding depression.)
Has anyone noticed if you gasp for air or move your legs while
sleeping?
Past medical
history
Medications/
allergies
Family history
smoke?
Social history
Do you drink alcohol, including beer? How much and how often? Do
you drink any alcohol before you go to bed?
Wash your hands.
Examine for thyromegaly.
Neck
Check oral cavity.
Lungs Auscultate for breath sounds and adventitious sounds.
Adomen Palpate for any masses/tenderness.
Extremities Look for edema.
Conclusion
Possible suggestions
Maintain sleep diary to record sleep patterns.
Keep regular bedtimes and wake times, even on weekends and days off
from work.
Limit or stop the use of nicotine, caffeine, and alcohol.
Exercise regularly, but no later than late afternoon or early evening.
Do not use the bed as a place to worry, especially about not sleeping.
Write down all worries and concerns before going to bed and place list on
the dresser to examine the next morning.
Use the bedroom only for sleep. Don't read, watch television, eat, or do
other activities in bed.
Try to avoid daytime naps. But if you must nap, do so in the early afternoon
and for no longer than 30 minutes per day.
Eat a light snack before bedtime if hungry.
Get regular exposure to outdoor sunlight, especially in the late afternoon.
Circadian rhythm sleep disorder
Mood disorder (depression or anxiety)
Periodic leg movements during sleep
Obstructive sleep apnea
Caffeine or alcohol intake at night
Medications
Hyperthyroidism
BPH (if urinary problems exist)
Investigations
TSH and free T4
Complete blood count
Polysomnography
Menopause Case Print
complaining of hot flashes.
Vital signs
Heart rate, 80/min
History
Please tell me when the hot flashes began.
How often do they occur?
Do you feel anything else when these flashes occur?
Can you feel the symptoms coming on before they actually begin?
When did you have your last menstrual period?
Have you noticed anything that makes these flashes get worse? (eg,
food intake)
HPI
Do you have any diarrhea or constipation?
Do you feel any burning or pain when urinating?
Have you had any pain with sexual intercourse?
How has your mood been recently?
Have you had any fever or chills?
Do you have any headache?
Have you had any weight loss?
Past medical
history
Medications/
allergies
Family history
Social history
smoke?
Wash your hands.
Examine for cervical lymphadenopathy.
Neck
Abdomen Palpate for masses and tenderness.
Neurologic Evaluate deep tendon reflexes.
Conclusion
Menopause
Hyperthyroidism
Medicationinduced (eg, vasodilators)
Carcinoid syndrome
Pheochromocytoma
Investigations
Serum TSH
Serum FSH and LH (only in some doubtful cases)
Miscellaneous Cases Print
Other Important Cases
1. Upper extremity pain
In the history, just follow LIQOR AAA and PAM HUGS FOSS. Consider these issues during
your history taking:
Carpal tunnel syndrome (ask about the occupation)
Cervical spondylitis
Herniated cervical disc
Thoracic outlet syndrome (ask whether the symptoms worsen with the above head
activities, like combing)
Tenosynovitis
Trauma
Referred pain from coronary ischemia
Physical Examination:
Wash your hands.
Check the thyroid gland.
Check the neck movements and the range of motion.
Do thoracic outlet test. (Adson's test)
Ask him to take a deep breath. Extend the neck and turn the chin towards the
opposite side.
Repeat the test with the chin on the opposite side.
In the presence of thoracic outlet syndrome, the radial pulse will disappear.
Do Phalen's test (for carpal tunnel syndrome)
Hold the patient's wrists in acute flexion for 3060 seconds.
Patient will complain of pain, numbness, and tingling over the distribution of
medial nerve, if the test is positive.
You can also elicit Tinel's sign, if you want.
With your finger, percuss over the course of the medial nerve in the carpal
tunnel.
Patient will complain of pain, numbness, and tingling over the distribution of
the medial nerve, if the test is positive.
Check sensations, muscle strength, and reflexes of both upper extremities.
Investigations:
CBC with differential, ESR
EMG and nerve conduction studies
Xray of the cervical and thoracic spine
ECG
MRI of the spine
2. A 34 yo F who came for a bronchial asthma drug refill
This case is not that important, but there is always the possibility that you may
encounter this in the step 2 CS, so just take a look.
Start with a formal greeting. Ask openended questions like, "What brought you in
today?"
The things that you need to ask specifically for this case are:
"Can you please tell me more about your asthma? When were you diagnosed
for the first time? How have you been doing since then?"
"Can you please tell me about your current medications?" or "What
medications are you on?"
"Did you notice any problems or side effects with your medications?"
"Do you have any trouble breathing during the day or night with regular
activity?"
"How often does this occur on a weekly basis?"
"Do you have any trouble breathing with exercise?"
"Do you have episodes of excessive coughing during the day or night time?"
"Have you ever been admitted to the hospital for an acute or severe attack?"
"Tell me, what do you think about the severity of your asthma? Do you think
it is getting better or worse?"
"Do you know what precipitates your asthma?"
"Are you taking any precautions to avoid those?"
After this you, will just have to follow PAM HUGS FOSS. Make sure you ask about
her smoking history, and talk about the importance of smoking cessation.
The PE basically requires:
an HEENT exam to look for any sinus tenderness (sinusitis), or signs of upper
respiratory tract infection, which can aggravate or precipitate asthma.
a complete lung examination
looking for JVD and pedal edema (for signs of cor pulmonale, even though it
is a very rare complication of asthma)
Investigations:
Spirometry or pulmonary function tests are usually not required, unless the patient
is elderly and having persistent asthma.
For chronic, persistent, and refractory asthma, request:
Aspergillus serology
Chest xray
Xray of paranasal sinuses
24 hour pH for GERD
Skin tests
Differential diagnosis for chronic, persistent asthma in a smoker includes:
Bronchial asthma
Chronic obstructive pulmonary disease
Bronchopulmonary aspergillosis
Sinusitis
Atypical GERD
Nightsweats Case Print
complaining of night sweats.
Vital signs
Heart rate, 80/min
History
How long have you had night sweats?
Have you had any fevers or chills?
Have you lost any weight unintentionally?
Do you have any weakness or fatigue?
Do you have itching (pruritus)?
Do you have pain anywhere (back pain and fever suggest
osteomyelitis)?
HPI
Do you have a cough?
Have you had any headaches?
Have you had any palpitations (racing or pounding heart)?
Have you had any diarrhea?
Do you feel warm if everyone else in the room feels comfortable?
Have you traveled anywhere recently?
Have you been exposed to any sick contacts recently?
Past medical
history
Medications/
allergies
Family history
Are you sexually active?
Do you have sex with men, women, or both?
Wash your hands.
Examine for lid lag/exophthalmos.
HEENT
Examine oropharynx for thrush.
Neck
Abdomen Palpate for hepatosplenomegaly.
Evaluate deep tendon reflexes.
Neurologic
Examine for hand tremor.
Skin Examine for rashes.
Conclusion
Malignancy (lymphoma, solid tumors)
Infections (tuberculosis, HIV, endocarditis)
Endocrine disorders (hyperthyroidism,
pheochromocytoma)
Medications (antidepressants, cholinergic
agonists, hypoglycemic agents)
Investigations
ESR
Blood cultures
Chest xray and PPD
TSH
ELISA for HIV
CT scan of chest and abdomen for lymphoma
Obesity Case Print
complaining of weight gain.
Vital signs
Temperature, 98 F (36.7 C)
Heart rate, 68/min
History
I see that you are concerned about weight gain. How long have you
noticed the weight gain?
How many pounds have you gained?
Can you think of any reasons for this weight gain?
If increased, how long have you had this increased appetite?
How many meals do you eat in a day?
Give me examples of what you eat at each meal (breakfast, lunch,
and dinner).
Do you eat any snacks in between?
HPI How often do you eat out?
How much food (portion size) do you eat during your meals?
How is your mood? Are you feeling okay?
Do you have any problems with your breathing, especially at night?
Are you urinating more often? If so, do you urinate more than usual?
Are you feeling thirstier than usual?
Have you had any diarrhea or constipation?
Do you feel cold if everyone else in the room feels comfortable?
Do you have any joint pain?
When was your last period?
Have your periods been irregular at all?
Has a doctor diagnosed you with any other medical conditions (eg,
Past medical diabetes, HTN)?
history Have you had your cholesterol checked recently?
Medications/ Are you allergic to any medications?
allergies If so, what reaction do you have?
Have you ever taken steroids?
Family history
Wash your hands.
Examine for lid lag.
HEENT
Examine for exophthalmos.
Neck Examine for thyromegaly.
Extremities Examine for peripheral edema.
Conclusion
Obesity
Hypothyroidism
Cushing's syndrome
Investigations
Fasting blood sugar
Serum TSH
Urine cortisol levels
Fasting lipid profile
Palpitations Case Print
complaining of episodes of palpitations.
Vital signs
Heart rate, 80/min
History
Please describe an episode of what you mean by palpitations.
Do you have any symptoms other than the palpitations?
When did these episodes begin?
How often are they happening?
How long do they last?
Do you feel that your heart is skipping any beats?
What are you doing when you have these episodes?
Does anything seem to trigger them?
Do you drink any caffeine? If so, how much?
What makes the symptoms better?
HPI Have you had any chest pain?
Have you had any breathing problems?
Do you feel any dizziness or lightheadedness?
Have you ever passed out?
Do you have a fever?
Do you get tremors in your hands?
Do you sweat excessively?
Do you get headaches with these episodes?
Have you noticed any swelling in your legs?
Do you check your blood pressure during these episodes? If so, is it
high?
Past medical
history
Medications/
allergies
Family history
Wash your hands.
Examine conjunctiva for pallor.
HEENT
Examine for exophthalmos.
Neck
Abdomen Palpate for hepatosplenomegaly.
Evaluate deep tendon reflexes.
Neurologic
Examine for hand tremor.
Extremities Examine for any peripheral edema.
Conclusion
Cardiac arrhythmias
Valvular heart disease
Hyperthyroidism
Pheochromocytoma
Anxiety/panic attacks
Anemia
Hypoglycemia (diabetic patients)
Investigations
12lead EKG
Serum TSH and free T4
Event monitor
Transthoracic echocardiogram
Preemp Checkup Print
Case of a 25 yo M who came for Preemployment Checkup
You may get these kinds of cases as either "Preemployment checkup" or as an
"Insurance checkup". They will tell you everything you have to do. Some may ask
you to fill out a form (It will be provided for you.). If they want you to do any
specific examination, do that, but do all the things that are mentioned in the form
first.
You can fill out the form after you leave the room. If the SP asks about the form,
tell him that you will mail it to his home.
After you finish the examination, ask, "Do you have any questions?" Answer any
questions, and then take a relevant history.
In case you were not provided with a form, you will have to take a simple general
history. Ask cardinal symptoms of each system.
"Do you have any cough?" ("No.")
"Do you have any problems with breathing?" ("No.")
"Do you have any chest pain?" ("No.")
"Do you have headaches?" ("No.")
"Do you have a fever?" ("No.")
"Do you have any pain?" ("No.")
"Do you have weakness in the extremities?" ("No.")
"How is your bowel habit?" ("Pretty good.")
"How is your bladder function?" ("Good.")
Then you must ask PAM HUGS FOSS.
Please do not forget to ask about allergy, smoking, alcohol, and sexual history.
Here is the sample of the form that you might get. It may not be exactly like this.
You may get some of the components of this form.
If they ask you to measure blood pressure (on the form/doorway information), you
have to measure it. This is different from all other cases where you don't need to
check blood pressure.
After finishing the case, you just have to fill out this form. You don't need to write
any history, or things that they have not asked you. All you have to do is fill out
the form.
Height
Weight
Blood
pressure
Pulse rate
Lung

auscultation
Heart

auscultation
CNS

reflexes
Abdomen
Spine

examination
Shoulder pain Case Print
complaining of shoulder pain.
Vital signs
Heart rate, 80/min
History
Be careful to shake hands because the patient may be supporting the
painful hand with the opposite hand. (Try not to cause the patient
unnecessary pain.)
When did this pain begin?
Did you fall or have any trauma?
Describe the pain.
Does the pain move anywhere?
How severe is the pain on scale of 1 to 10?
Show me where the pain is with one finger?
HPI What makes it worse?
What makes it better?
Is it constant or intermittent?
Do you have any numbness or tingling in your arms or hands?
Have you noticed any redness or swelling in the shoulder?
Do you have pain in any other part of your body?
Do you have weakness in any other part of your body?
Do you have any other symptoms? (cough, shortness of breath)
Have you taken any medications for this? If so, did they help?
How is this affecting your daily activities?
Past medical
history
Medications/
allergies
Family history
Wash your hands.
Inspect painful joint for swelling or redness.
Palpate joint for warmth or tenderness.
Compare to other arm.
Musculoskeletal
Check range of motion (passive and active) of shoulder, arm, and
hand, including flexion, extension, abduction, and adduction.
Always adduct arm across chest (crossover test).
Check reflexes.
Neurologic Check motor function and gross sensory examination in hand and
arm.
Conclusion
Rotator cuff injury
Subacromial bursitis
Frozen shoulder (adhesive capsulitis)
Shoulder dislocation/ fracture
Referred pain
Investigations
ESR
Xray of shoulder joint: 2 views, including elbow
Chest xray in a smoker to rule out lung cancer
involving brachial plexus
MRI of shoulder pending above results
Smoking Cessation Print
for counseling on smoking cessation.
Vital signs
Heart rate, 70/min
History
When did you start smoking?
As you know, some people smoke and some don't. What were the
circumstances that caused you to begin smoking?
Do you enjoy smoking?
HPI How many cigarettes do you smoke a day?
Are you concerned about your health?
Is stress or depression a reason for your smoking?
Have you ever had any smokingrelated problems like a cough or
shortness of breath?
Past medical Do you have any other medical problems (especially cancer or recent
history infection)?
Do you take any medications?
Medications/
allergies
Family history
Social history Do you drink alcohol, including beer? How much and how often?
Conclusion/counseling
Don't address the patient negatively, such as saying,
“You must stop smoking; you're killing yourself.”
Always start in a nonjudgmental manner.
Most patients I've counseled have tried to stop
smoking at some point. Have you ever tried to
quit?
What happened?
Stopping smoking can decrease your risk of
cancer, heart attack, and lung disease.
Your breathing will improve and you will have
more energy.
Have you ever tried a nicotine patch or gum?
If the patient does not want to quit smoking you can
say, “It seems you really don't want to give up
smoking right now. I wonder if you could cut back
from 2 packs a day to 1.”
Always praise the patient using positive language
("Excellent" or “That's great”).
Finally, repeat sentences such as, “I appreciate your
motivation to quit smoking.”
Spells Case Print
complaining of passing out.
Vital signs
Heart rate, 80/min
History
Please describe what happened.
What were you doing when this happened?
Has this happened before?
Did someone see you pass out?
How long were you out?
Did you have any jerky movements of your hands or legs?
Did you bite your tongue?
Did you lose control of your urine?
Did you lose control of your bowels?
HPI
Were you feeling fine before the event and between spells?
Did you have any nausea or vomiting before the spell?
Have you had any chest pain?
Have you had any breathing problems?
Have you had any palpitations?
Have you had any weakness in your legs and arms?
Have you noticed tingling and numbness anywhere?
Have you had any blurry vision or changes in your vision?
Have you had any recent trauma or injury?
Past medical
history
Medications/
allergies
Family history
Wash your hands.
Vital signs Check for orthostatic hypotension if not given in vital signs already.
Evaluate motor strength in all areas.
Perform gross sensory examination in extremities.
Neurologic
Check reflexes.
Evaluate gait.
Conclusion
Cardiac arrhythmias
Vasovagal syncope (neurocardiogenic)
Orthostatic hypotension
Structural heart disease (aortic disease)
Seizures
TIA/stroke
Investigations
ECG
Event monitor
Echocardiogram
Upright tilt table test (neurocardiogenic syncope)
CT or MRI of brain
EEG pending above results
Telephone Encounter Print
The patient is a 5yearold boy who has been vomiting for 1
day. His mother has left a phone message with the clinic.
You will talk with the patient's mother on the phone.
History
I'd like to get a few details from you about your son.
How old is he?
How long has he been vomiting?
How many times has he vomited since yesterday?
Has he been vomiting large amounts?
What does the vomitus contain?
Did you notice any blood in the vomitus?
Does he have any pain in his belly?
HPI Is he having any diarrhea or constipation?
Does he have a fever?
How is his appetite?
Did he eat out recently, at a party or restaurant?
Does he have any headaches?
Is he usually a healthy child or does he frequently get sick?
Has he been exposed to any sick contacts?
Has he traveled anywhere recently?
Has he had all of his recommended vaccinations?
Has he had a similar problem before?
Past medical
Has a doctor diagnosed him with any other medical conditions?
history
Were there any problems at birth or during the pregnancy?
Has he had any surgeries?
Does he take any medications (prescription and overthecounter)?
Medications/
Is he allergic to any medications?
allergies
If so, what reaction does he have?
How old are you and his father?
Do either of you have any medical conditions?
Family history
How old are his brothers and sisters?
Who does he live with?
Social history What grade is he in school?
Is he doing OK in school?
Conclusion
Explain the next steps in workup (bring child to
clinic or hospital).
If the child is very sick, he needs to be seen for
proper assessment of volume status.
Gastroenteritis
Gastroparesis
Intussusception
Adrenal insufficiency
Intracranial hypertension
Meningitis
Medications/toxins
Terminal cancer Case Print
The patient is a 69yearold man with a history of terminal
lung cancer who comes to the clinic requesting pain
medication.
Vital signs
Heart rate, 80/min
History
I understand that you have been diagnosed with cancer. How can I
help you today?
Please tell me more about your cancer.
I am very sorry to hear that and I am sure that it has been difficult
for you. Tell me more about your pain.
How severe is the pain, on a scale of 1 to 10, with 10 being the
worst?
Does anything improve your pain?
What makes your pain worse?
Do you have pain anywhere else?
HPI
Are you using any medication, such as morphine, for your pain?
Do you have any complaints other than pain?
Have you had fever?
Have you had diarrhea or constipation?
Do you have any problems urinating?
Have you been able to sleep well?
How is your mood?
Have you thought about hurting yourself at all?
Have you been diagnosed you with any other medical conditions by a
Past medical
history
Medications/
allergies
Do you have other family members or friends who provide emotional
Family history/ support for you?
smoke?
Wash your hands.
HEENT Examine conjunctiva for pallor or jaundice.
Abdomen Palpate for masses and tenderness.
Extremities Evaluate for any edema.
Conclusion
Show support, be sensitive, and convey
necessary information.
Discuss pain medications such as narcotics, etc.
Discuss the patient's living situation (home,
assisted living).
Discuss hospice care
Can allow patient to live painfree with
comfort care.
Can provide social, spiritual, and physical
support for patient and family.
All hospice care is under professional
medical supervision.
Discuss advance directives.
Vaginal Bleeding Print
Case of a 20 yo F Complaining of Vaginal Bleeding
Vital Signs:
BP: 110/70 mm Hg
Pulse: 80/min
RR: 16/min
T: 36.7C(98F)
History Taking:
When did the bleeding start?
Was the onset gradual or sudden?
Can you describe the bleeding?
For example, is it bright red or clotted blood?
Is the blood pure or does it contain tissue like substance? (A molar
pregnancy would have grape like tissue.)
Has it been a continuous flow or spotting?
What were you doing when it started? Were you sleeping or having sex?
Do you have any other symptoms besides bleeding? Did you have abdominal pain?
Fever? Vomiting?
Were you ever involved in any accident/trauma?
Have you ever been pregnant?
When was your last menstrual period (LMP)?
Can you describe more about your menstrual cycle?
How heavy is the flow?
How many pads do you use per day?
How long are your periods?
Are your periods regular or irregular?
Have you had any abortions?
Have you ever been tested for STDs?
Past Medical History:
Have you ever had any history of bleeding? Were you ever hospitalized for
bleeding?
Medications:
Are you currently taking any medications?
What medications have you recently taken?
Family history:
Do you have a family history of bleeding disorders?
Does anyone in your family have a history of multiple abortions?
Sexual History:
Are you married?
If yes:
Do you have any other sexual partners? (yes)
Do you use any means of contraception?
If no:
Do you have any other sexual partners? (yes)
Do you use any means of contraception?
When was your last sexual contact?
Social History:
Do you smoke?
Do you drink alcohol?
Do you use illicit drugs? (Cocaine may cause bleeding.)
Wash your hands.
Perform the proper draping technique.
Look for other sites of bleeding, i.e. nose or gums
Check for orthostatic hypotension.
Auscultate the abdomen.
Percuss the abdomen for liver span.
Palpate the abdomen superficially.
Palpate the abdomen deeply.
Check for rebound tenderness.
Ask to perform a pelvic exam.
Differential Diagnosis:
Regular menses
Abortion
Pregnancy
Ectopic pregnancy
Hydatiform mole
Investigations:
Pelvic examination
Pregnancy test
Transvaginal ultrasound
Serum RHCG levels
Serum TSH
Vomiting Case Print
complaining of vomiting.
Vital signs
Temperature, 98 F (36.7 C)
Heart rate, 80/min
History
When did the vomiting start?
Was the vomiting projectile (forceful)?
Was there any blood in the vomitus?
How often are you vomiting?
Did you eat at a restaurant? Is anyone else who ate there sick?
Have you been exposed to any sick contacts?
Do you have any abdominal pain?
HPI Do you have any back pain?
Do you have diarrhea?
Do you have constipation?
Do you have fever and chills?
Have you had any headaches?
Do you have any burning with urination?
When was your last menstrual period?
Is there a chance you could be pregnant?
Past medical
history
Medications/
allergies
Family history
Wash your hands.
Vital signs Check for orthostatic hypotension if not given in vital signs already.
Examine oropharynx for dry mucous membranes.
HEENT
Examine fundi if suspecting increased intracranial pressure.
Inspect for abdominal distention.
Abdomen Percuss for bowel gas pattern.
Palpate for tenderness and rebound tenderness.
Examine for CVA tenderness.
Conclusion
Gastroenteritis
Intestinal obstruction
Pregnancy
Medications/toxins
Meningitis
Pancreatitis
Hepatitis
Cholecystitis
Pyelonephritis
Investigations
Serum electrolytes
Pregnancy test
Urinalysis and urine culture
Abdominal xray after negative pregnancy test
Serum amylase and lipase
Liver function panel
Abdominal ultrasound
Stool studies
case1 Scenario Print
30 Yr. O/F Complaining of Abdominal Pain
Vitals
Pulse98/min
B.P120/75 mm of Hg
Temp101.3
R.rate22/min
Make a mental checklist of Differential Diagnosis
Pelvic inflammatory disease
Pelvic abscess
Endometriosis
Urinary tract infection
Appendicitis
Rupture/torsion of ovarian cyst
Acute cholecystitis
Renal colic
Ectopic pregnancy
Abortion
Acute gastroenteritis
Inflammatory bowel disease
case1 SP Print
If the doctor asks you anything other than these just say 'no' (or) say things that
are normal in daily routine life.
You are Mrs. Mary, age: 30yrs
Have abdominal pain since 12 hrs
Started slowly, progressively increasing
67/10 in severity
Right below the umbilicus
It's a type of sharp pain
All over your lower abdomen
Began after eating a large meal
Moving around makes it worse
No alleviating factors
Associated with nausea and vomiting
Passing urine more number of times and have burning urination
No bowel problems
Last menstrual period was 3 weeks ago
No discharge from vagina/no bleeding from vagina
Have fever since yesterday associated with chills and rigors
Have one episode of urinary tract infections (UTI) in the past
No allergies
Once hospitalized for evaluation of UTI
Have multiple sexual partners
Using oral contraceptive pills
Familie's health is normal
Smoking No
Alcohol No
Recreational drugs No
Occupation: Working as a receptionist
Appetite and wt is normal
No illicit drug intake
Ask this qt Doc is it an appendicitis?
case1 Pt Notes Print
Clinical Skills Evaluation
Case 1 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).
30 YO female with 12 hours of abdominal pain and previously well.
Ate a heavy meal at a local barbecue restaurant one day ago.
Developed acute onset of periumbilical abdominal pain 12 hours later described as
sharp, lasting a few minutes at a time, radiates diffusely in the abdomen, made
worse with movement, and relieved with rest.
Also notes dysuria, increased urinary frequency, fever to 100.5 F, chills, nausea,
and one episode of nonbloody and nonbilious vomiting.
ROS: No chest pain, shortness of breath, diarrhea, constipation
PMHx: Previous UTI with possible pyelonephritis
PSHx: none
FHx: Noncontributory
SHx: Has had 2 sexual partners with unprotected intercourse in the past month
Physical Examination: Describe any positive and negative findings relevant to this
patient’s problem(s). Be careful to include only those parts of examination performed in
this encounter.
Vital signs: temperature of 101.3 F, blood pressure of 120/75, heart rate of
98/min, and respiratory rate of 22/min
Abdominal exam shows tenderness in periumbilical, RLQ, and LLQ regions.
No abdominal distention or guarding
Normoactive bowel sounds
Negative Murphy’s sign, Rovsing’s sign, psoas sign, and obturator sign
No CVA tenderness
Lungs are clear to auscultation. Heart sounds are normal and there are no
murmurs.
Data interpretation: Based on what you have learned from the history and 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 examination maneuvers, laboratory tests, imaging, ECG, etc.).
Diagnosis #1: Appendicitis
History finding(s) Physical Exam finding(s)
Diffuse abdominal pain Diffuse abdominal tenderness
Fever, chills Fever
Nausea, vomiting
Diagnosis #2: UTI
Dysuria Fever
Increased urinary frequency
Fever
Diagnosis #3: Pelvic Inflammatory Disease
Multiple sexual partners with unprotected
Diffuse abdominal tenderness
intercourse
Nausea, vomiting Fever
Diagnostic Studies
Pregnancy test
Urinalysis with urine culture
CT scan of abdomen
27 Yr. O/F complaining of rash
Vitals
Pulse78/min
B.P120/75 mm of Hg
Temp98.3 F
R.rate22/min
Make a mental checklist of Differential Diagnosis
Infections
Insect borne diseases
SLE
Photo dermatitis
Drug induced
Occupational exposure
Rheumatoid arthritis
Other autoimmune diseases
case2 SP Print
If the doctor asks you anything other than these just say 'no' (or) say things that
You are a 27yearold female who presents with 1 week of rash.
History of Present Illness:
You are a 27yearold female with no past medical history who presents with 1 week of
rash. You were well until 1 week ago when you worked in the garden for 3 hours. A few
hours later, you developed a flat rash on the face and neck with no itching, numbness,
burning sensation, or tenderness.
The rash is getting larger, but it is not affecting any new areas of the body. Also, the
rash has remained flat without any blisters. It seems to be worse with exposure to the
sun and nothing seems to improve the rash. You also noted 4 days of joint pain and
stiffness in the early morning that lasts about 1 hour and seems to improve afterwards.
You also have subjective fever but did not check your temperature. You have no chills,
eye redness, chest pain, shortness of breath, nausea, vomiting, diarrhea, constipation, or
urinary symptoms. You also have not had any recent travel or sick contacts.
Past medical history:
You have had joint pains in the past on and off that seem to go away on their own.
You have had no pregnancies in the past
Past surgical history: None
Medications: None, except for aspirin 7 days ago for mild headache
Family history:
Father is 55 and healthy
Mother is 54 with “rheumatism”
Sister is 28 with hypothyroidism
Social history:
You work in a chemical manufacturing company and live alone. You have had 1 sexual
partner in the last month and use condoms regularly. You don't smoke, drink, or do any
illegal drugs. You have not had transfusions or tattoos. Last menstrual period was 2
weeks ago.
Physical Exam:
The following are your temperature (T), blood pressure (BP), heart rate (HR), and
respiratory rate (RR).
Vital signs: T 98.3 F, BP 120/75, HR 78/min, RR 22/min
Skin: Multiple wellcircumscribed lesions on face and neck without vesicles; no
tenderness to touch
The student needs to do a skin examination at the minimum, and you should not have
any pain around the rash.
The student may perform a heart and/or lung exam, but these will be normal.
Case 2 Patient Note
27 YO female with 1 week of rash; she was previously well
Did 3 hours of gardening 1 week ago and developed a rash on her face and neck a
few hours later
Rash has increased in size but does not involve other areas of body
Rash is worse with sun exposure and not improved with anything
Also notes morning joint pains and subjective fever
ROS: No chest pain, shortness of breath, diarrhea, constipation, sick contacts, recent
travel
PMHx: Previous joint pain and stiffness episodes in the past with spontaneous resolution
PSHx: none
FHx: Mother has possible rheumatoid arthritis
SHx: Has 1 sexual partner and uses condoms
this encounter.
Vital signs: temperature of 98.3 F, blood pressure of 120/75, heart rate of 78/min,
and respiratory rate of 22/min
Face and neck have multiple, wellcircumscribed, erythematous macules without
tenderness to palpation
No scaliness, vesicles, or cysts noted in rash area
Normal range of motion in all joints without tenderness, edema, or erythema
HEENT with no pallor, jaundice, or eye lesions
Lungs: CTA bilaterally
Heart: RRR without M/G/R
physical exam maneuvers, laboratory tests, imaging, ECG, etc.).
Diagnosis #1: SLE
Cutaneous photosensitive rash Discoid lupus rash
Fever
Joint pain
Diagnosis #2: Rheumatoid arthritis
Joint pain and stiffness
Fever
Family history
Diagnosis #3: Photodermatitis
History of sun exposure followed by rash Photosensitive rash on face and neck
No progression of rash to other areas
Diagnostic Studies
ANA and antids DNA
Rheumatoid factor and ESR
Skin biopsy
65yearold female complaining of arm and leg weakness
Vitals:
PR: 78/min
BP: 160/90 mmHg
Temp: 98.3 F (36.7 C)
RR: 16/min
Make a mental checklist of Differential Diagnosis:
Stroke
Transient Ischemic Attack (TIA)
Hypoglycemia
Subarachnoid hemorrhage
Subdural hematoma
Intracranial mass
Guillain Barrn syndrome
Complex migraine
Conversion disorder
case3 SP Print
If the student asks you anything other than these, just say 'no,' (or) say things
that are normal in daily routine life.
You are a 65yearold female who presents with 1 hour of right arm and leg weakness.
You are a 65yearold woman who presents with 1 hour of weakness in the right arm and
leg that gradually worsened to involve numbness in the entire right arm and right leg.
You also noticed a mild headache that is diffuse and is a 5/10 in severity and nausea
without vomiting.
You have not had these symptoms in the past and also have no slurred speech, fever,
blurry or double vision, problems with swallowing, chest pain, urinary symptoms,
diarrhea, constipation, seizures, or palpitations. You have not passed out or fallen down
recently.
High blood pressure for 25 years
Heart attack 6 years ago
High cholesterol
Heart bypass surgery 6 years ago
Medications:
Simvastatin 20 mg a day
Aspirin 81 mg a day
Atenolol 50 mg a day
Allergies: None
Family history:
Mother died at age 68 with a heart attack and had high blood pressure
Father died at age 65 with a heart attack and had high blood pressure
Brother age 70 with high blood pressure and high cholesterol
Social history:
You are a widow whose husband died 8 years ago. You live alone. Your neighbor Steve,
who is like a son to you, brought you to the hospital. You smoked 2 PPD for 35 years
and quit 6 years ago. You drink alcohol once a month and have never used illegal drugs
or had transfusions or tattoos.
Ask this question, if the student does not address about the stroke: “Doctor, is it a
stroke?”
Physical Exam:
Neurological:
Cranial nerves 212 intact
Motor 5/5 in left upper and lower extremity but 3/5 in right upper and lower extremity,
DTR 3+ on right and 2+ on left
Upgoing toe on right and downgoing toe on left
Unable to perform gait due to inability to stand
The student needs to do a neurological exam at the minimum, and you should be weaker
on the right side of the body.
You should be unable to lift your leg or arm without help from the student. You also
cannot stand up if the student asks you to. In addition, your reflexes on the right side
should be more hyper than the left. The sensation is the same on both sides of the body.
The student may perform a heart and/or lung exam, but these will be normal.
Case 3 Patient Note
65 YO female with 1 hour of acute onset rightsided weakness and headache
The symptoms have progressed gradually over the past hour
She also has nausea without vomiting
No history of fall or syncope
ROS: No fever, chest pain, shortness of breath, vision changes, dysarthria, seizures
PMHx: HTN, hypercholesterolemia, CAD
PSHx: CABG 6 years ago
Meds: Aspirin, simvastatin, atenolol
FHx: Mother died of MI and had HTN, father died of MI and had HTN, brother with HTN
and hypercholesterolemia
SHx: Smoked 2 PPD for 35 years but quit 6 years ago
this encounter.
Vital signs: temperature of 98.3 F (36.8 C), blood pressure of 160/90, heart rate of
Neuro: A&O x 3, CN 212 intact, Motor 5/5 on LUE and LLE but 3/5 in RUE and RLE,
sensory grossly intact, DTR 2+ on left but 3+ in RUE and RLE, upgoing toes on right
and downgoing on left, gait unable to be assessed
physical examination maneuvers, laboratory tests, imaging, ECG, etc.).
Diagnosis #1: Evolving stroke
Acute onset weakness Right hemiparesis
Gradually progressing symptoms Rightsided hyperreflexia
Right Babinski present
Diagnosis #2: TIA or reversible ischemic neurological deficit
Acute onset weakness Right hemiparesis
Rightsided hyperreflexia
Right Babinski present
Diagnosis #3: Subarachnoid hemorrhage
Headache Right hemiparesis
Nausea Rightsided hyperreflexia
Acute onset weakness Right Babinski present
Diagnostic Studies
CT scan of head without contrast
Transesophageal echocardiogram
Carotid Doppler
29 Yr. O/F known sickle cell anemia pt c/o chest pain
Vitals:
P.R: 98/min
B.P: 120/75 mm of Hg
Temp: 101.3F
R.R: 22/min
Chest syndrome due to sickle cell anemia
Pneumonia
Costochondritis
Pericarditis
Pulmonary thromboembolism
Salmonella Osteomyelitis
Panic attacks
case4 SP Print
If the student asks you anything other than these, just say 'no,' (or) say things
You are a 29yearold female who presents with 12 hours of chest pain.
You are a 29yearold woman with sickle cell anemia presenting with 12 hours of chest
pain in the middle of the chest. The pain is sharp and started slowly, but has been
increasing over the past 12 hours and is now a 78/10 in severity. The pain does not
move anywhere, but it is worse with any movement and breathing. You took Tylenol,
which helped reduce the pain a little.
You also have had mild shortness of breath, fever to 101 F for the past 3 days, cough
with green sputum, and chills with rigors. You have not had chest trauma, nausea,
vomiting, blood in the sputum, leg pain or swelling, abdominal pain, back pain, urinary
symptoms, or diarrhea.
Sickle cell anemia diagnosed in childhood you had mild pain episodes as a child and
have done relatively well in adulthood. You were admitted once for abdominal pain 5
years ago that resolved with supportive care in the hospital.
You have had no pregnancies in the past.
Medications:
Birth control pills
Tylenol as needed
Allergies: None
Family history:
Mother 53 with sickle cell anemia
Father 55 healthy
Brother 25 healthy
Social history:
You are a teacher and live alone. You are sexually active with your boyfriend and use
condoms. You have not smoked, drank alcohol, or used illegal drugs. You had a
transfusion as a child. Last menstrual period was 2 weeks ago.
Physical Exam:
Head and Neck: No redness or exudates in the mouth, no enlarged lymph nodes
Chest/Lungs: No tenderness to palpation of the chest wall, clear to auscultation
bilaterally
Heart: Regular rate and rhythm
Abdomen: Nontender, nondistended, normoactive bowel sounds throughout; tympanic
to percussion; no hepatosplenomegaly
Extremities: No cyanosis, clubbing, edema, or tenderness in the legs
The student needs to do the above exams at the minimum, and you should not have any
chest pain when it is palpated. You should also try to breathe a little faster to a rate
near 20/minute. The rest of the examination is normal.
Case 4 Patient Note
29 YO female with history of sickle cell anemia with 12 hours of acute onset chest
pain
The pain has gradually increased to 78/10 intensity over the past 12 hours
Pain is worse with movement and respiration, improved with Tylenol
3 days of fever to 101 F, productive cough of green sputum, and mild shortness of
breath
ROS: No nausea, vomiting, trauma to chest, dysuria, diarrhea, leg swelling, or leg pain
PMHx: Admitted once for abdominal pain that resolved 5 years ago
PSHx: None
Meds: Birth control pills, Tylenol PRN
FHx: Mother has sickle cell anemia
SHx: Denies smoking, alcohol, illegal drugs. She had a blood transfusion as a child.
this encounter.
HEENT: Oropharynx without erythema or exudates
Neck: No cervical lymphadenopathy, trachea midline
Lungs: CTA bilaterally, no chest tenderness to palpation
Abdomen: Nontender, nondistended, normoactive bowel sounds throughout;
tympanic to percussion; no hepatosplenomegaly
Extremities: No cyanosis, clubbing, or edema. No swelling or tenderness in the
legs.
Diagnosis #1: Acute chest syndrome
Acute onset chest pain No chest pain to palpation
Shortness of breath Fever
History of sickle cell anemia
Diagnosis #2: Pneumonia
Fever Fever
Productive cough of green sputum Tachypnea
Shortness of breath
Diagnosis #3: Pulmonary embolism
Pleuritic chest pain Fever
Fever No chest tenderness to palpation
Shortness of breath
Birth control pills
Diagnostic Studies
Chest xray
ABG
Blood cultures
35yearold male with recent onset cough
Vitals:
PR: 98/min, regular
BP: 120/75 mmHg
Temp: 38.3 C (101.0 F)
RR: 20/min
Differential diagnosis for recent onset Cough:
Common cold
Acute sinusitis
Allergic rhinitis
Acute bronchitis
Pneumonia
Pertussis
Pulmonary embolism
Drugs (ACE inhibitors)
Asthma
In elderly patients also consider:
Congestive heart failure
Chronic obstructive pulmonary disease (COPD) exacerbation
case5 SP Print
If the doctor asks you anything other than these, just say 'no,' or say things that
You are a 35yearold male who presents with 5 days of cough.
You are a 35yearold male with history of seasonal allergies and mild asthma who
presents with 5 days of cough productive of yellow sputum. You were well until 7 days
ago when you noted a sore throat, sinus congestion, runny nose, mild frontal headache,
and subjective fever to 100.2 degrees. The symptoms persisted and you then developed
a worsening cough that is keeping you awake at night. You are coughing up a
teaspoonful of sputum each time.
You are also still having a mild frontal headache that is slightly worse with lying down.
There is no blood in the sputum, chills, night sweats, chest pain, shortness of breath,
wheezing, or abdominal pain. There was some slight relief with Tylenol and Robitussin
DM. Your 8yearold son was also recently sick.
Asthma had it since childhood with mild intermittent symptoms.
Seasonal allergies mainly in the Fall and Spring.
Medications: Albuterol inhaler, 12 puffs as needed
Allergies: No medications, but you are allergic to cats.
Family history:
Father is 60 years old and has asthma
Mother is 59 and is healthy
You have no other siblings
Social history:
You live with your husband and son. You currently work as a paramedic. You have
smoked 1 PPD for the past 10 years and drink occasionally. You have never used illegal
drugs and also have not had any blood transfusions.
Physical Exam:
Head and Neck: No redness or exudates in the mouth, no sinus tenderness to
percussion, no enlarged lymph nodes
Chest/Lungs: Clear to auscultation bilaterally
The student needs to do the above exams at the minimum, and you should not have
significant sinus pain when they are palpated. You should also try to breathe a little
faster to a rate near 20/minute. The rest of the examination is normal.
Case 5 Patient Note
35 YO male with 5 days of worsening cough
He initially developed sore throat, fever, rhinorrhea, and frontal headache 7 days
ago
Cough is productive of yellow sputum without hemoptysis, about 1 teaspoonful
Recent sick contact 8 YO son
ROS: No chills, night sweats, chest pain, shortness of breath, wheezing, or abdominal
pain.
PMHx: Mild asthma, seasonal allergic rhinitis
PSHx: None
Meds: Albuterol MDI PRN
Allergies: Cats
FHx: Father has asthma
SHx: Smokes 1 PPD for past 10 years and drinks occasionally.
this encounter.
HEENT: Oropharynx without erythema or exudates, no sinus tenderness to
percussion
Neck: No cervical lymphadenopathy, trachea midline
Diagnosis #1: Acute sinusitis
History of allergic rhinitis Fever
Frontal headache
Fever
Fever Fever
Productive cough of yellow sputum Tachypnea
Smoking history
Diagnosis #3: Acute bronchitis
Cough Fever
Fever
Smoking history
Diagnostic Studies
Chest xray
Sputum Gram stain and cultures
50yearold male complaining of fatigue and loss of weight
Vitals:
PR: 78/min
BP: 120/76 mmHg
Temp: 98.0 F (36.7 C)
RR: 18/min
Make a mental checklist of DD for weight loss:
Malignancy
Diabetes mellitus
Hyperthyroidism
Depression
Infections like TB, HIV
Malabsorption
Addison's disease
Case 6 Patient Note
50 YO male with 5 months of increased fatigue
Spouse died 3 months ago and he has had worsened symptoms
Has had a 30pound weight loss, decreased appetite, periumbilical abdominal pain,
early satiety
He has loss of interest in activities and terminal insomnia, but is not suicidal
ROS: No dysphagia, fever, chills, night sweats, chest pain, shortness of breath, or
cough.
PMHx: None
PSHx: None
Meds: None
Allergies: None
FHx: Mother died at age 60 from pancreatic cancer, father died at age 55 from heart
attack
SHx: Denies smoking
this encounter.
Vital signs: temperature of 98.0 F, blood pressure of 120/76, heart rate of 78/min,
and respiratory rate of 18/min
Head and Neck: No redness or exudates in the mouth, no enlarged lymph nodes,
no jaundice, no thyromegaly
bilaterally
Extremities: No cyanosis, clubbing, or edema
Neurological: Motor 5/5 throughout, DTR 2+ bilaterally
Diagnosis #1: GI malignancy (ex: colon cancer, gastric cancer)
Fatigue None
Weight loss
Early satiety
Diagnosis #2: Depression
Fatigue None
Weight loss
Death of spouse
Terminal insomnia
Diagnosis #3: Hyperthyroidism
Weight loss None
Fatigue
Diagnostic Studies
TSH and T4
Rectal examination with FOBT
Colonoscopy
CT scan of the abdomen
case6 SP Print
If the doctor asks you anything other than these just say 'no,' (or) say things that
You are a 50yearold male who presents with 5 months of fatigue.
You are a 50yearold male who presents with 5 months of generalized weakness and
fatigue. It initially started as a mild decrease in energy but has been getting worse over
the past 3 months. You also notice abdominal pain around the belly button described as
a gas feeling that has been happening on and off during this time. You seem to get full
easier after eating less food.
(You need to have the student ask the following and only volunteer if asked)
Your symptoms got worse after your spouse died 3 months ago. You started having
decreased appetite, a 30pound weight loss, increasing fatigue, decreased interest in
activities, and difficulty falling asleep at night. You also have been getting up at night
and have been unable to get back to sleep during this time. You have not thought about
suicide, but you do have feelings of guilt. You also have difficulty concentrating on tasks.
You do not have fever, chills, nausea, vomiting, chest pain, shortness of breath, jaundice,
diarrhea, constipation, or tremors. You think that your family does not understand what
you are going through and you feel isolated from many of your friends.
Past medical history: None
Medications: None
Allergies: None
Family history:
Mother died at age 60 of pancreatic cancer
Father died at age 55 of heart attack
You have no siblings
Social history:
You currently live alone and are a widow. You have 2 children who are ages 28 and 25.
Your spouse died 3 months ago and you work as a manager in a local restaurant (not
stressful). You do not smoke but drink occasionally. You have not used any illegal
drugs. You have not had transfusions or tattoos.
Physical Exam:
Head and Neck: No redness or exudates in the mouth, no enlarged lymph nodes, no
jaundice, no thyromegaly
bilaterally
Extremities: No cyanosis, clubbing, edema
Neurological: Motor 5/5 throughout, DTR 2+ bilaterally
The student needs to do the above exams at the minimum, and are all normal.
35yearold male with acute onset diarrhea
Vitals:
PR: 100/min, regular
BP: 110/65 mmHg
RR: 18/min
Temp: 98.0 F (36.7 C)
Make a mental checklist of DD for acute onset diarrhea:
Viral gastroenteritis
Bacterial gastroenteritis
Medication induced
Clostridium difficle colitis
Irritable bowel disease
Malabsorption
HIV
Case 7 Patient Note
35 YO male with 1 day of diarrhea with 67 loose BM/day without blood or mucus
Ate seafood and salad at a local restaurant 68 hours before symptom onset
Recent sinus infection treated with amoxicillin, last dose 2 days ago
Developed diffuse crampy abdominal pain, nausea, vomiting, decreased PO intake
Two other friends that ate at the restaurant have the same symptoms
ROS: No fever, chills, chest pain, shortness of breath, burning with urination, recent
travel, or back pain.
PMHx: None
PSHx: None
Meds: None
Allergies: None
SHx: Denies smoking and alcohol use
this encounter.
Head and Neck: Oropharynx with dry mucous membranes but no erythema or
exudates, no enlarged lymph nodes, no jaundice
Heart: Regular rate and rhythm without M/G/R
Diagnosis #1: Viral gastroenteritis
Diarrhea without fever No fever
No blood in stool
Other sick friends who also ate at same place
Diagnosis #2: Bacterial gastroenteritis
Symptom onset 68 hours after eating at
None
restaurant
Nausea, vomiting
Diagnosis #3: Clostridium difficile colitis
Symptoms started 2 days after recent
None
amoxicillin use
No blood in stool
Diagnostic Studies
Stool for leukocytes
Stool for Clostridium difficile
Rectal examination with FOBT
case7 SP Print
You are a 35yearold male who presents with 1 day of diarrhea.
You are a 35yearold male who presents with 1 day of diarrhea. You ate at a local
seafood restaurant one day ago and had salad and some shrimp. You started having
diarrhea 68 hours later. You have had 67 bowel movements a day described as loose,
watery, and without blood or mucus. Nothing seems to worsen the diarrhea, and you
have not taken any medications to improve it.
You also have diffuse, crampy abdominal discomfort. You later started having nausea,
vomiting, and difficulty keeping liquids and solids down. You have not had fever, chills,
chest pain, shortness of breath, urinary problems, or back pain. A couple of your friends
who ate with you also have had similar symptoms. You recently had a sinus infection 2
weeks ago treated with amoxicillin; you took your last dose 2 days ago.
You do not have fever, chills, chest pain, shortness of breath, burning with urination, or
back pain. You have not had any recent travel.
Medications: None
Allergies: None
Family history: Both of your parents and your siblings are healthy.
Social history:
You live alone and work as a computer programmer. You do not smoke, drink, or do
illegal drugs. You have not had transfusions or tattoos.
Physical Exam:
Head and Neck: No redness or exudates in the mouth, dry mucous membranes, no
enlarged lymph nodes, no jaundice
Heart: Regular rhythm without murmurs, gallops, or rubs
The doctor needs to do the above exams at the minimum, and the dry mucous
membranes are the main finding indicating dehydration.
25yearold female complains of sore throat
Vitals:
PR: 90/min, regular
BP: 120/70 mmHg
RR: 16/min
Temp: 101.0 F (38.3 C)
Make a mental checklist of DD for sore throat:
Viral pharyngitis (rhino virus and influenza)
Bacterial pharyngitis
Group A Streptococcal pharyngitis
Mycoplasma pneumonia
Neisseria gonorrhea
EBV mononucleosis
Postnasal drip secondary to rhinitis
Chronic tonsillitis
Primary HIV
Case 8 Patient Note
25 YO female with 3 days of sore throat
Initially started with sore throat, sinus congestion, runny nose, fever, and dry
cough
Sore throat has worsened with pain when swallowing
Sick contact (boyfriend) had similar symptoms that resolved
ROS: No chills, chest pain, shortness of breath, nausea, vomiting, or abdominal pain
PMHx: None
PSHx: None
Meds: None
Allergies: None
SHx: Denies smokingand alcohol use
this encounter.
Vital signs: temperature of 101.0 F (38.3 C), blood pressure of 120/70, heart rate
of 90/min, and respiratory rate of 16/min
HEENT: Oropharynx withtonsillar exudates, TM clear bilaterally
Neck: No enlarged lymph nodes
Diagnosis #1: Bacterial pharyngitis
Sore throat Fever
Fever Tonsillar exudates
Diagnosis #2: Viral pharyngitis
Fever Fever
Sore throat
Boyfriend with similar illness that resolved
Diagnostic Studies
Rapid strep test
Throat culture if rapid strep negative
case8 SP Print
You are a 25yearold female who presents with sore throat.
You are a 25yearold female who presents with 3 days of sore throat. You initially had
headache, nasal congestion, sore throat, dry cough, fever to 100.5, and some pain with
swallowing food. You then started having some body aches and tried Tylenol with mild
relief. Your boyfriend also had similar symptoms 2 weeks ago and is better now.
You have no abdominal pain, pelvic pain, rash, chills, chest pain, or shortness of breath.
You had frequent sore throat episodes as a child, but have only had this twice in the past
2 years.
You had frequent episodes of tonsillitis in childhood. You have never been pregnant.
Medications: None
Allergies: None
Family history: Your parents and sister are healthy
Social history: You are a college student. You do not smoke, drink, or do illegal drugs.
You have not had transfusions or tattoos. You are sexually active with your boyfriend
and use condoms. Your last menstrual period was 2 weeks ago.
Physical Exam:
Head and Neck: Oropharynx with tonsillar exudates, tympanic membranes clear
bilaterally, no sinus tenderness to palpation, no enlarged lymph nodes, no jaundice.
Chest/Lungs: Clear to auscultation bilaterally.
Heart: Regular rhythm without murmurs, gallops, or rubs.
to percussion; no hepatosplenomegaly.
The doctor needs to do the above exams at the minimum, and should note exudates in
the mouth. They must also look in the ears. The rest of the examination is normal.
56yearold male for BP Check and refill of the medications
Vitals:
PR: 80/min
BP: 150/90 mmHg
Temp: 97.0 F (36.1 C)
RR: 16/min
Make a metal checklist of complications of BP:
Diastolic congestive cardiac failure
Coronary artery disease (angina)
Peripheral vascular disease
Retinopathy
Side affects of the medications
Case 9 Patient Notes
56YO man here for BP check and medication refill
Noticed BP ranges from 140150 systolic and 8090 diastolic at home 3x/week in
morning and evening
Is not compliant with lowsalt diet and does not exercise regularly
Compliant with medications
Developed cough with ACE inhibitor, ED with beta blockers
ROS: No headaches, palpitations, blurry vision, chest pain, shortness of breath, nose
bleeds, dizziness, or leg swelling
PMHx: Hypertension and hypercholesterolemia for past 10 years
PSHx: None
Meds: HCTZ 50 mg a day, simvastatin 20 mg a day
Allergies: None
FHx: Father with hypertension, mother with diabetes
SHx: Smokes 1 PPD for 30 years, drinks occasionally
Physical examination: Describe any positive and negative findings relevant to this
this encounter.
Vital signs: Temperature, 98.6 F (37.0 C); blood pressure, 150/90 mm Hg in both
arms; heart rate, 90/min; and respiratory rate, 16/min
HEENT: PERRLA, EOMI. Fundi without papilledema, exudates, or AV nicking
Neck: No enlarged lymph nodes, no bruits
Chest/lungs: Clear to auscultation bilaterally
Extremities: No cyanosis, clubbing, or edema. Pulses 2+ bilaterally in carotid,
radial, posterior tibialis
appropriate. Then enter the positive or negative findings from the history and the
physical examination (if present) that support each diagnosis. Finally, list initial
diagnostic studies (if any) you would order for each listed diagnosis (eg, restricted
physical examination maneuvers, laboratory tests, imaging, ECG)
Diagnosis #1: Essential hypertension, suboptimally controlled
History finding(s) Physical examination finding(s)
Hypertension Elevated blood pressure to 150/90
Poor dietary compliance No neck bruits
No regular exercise Symmetrical peripheral pulses
Normal funduscopic examination
Diagnostic studies
Serum electrolytes to monitor creatinine
Lipid panel
case9 SP Print
If the doctor asks you any questions other than these, just say “no” or “things are
normal in my daily life.”
You are a 56yearold man who needs a blood pressure recheck and medication refill.
History of present illness:
You are a 56yearold man who comes to the physician for a blood pressure check and
medication refill. You were diagnosed with high blood pressure and high cholesterol 10
years ago and have been compliant with your medications. However, you are not very
compliant with dietary sodium restrictions and do not exercise regularly. You check your
blood pressure 3 times a week in the morning and evening. It ranges from 140150
systolic and 8090 diastolic.
You have no headaches, palpitations, blurry vision, chest pain, shortness of breath, nose
bleeds, dizziness, or leg swelling.
Hypertension for the past 10 years. You tried taking lisinopril before and developed a
cough and had sexual problems with atenolol. (The doctor needs to ask about this; do
not volunteer this information.)
Hypercholesterolemia for the past 10 years. You had normal numbers a year ago on
your medication.
Medications:
Hydrochlorothiazide 50 mg once a day
Simvastatin 20 mg at bedtime daily
Allergies: None
Family history:
Your father has high blood pressure and your mother has diabetes.
Social history:
You are an accountant. You have smoked 1 pack of cigarettes a day for the past 30
years. You drink 1 glass of wine occasionally. You do not use illegal drugs. You have
had no transfusions or tattoos.
Physical examination:
Vital signs: T 98.6 F (37 C), BP 150/90 mm Hg in both arms, HR 90/min, RR 16/min
HEENT: Pupils are equally round and reactive to light and accommodation; extraocular
movements are intact. Funduscopic examination is without papilledema, exudates, or AV
nicking.
Neck: No enlarged lymph nodes, no bruits, carotid pulse 2+ bilaterally
Extremities: No cyanosis, clubbing, or edema. Peripheral pulses 2+ at radial and
posterior tibialis
The doctor needs to do the above minimum examinations but does not note any
abnormal findings.
66yearold male complaining of constipation
Vitals:
PR: 70/min, regular
BP: 120/70 mmHg
RR: 16/min
Temp: 98.0 F (36.7 C)
Make mental checklist for constipation:
Functional constipation
Obstructive lesions (bowel obstruction, carcinoma of colon)
Metabolic disturbances (hypothyroidism, diabetes mellitus, hypercalcemia)
Neurologic dysfunction (stroke, autonomic neuropathy, spinal cord trauma, multiple
sclerosis, and Parkinson's)
Medication induced (iron preparations, opiates, anticholinergics)
Case10 Pt Notes Print
66YO man here for constipation for 5 months with worsening over past 2 months
Fatigue, 10pound weight loss
Change in bowel movement from 1/day to 1 every other day
Occasional black stools
ROS: No diarrhea, abdominal pain, nausea, vomiting, fever, chills, night sweats, or
urinary problems
PMHx: Hashimoto’s thyroiditis, severe DJD of right knee
PSHx: None
Meds: Levothyroxine, Lortab (started 2 months ago)
Allergies: None
FHx: Father died at age 67 of colon cancer
SHx: No smoking but drinks 13 glasses of wine/week
this encounter.
Vital signs: Temperature, 36.7 C (98.0 F); blood pressure, 120/70 in both arms;
heart rate, 70/min; and respirations, 16/min
HEENT: No pallor or jaundice
Abdomen: Nontender, nondistended, hypoactive bowel sounds throughout, no
hepatosplenomegaly
Neurologic: Muscle strength 5/5 throughout, DTR 2+ bilaterally and symmetrical
Diagnosis #1: Colon cancer
Worsening constipation Hypoactive bowel sounds
Fatigue
Weight loss
Black stools
Diagnosis #2: Functional constipation from medications
New drug (Lortab) started with worsening of
Hypoactive bowel sounds
constipation
Diagnosis #3: Hypothyroidism with suboptimal control
Fatigue
Constipation
Diagnostic studies
Rectal examination with stool for occult blood
Serum TSH
Colonoscopy
Serum calcium
case10 SP Print
You are a 66yearold man with constipation.
You are a 66yearold man with 5 months of constipation that has worsened over the
past 2 months. You previously had 1 bowel movement a day that was well formed but
started becoming harder 5 months ago. You started straining more in the last 2 months
and had increased difficulty passing the stool, a sense of incomplete evacuation, and
decreased frequency to 1 bowel movement every other day. You have also noticed
occasional black stools without any blood in the past month. You are tired and have lost
10 pounds in the past 2 months. You have not changed your diet and eat plenty of fruits
and vegetables.
You have no diarrhea, abdominal pain, nausea, vomiting, fever, chills, night sweats, or
urinary problems.
Arthritis of the right knee
Hashimoto’s thyroiditis you had normal blood work 1 year ago.
Medications:
Levothyroxine 100 µg once a day
Hydrocodone/acetaminophen (Lortab) 5 mg/650 mg 1 pill 3 times/day (started 2 months
ago for knee pain)
Allergies: None
Family history:
Your father died of colon cancer at age 67 and your mother is healthy.
Social history:
You are a supervisor in a pharmaceutical company. You do not smoke. You drink 23
glasses of wine a week. You do not use illegal drugs. You have had no transfusions or
tattoos.
Health maintenance:
You have not had a colonoscopy before but had a normal rectal examination 2 years ago.
Vital signs: T 98.0 F (36.7 C), BP 120/70 mm Hg, HR 70/min, RR 16/min
HEENT: No pallor or icterus
Abdomen: Nontender, nondistended, hypoactive bowel sounds throughout, no
hepatosplenomegaly
Neurologic: Muscle strength 5/5 throughout, DTR 2+ bilaterally and symmetrical
The doctor needs to do the above minimum examinations.
50yearold male complaining of impotence
Vitals:
PR: 80/min, regular
BP: 150/80 mmHg
RR: 16/min
Temp: 98.0 F (36.7 C)
Make mental checklist for Impotence:
Diabetic neuropathy
Atherosclerotic vascular disease
Anxiety and other psychiatric disorders
Medications, like antihypertensives
Chronic alcoholism
Pituitary dysfunction
Spinal cord dysfunction
History: Describe the history you just obtained from this patient. Include only information
(pertinent positives and negatives) relevant to this patient’s problem(s).
50YO man here with 4 months of worsening erectile dysfunction
Started new blood pressure medication 4 months ago (atenolol)
Increased stress for past 6 months, mild fatigue
Poorly controlled diabetes with sugars near 200 most of the day
ROS: No headaches, leg pain, visual disturbances, nausea, vomiting, or abdominal pain
PMHx: Diabetes, hypertension, anxiety
PSHx: None
Meds: Metformin, glyburide, fluoxetine, atenolol (started 4 months ago)
Allergies: None
FHx: Parents and siblings are healthy.
SHx: Occasional smoking but drinks 23 beers/day for 25 years
Physical examination: Describe any positive and negative findings relevant to this patient’s
problem(s). Be careful to include only those parts of examination performed in this encounter.
Vital signs: Temperature, 98.0 F (36.7 C); blood pressure, 150/80 mm Hg; heart rate,
80/min; and respiratory rate, 16/min
HEENT: PERRLA, EOMI
Abdomen: Nontender, nondistended, normoactive bowel sounds throughout, no
hepatosplenomegaly, no bruits
Extremities: Pulses 2+ in bilateral lower extremities
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. Finally, 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: Medicationinduced ED
Started beta blocker 4 months ago
No nighttime erection
Difficulty having daytime erection
Diagnosis #2: Testosterone deficiency
Fatigue
Erectile dysfunction
Diagnosis #3: Anxiety
History of anxiety No focal findings on examination
Increased stress over past 6 months
Diagnostic studies
Serum glucose and hemoglobin A1C
Serum testosterone and TSH
case11 SP Print
You are a 50yearold man who has erectile dysfunction.
You are a 50yearold man who has had 34 months of gradually increasing difficulty
getting an erection. You have sexual desire but have been unable to get or maintain an
erection during this time. You have been under more stress over the past 6 months due
to financial difficulties and have not had sexual problems before. You have diabetes and
try to follow a good exercise and diet regimen. Your sugars range from 150200
throughout the day. On further questioning, you say that you also have minimal
nighttime erections. You also mention mild fatigue during this time.
You have no headaches, leg pain, visual disturbances, nausea, vomiting, or abdominal
pain.
Diabetes for 10 years
Hypertension
Generalized anxiety disorder
Medications:
Atenolol 50 mg a day (started 4 months ago)
Metformin 500 mg a day
Glyburide 10 mg a day
Fluoxetine 20 mg a day
Allergies: None
Family history: Parents and siblings are healthy.
Social history: You are a truck driver and live with your wife. You smoke 12 cigarettes
a week. You have consumed 23 beers/day for 25 years. You do not do illegal drugs.
You have had no transfusions or tattoos.
HEENT: PERRLA, EOMI
Mother of 1 Yr. O/Baby With Fever
Make a mental note of differential diagnosis of fever
Respiratory tract infections
Ear infections
Exanthematous diseases
Meningitis
Urinary tract infections
Gastroenteritis
case12 SP Print
If the doctor asks you any questions other than these, just say “no,” or “things are
normal in my daily life.” This is a telephone encounter with the doctor asking you
questions on the phone about the child.
You are a 28yearold woman who calls for evaluation of fever in your 1yearold child.
You are a 28yearold woman whose 1yearold child has had fever for 2 days. The child
was previously well but has developed fever to 102 F and dry cough. The child has not
been feeding well for the past 2 days but does not appear drowsy or lethargic.
Acetaminophen decreases the fever to 99 F. The child passes yellow urine but cries
while urinating. The child also has had 2 episodes of vomiting ingested food without
diarrhea. The child also has been picking at the right ear more often during this time.
You also noticed 1 episode in which the child shook with rhythmic jerking on both sides
and lost urine. After the episode, the child became silent, was irritable for a few
minutes, and then slept. You have bathed the child using tepid sponges with cold water
with some relief. Your child's 3yearold sibling has no complaints. The child stays at
home with you. All of the child's immunizations are up to date. The most recent well
child visit at 9 months had placed the child at 75%ile for height and 60%ile for weight.
There is no recent travel, rashes, sick contacts, or other complaints.
Past medical history/birth history:
The child was full term without complications at delivery. He/she was breastfed until 2
months and then started on formula. The child is able to stand, hold objects in the
hands, and say “mama” and “dada.” The child has no other medical conditions and no
hospitalizations.
Medications: Tylenol as needed
Allergies: None
information (pertinent positives and negatives) relevant to this patient's problem(s).
Telephone encounter with mother of 1YO child
1YO child with 2 days of fever to 102 F, cough, and picking at the right ear
Two episdoes of vomiting but no diarrhoea
Also had 1 episode of rhythmic total body shaking with passing urine
Crying when passing yellow urine
No lethargy
No previous infections or hospitalizations
No sick contacts; sibling is without symptoms
Birth history unremarkable with normal developmental milestones
Immunizations up to date
ROS: No recent travel or rashes
PMHx: None
PSHx: None
Meds: Acetaminophen
Allergies: None
patient's problem(s). Be careful to include only those parts of examination performed in
this encounter.
Not done as this is a telephone encounter
examination, list up to 3 diagnoses that might explain this patient's complaint(s). List
Diagnosis #1: Acute otitis media
Fever
Picking at right ear
Diagnosis #2: Urinary tract infection
Fever
Pain with urination
Diagnosis #3: Febrile seizure
Fever
Rhythmic tremor with fever that subsides
Passing urine with shaking movements
Diagnostic studies
Office visit for ear examination
Urinalysis
45yearold female complaining of acute, right upper quadrant abdominal pain
Vital signs:
PR: 100/min
Temp: 101.0 F (38.3 C)
RR: 20/min
BP: 130/80 mmHg
Make a mental checklist of DD for RUQ abdominal pain:
Acute cholecystitis
Biliary colic
Acute hepatitis
Perforation of peptic ulcer
Acute pancreatitis (biliary pain)
Right lower lobe pneumonia
Myocardial infarction
Congestive hepatomegaly
Hepatic abscess
Retrocecal appendicitis
case13 SP Print
You are a 45yearold woman complaining of abdominal pain.
You are a 45yearold woman who has had acute abdominal pain for 2 hours. The pain
started suddenly in the right upper part of the abdomen and has been gradually
worsening. The pain is 89/10 in severity and feels like a stabbing sensation that
radiates to the back of the right shoulder. It started 30 minutes after you ate a meal
today. You also have occasional nausea and vomiting without blood or bile. The pain is
worsened with deep breathing and is not relieved with antacids.
You have had previous episodes of similar pain approximately 34 times a month starting
5 months ago. The episodes usually begin 23 hours after meals and sometimes improve
with antacids. You eat a lot of fast food for lunch and dinner because you are very busy
with work and have no time to cook. You also feel warm but did not check your
temperature.
You have no jaundice, cough, shortness of breath, itching, chest pain, or diarrhea.
Past surgical history: Csection 20 years ago
Medications: Overthecounter antacids as needed
Allergies: None
Social history: You are an accountant and live with your husband. You have smoked 1
pack of cigarettes a day for 25 years. You have consumed 23 beers a day for 15 years.
You do not take illegal drugs. You have had no transfusions or tattoos.
HEENT: PERRLA, EOMI, no jaundice
Abdomen: RUQ discomfort with deep palpation and slightly worse with deep breath;
nondistended, normoactive bowel sounds throughout; no hepatosplenomegaly; no bruits
45YO female with 2 hours of worsening RUQ abdominal pain radiating to the right
scapula
Has had 5 months of intermittent similar episodes 34 times a month that resolved
with antacids
Stabbing pain starting 30 minutes after food with nausea and nonbilious and non
bloody vomitus
Pain is worsened with deep breathing and not improved with antacids
ROS: No jaundice, cough, shortness of breath, itching, chest pain, or diarrhea
PMHx: None
PSHx: Csection 20 years ago
Meds: OTC antacids PRN
Allergies: None
SHx: 1 PPD smoker for 25 years and drinks 23 beers/day for 15 years
this encounter.
Vital signs: Temperature, 101.0 F (38.3 C); blood pressure, 130/80 mm Hg; heart
rate, 100/min; and respiratory rate, 20/min
Abdomen: RUQ discomfort with deep palpation; nondistended, normoactive bowel
sounds throughout; no hepatosplenomegaly; no bruits
Diagnosis #1: Acute cholecystitis
RUQ abdominal pain Fever
5 months of similar episodes RUQ tenderness
Pain radiating to right shoulder Positive Murphy’s sign
Pain worsened with deep breathing
Diagnosis #2: Acute pancreatitis
RUQ pain RUQ tenderness
Nausea and vomiting Fever
Alcohol use
Diagnosis #3: Peptic ulcer
Nausea and vomiting Fever
RUQ pain RUQ tenderness
Alcohol/Tobacco use
Diagnostic studies
Ultrasound RUQ abdomen
24 Yr. O/F Came for prenatal visit for the first time
Vitals
Pulse78/min
B.P120/75 mm of Hg
Temp98.8F
R.rate20/min
case14 SP Print
You are a 25yearold woman here for your first prenatal visit.
You are a 25yearold woman G1P0 who comes to the physician for her first prenatal
visit. Your last menstrual period was 12 weeks ago and you confirmed your pregnancy 6
weeks ago with a home pregnancy test. You have not yet felt any fetal movements and
this is your first pregnancy. You have no history of miscarriage or abortion. You had
menarche at age 13 and have had regular periods for 45 days each month.
You have no morning sickness, vomiting, abdominal pain, vaginal bleeding, fever, rash,
breathing problems, sleep disturbances, or swelling in the feet.
Medications: None
Allergies: None
Social history: You are currently not working and live with your husband. You have
smoked 1 pack of cigarettes a day for 5 years. You have consumed 13 beers a week for
3 years. You do not use illegal drugs. You have had no transfusions or tattoos.
Health maintenance: You are up to date on all immunizations
HEENT: PERRLA, EOMI, no jaundice, oropharynx clear
Lungs: Clear to auscultation bilaterally
Heart: Regular rate and rhythm without murmurs, gallops, or rubs
hepatosplenomegaly, and no bruits
Extremities: No cyanosis or edema
24YO woman G1P0A0 and LMP 12 weeks ago who presents for her first prenatal
visit
Has no fetal movements yet
ROS: No morning sickness, vomiting, abdominal pain, vaginal bleeding, fever, rash,
breathing problems, sleep disturbances, or swelling in the feet
PMHx: None
PSHx: None
Meds: None
Allergies: None
SHx: 1 PPD smoker for 5 years and drinks 13 beers/week for 3 years
this encounter.
HEENT: PERRLA, EOMI, no jaundice, oropharynx clear
Abdomen: Nontender, nondistended, normoactive bowel sounds throughout; no
hepatosplenomegaly; and no bruits
Extremities: No cyanosis or edema
Diagnosis #1: Normal pregnancy
LMP 12 weeks ago Nondistended abdomen
Home pregnancy test positive 6 weeks ago No edema
Diagnosis #2:
Diagnosis #3:
Diagnostic studies
Urine culture
Rhesus type and red cell antibody screen
Rubella and varicella titters
Serum RPR, HIV, Hepatitis B antigen
60yearold male complaining of acute shortness of breath
Vitals:
PR: 90/min
BP: 110/70 mmHg
Temp: 98 F (36.7 C)
RR: 26/min
Make a mental checklist for acute shortness of breath:
Pulmonary embolism
Chronic obstructive pulmonary disease exacerbation
Pneumonia
Spontaneous pneumothorax
Bronchial asthma
Anxiety and panic attacks
case15 SP Print
You are a 60yearold man complaining of shortness of breath.
You are a 60yearold man who comes to the physician with shortness of breath for 2
days. You were doing well until 1 year ago when you had onset of shortness of breath
with strenuous work that slowly worsened during the year. However, during the last 2
days you have had an acute worsening of the symptoms with trouble breathing at night.
You need 2 pillows when you sleep. Your breathing is worse when lying down and
improves with sitting up. You also have awakened with shortness of breath during the
night and take 20 minutes to get back to sleep.
You have dyspnea with mild exertion walking 1 block that improves with rest. You
also have occasional dry cough. You have no swelling in legs. You had spinal fusion
surgery 2 weeks ago for spinal stenosis that required 1 week in the hospital
postoperatively.
You have no chest pain, wheezing, fatigue, palpitations, syncope, fever, or chills.
Past medical history: Hypertension diagnosed 20 years ago
Past surgical history: Spinal stenosis in the low back requiring spinal fusion surgery as
noted above
Medications: Hydrochlorothiazide 25 mg once daily
Allergies: None
Family history: Father died at age 55 of heart attack; mother has hypertension; no
siblings
Social history: You are a computer software analyst and live with your wife. You have
smoked 1 pack of cigarettes a day for 40 years. You have consumed 12 glasses of
wine/day for 35 years. You have never used illegal drugs. You have had no transfusions
or tattoos.
Neck: Supple without lymphadenopathy, no JVD, no thyromegaly
Lungs: Clear to auscultation
Heart: Regular rate and rhythm without murmurs, gallops, rubs
Extremities: No edema, pulses 2+ bilaterally, no cyanosis or clubbing, no lower
extremity tenderness to palpation
60YO man with 2 days of worsening shortness of breath
Has had 1 year of gradually worsening shortness of breath that acutely worsened 2
days ago
New 2pillow orthopnea, PND
Spinal fusion surgery 2 weeks ago
Occasional dry cough
ROS: No chest pain, wheezing, fatigue, palpitations, leg swelling, syncope, fever, or
chills.
PMHx: HTN
PSHx: Spinal fusion surgery
Meds: Hydrochlorothiazide 25 mg a day
Allergies: None
FHx: Father died of MI at age 55; mother has HTN
SHx: 1 PPD smoker for 40 years and drinks 12 glasses of wine/day for 35 years
this encounter.
Neck: Supple without lymphadenopathy, no JVD, no thyromegaly
Extremities: No edema, pulses 2+ bilaterally, no cyanosis or clubbing, no lower
extremity tenderness to palpation
Acute worsening of dyspnea
Recent spinal fusion surgery
Diagnosis #2: Congestive heart failure
1 year of gradually worsening dyspnea
Dyspnea worse with exertion
Orthopnea and PND
Diagnosis #3: COPD
History of smoking
1 Year of gradually worsening dyspnea
Cough
Diagnostic studies
Chest xray
CT angiogram of chest
EKG, Echocardiogram

40yearold female with increased urination
Vitals:
PR: 86/min,regular
BP: 110/70 mmHg
RR: 16/min
Temp: 98.0 F (36.7 C)
Make a mental checklist of DD for polyuria:
Diabetes mellitus
Central diabetes insipidus
Nephrogenic diabetes insipidus
Psychogenic Polydypsia
Cystitis (Urinary Tract Infection)
Diuretics and other drug intake
Hypercalcemia
case16 SP Print
You are a 40yearold woman complaining of increased urinary frequency.
You are a 40yearold woman with 2 months of increased urinary frequency. You have
been urinating 810 times during the day and 23 times at night with increased urinary
volume. You have also become increasingly thirsty for the past month and have felt
tired for the past 2 months. You drink a lot of water and are also eating more but have
lost 10 pounds during the past 23 months.
You have no burning with urination, urinary urgency, fever, or chills.
Bipolar disorder diagnosed 20 years ago
G2P2
Minor head trauma after falling off bicycle 3 months ago; seen in emergency department
and discharged without intervention
Medications: Lithium 600 mg two times daily
Allergies: None
Family history: Father and mother both have diabetes, no siblings
Social history: You are a homemaker and live with your husband. You do not smoke or
drink alcohol. You have never used illegal drugs. You have had no transfusions or
tattoos.
HEENT: PERRLA, EOMI, visual fields intact
Abdomen: Nontender without suprapubic tenderness, no CVA tenderness
Neurologic: Muscle strength 5/5 throughout, sensation grossly intact in bilateral lower
extremities, DTR 2+ bilateral lower extremities
40YO woman with 2 months of polyuria, polydipsia, nocturia, and polyphagia
Has had 23 months of 10pound weight loss with fatigue
No dysuria or urinary urgency
ROS: No fever or chills
PMHx: Bipolar disorder diagnosed 20 years ago, minor head trauma 3 months ago seen
in emergency department and discharged without any intervention
PSHx: None
Meds: Lithium 600 mg 2 times daily
Allergies: None
FHx: Father and mother have diabetes.
SHx: No history of tobacco or alcohol use
this encounter.
rate, 86/min; and respiratory rate,16/min
HEENT: PERRLA, EOMI, visual fields intact
Abdomen: Nontender without suprapubic tenderness, no CVA tenderness
Neurologic: Muscle strength 5/5 throughout, sensation grossly intact in bilateral
lower extremities, DTR 2+ bilateral lower extremities
Diagnosis #1: Diabetes mellitus
Polyuria
Polydipsia and polyphagia
Family history of diabetes in father and

mother
Weight loss
Diagnosis #2: Diabetes insipidus
History of bipolar disorder
Lithium use
Polyuria
Diagnosis #3: Psychogenic polydipsia
History of bipolar disorder
Polyuria
Polydipsia
Diagnostic studies
Fasting blood sugar
Hemoglobin A1C
Urinalysis
Serum electrolytes, lithium level
Urine and serum osmolality
35 Yr. O/F Came for evaluation of jaundice
Vitals
Pulse98/min
B.P120/75 mm of Hg
Temp101.3
R.rate22/min
Make a mental checklist of Differential Diagnosis for jaundice
Infectious hepatitis
Hemolytic jaundice
Alcoholic hepatitis
Drug induced hepatitis
Primary biliary cirrhosis
Wilson's disease
Hemochromatosis
Malignancy
case17 SP Print
You are a 35yearold woman complaining of jaundice.
You are a 35yearold woman who has had jaundice for 2 days. You were well until 5
days ago when you developed fever. You noticed dark urine and pale stools 3 days ago,
and then yellow eyes 2 days ago. You also have had mild abdominal discomfort, nausea,
and 23 episodes of nonbilious and nonbloody vomiting. You returned 3 weeks ago
from a trip to India, where you ate local food and drank bottled water. You have not had
vaccines for hepatitis.
You have no sore throat, headache, stiff neck, dysuria, weight loss, itching, diarrhea, or
constipation.
Ask the doctor: “Do you think that this is hepatitis?”
Car accident 2 years ago requiring hospitalization and blood transfusion
G2P2
Medications: None
Allergies: None
Family history: Father and mother are healthy; 3 siblings are also healthy.
Social history: You are a homemaker and live with your husband. You do not smoke.
You have consumed 23 beers a day for the past 15 years. You have never used illegal
drugs. You have no tattoos.
HEENT: PERRLA, EOMI, icterus present, oropharynx clear
Neck: No lymphadenopathy
Abdomen: Nontender, nondistended, no hepatosplenomegaly, normoactive bowel
sounds
35YO woman with 2 days of jaundice associated with fever
Returned 3 weeks ago from trip to India
Dark urine and pale stools
Mild diffuse abdominal discomfort, nausea, vomiting
ROS: No sore throat, headache, stiff neck, dysuria, weight loss, itching, diarrhea, or
constipation
PMHx: Car accident 2 years ago requiring hospitalization and blood transfusion
PSHx: None
Meds: None
Allergies: None
FHx: Father, mother, and siblings are healthy.
SHx: No history of tobacco use. She drinks 23 beers/day for the past 15 years.
this encounter.
rate, 98/min; respiratory rate, 22/min
HEENT: PERRLA, EOMI, icterus present, oropharynx clear
Neck: No lymphadenopathy
sounds
Diagnosis #1: Infectious hepatitis
Travel to India Fever
Jaundice Jaundice
Nausea, vomiting, abdominal discomfort
Dark urine with pale stools
Diagnosis #2: Alcoholic hepatitis
Alcohol use Fever
Nausea, vomiting, abdominal discomfort Jaundice
Diagnostic studies
Hepatitis serologies: A, B, and C
Urinalysis
35 Yr. O/F Complaining of Chest Pain
Vitals
Pulse98/min
B.P120/75 mm of Hg
Temp98.3
R.rate12/min
Make a mental checklist of Differential Diagnosis.
If a young adult female comes with chest pain think of non cardiac causes first because
that is the one that you are going to get in the exam.
Pneumonia
Gastro esophageal reflux disease (GERD)
Panic disorder
Hyperthyroidism
Pheochromocytoma
Hyperventilation syndrome
Angina
Costochondritis
case18 SP Print
You are a 35yearold woman complaining of chest pain.
You are a 35yearold woman who has had chest pain for 1 day. You were well until 1
year ago, when you started having episodes of chest pain described as squeezing
tightness all over the chest without radiation. These episodes lasted around 20 minutes.
Each episode is a 45/10 in severity without aggravating or relieving factors. You also
note hyperventilation, increased sweating, headache, palpitations, and a sense of
impending doom. You had 45 episodes for the first 6 months but they have increased to
once a week since then. Today, you have had 2 episodes.
You were hospitalized 6 months ago with chest pain and were tested, but everything
came back normal. No cause for the chest pain was determined. The symptoms seem
to occur when you go out in public. You have tried antacids without relief.
You have no nausea, vomiting, dysuria, diarrhea, constipation, flushing, sleep
disturbances, or abdominal pain.
Ask the doctor: “Do you think that this is a heart attack?”
Car accident 2 years ago requiring hospitalization and blood transfusion
G0P0
Medications: None
Allergies: None
Family history: Father is healthy. Mother has hypochondriasis. Sister has
hyperthyroidism.
Social history: You live alone and are a secretary for a large law firm. You have
smoked 1 pack a day for the past 15 years. You do not drink alcohol. You have never
used illegal drugs. You have no tattoos.
Neck: No lymphadenopathy or thyromegaly
Case 18 Patient Note
35YO woman with 1 year of worsening chest pain episodes
Episode described as diffuse chest tightness associated with headache, palpitations,
diaphoresis, hyperventilation, and sense of impending doom
Has been hospitalized previously with normal testing
Episodes occur more often when out in public and are not relieved with antacids
ROS: No nausea, vomiting, dysuria, diarrhea, constipation, flushing, sleep disturbances,
or abdominal pain.
PMHx: None
PSHx: None
Meds: None
Allergies: None
FHx: Father is healthy, mother has hypochondriasis, and sister has hyperthyroidism.
SHx: 1 PPD smoker for 15 years. She does not drink alcohol or use illegal drugs.
this encounter.
rate, 98/min; and respiratory rate,12/min
Neck: No lymphadenopathy or thyromegaly
physical examination maneuvers, laboratory tests, imaging, ECG).
Diagnosis #1: Panic attack disorder
Episodes of chest pain Normal vital signs
Worse when out in public Normal cardiac examination
Normal investigation in the past
Family history
Palpitations
Diagnosis #3: Cardiac arrhythmia (eg, SVT)
Episodic palpitations
Chest pain and diaphoresis
Diagnostic studies
EKG
Event monitor
45 Yr. O/M complaining of Rt lower abdominal pain
Vitals
Pulse100/min
Temp98.7
R.Rate20/min
B.P130/80 mm of Hg.
Make a mental check list for Rt Lower Quadrant abdominal pain in a male pt
Appendicitis
Meckel's diverticulitis
Perforated viscus
Intestinal obstruction
Yersinia enterocolitica
Pancreatitis
Urolithiasis
Even acute cholecystitis
case19 SP Print
You are a 45yearold man complaining of abdominal pain.
You are a 45yearold man who has had abdominal pain for 2 hours. The sharp pain
started suddenly behind the belly button and radiated to the right lower part of the
abdomen. It is an 89/10 severity and has been increasing progressively. The
symptoms started an hour after you ate a large meal and are worse with movement.
You also have had nausea and 2 episodes of nonbilious and nonbloody vomiting today.
Nothing improves the pain. Your last bowel movement was 20 hours ago and you are
passing gas.
You have no fever, chills, dysuria, diarrhea, constipation, or back pain.
Past medical history: Peptic ulcer disease that was treated 10 years ago with
omeprazole
Medications: None
Allergies: None
Family history: Father, mother, and 2 siblings are healthy.
Social history:
You live alone and work as a bus driver for a local company. You have smoked 1 pack a
day for the past 20 years. You have consumed 3 beers a day for the past 15 years. You
have never used illegal drugs. You have no tattoos.
Vital signs: T 98.7 F (37.1 C), BP 130/80, HR 100/min, RR 20/min
Abdomen: Right lower quadrant tenderness to superficial and deep palpation, rebound
tenderness noted, normoactive bowel sounds throughout, no hepatosplenomegaly, no
CVA tenderness, negative psoas and obturator signs
45 YO man with 2 hours of worsening midepigastric to RLQ abdominal pain
Pain worse with movement but not relieved with anything
Nausea and vomiting (nonbloody, nonbilious)
Last bowel movement 20 hours ago with passage of flatus
ROS: No fever, chills, dysuria, diarrhea, constipation, or back pain
PMHx: Peptic ulcer disease treated in the past
PSHx: None
Meds: None
Allergies: None
FHx: Father, mother, and siblings healthy
SHx: 1 PPD smoker for past 20 years. He drinks 3 beers/day for past 15 years.
this encounter.
Abdomen: Right lower quadrant tenderness to superficial and deep palpation,
rebound tenderness noted, normoactive bowel sounds throughout, no
hepatosplenomegaly, no CVA tenderness, negative psoas and obturator signs
Diagnosis #1: Appendicitis
Sudden onset of RLQ abdominal pain RLQ abdominal tenderness
Nausea and vomiting Rebound tenderness in abdomen
Diagnosis #2: Perforated peptic ulcer
History of peptic ulcer Rebound tenderness in abdomen
Abdominal pain
Alcohol use
Diagnosis #3: Intestinal obstruction
Abdominal pain Rebound tenderness in abdomen
Last bowel movement 20 hours ago
Diagnostic studies
Abdominal xray
CT abdomen
50yearold male with bilateral leg pain
Vitals:
Pulse: 78/min
Temp: 98.0 F (36.7 C)
RR: 20/min
BP: 140/80 mmHg
Make a mental check list of DD for bilateral leg pain:
Thromboangiitis obliterans
Atherosclerotic vascular disease
Lumbar spinal stenosis
Diabetic polyneuropathy
Radiculopathy due to spinal disease
Medications, such as statins
Trauma
Deep vein thrombosis (rarely bilateral)
Unilateral pain:
Cellulites/myofascitis
Deep vein thrombosis
Rupture of Bakers cyst
Osteomyelitis
Bleeding into the leg (if the patient is on warfarin/coumadin)
Radiculopathy
Pathological fracture of the bone
case20 SP Print
You are a 50yearold man complaining of bilateral leg pain.
You are a 50yearold man who has had bilateral leg pain for 2 months. The pain started
gradually and has been progressively increasing to a 56/10 severity. The pain is
throbbing and is located mainly over the calf muscles without radiation. It is made
worse with walking, running, and prolonged standing. The symptoms improve with rest
and sitting.
You have no pain at rest, fever, trauma, swelling, back pain, weakness, sexual
difficulties, numbness, or tingling in the legs.
Diabetes for the past 3 years on diet control
High cholesterol
Medications: Simvastatin 40 mg daily at bedtime
Allergies: None
Family history: Father died at age 65 of a stroke. Mother and 2 siblings are healthy.
Social history: You are a postal worker and live with your wife. You have smoked 2
packs per day for the past 30 years. You drink a beer occasionally. You have never
used illegal drugs. You have no tattoos.
Abdomen: No bruits
Extremities: Pulses 2+ and symmetrical in bilateral lower extremities
Musculoskeletal: Negative Homan's sign, no calf tenderness to palpation bilaterally
Neurologic: Bilateral lower extremities with 5/6 motor, grossly intact sensation, and
DTR 2+
50YO man with 2 months of worsening bilateral leg pain
Throbbing pain mainly over the calf muscles made worse with walking, running,
and prolonged standing
Symptoms improve with rest and sitting
ROS: No pain at rest, fever, trauma, swelling, back pain, weakness, sexual difficulties,
numbness, or tingling in legs
PMHx: Diabetes for 3 years under diet control
Hypercholesterolemia
PSHx: None
Meds: Simvastatin 40 mg daily at bedtime
Allergies: None
FHx: Father died at age 65 of stroke. Mother and other 2 siblings are healthy.
SHx: 2 PPD smoker for past 30 years, occasional alcohol use
this encounter.
Vital signs: Temperature, of 98.0 F (36.7 C); blood pressure, 140/80 mm Hg; heart
Abdomen: No bruits
Extremities: Pulses 2+ and symmetrical in bilateral lower extremities
Musculoskeletal: Negative Homan's sign, no calf tenderness to palpation bilaterally
Neurologic: Bilateral lower extremities with 5/5 motor strength, intact vibratory
sensation and proprioception, and DTR 2+
Diagnosis #1: Druginduced (statin) myopathy
Proximal muscle pain Normal motor strength in legs
History of statin use No sensory deficits in legs
Diagnosis #2: Atherosclerotic peripheral vascular disease
History of diabetes and high cholesterol
History of smoking
Family history of stroke
Diagnosis #3: Diabetic polyneuropathy
Dietcontrolled diabetes
History of high cholesterol
Diagnostic studies
Creatinine kinase
Fasting blood sugar and hemoglobin A1C
Lowerextremity arterial Doppler
40yearold male with vomiting of blood
Vitals:
PR: 88/min
Temp: 98.0 F (36.7 C)
RR: 20/min
BP: 110/80 mmHg
Make a mental checklist of DD for hematemesis:
Peptic ulcer decease
Gastric erosions
Esophageal varices
MalloryWeiss tear
Esophagitis
Duodenitis
Malignancy (esophageal and gastric)
case21 SP Print
You are a 40yearold man complaining of vomiting up blood.
You are a 40yearold man who has vomited up blood for 2 hours. You were well until 1
day ago when you developed sharp midepigastric abdominal pain of 45/10 severity and
no radiation. You also developed nausea that worsened today, throwing up twice with
almost a teaspoonful of blood each time. You have also had black stools for the past
week.
You have no changes in appetite, weight loss, fever, chills, shortness of breath,
dizziness, or chest pain.
Past medical history: GERD for past 2 years relieved with antacids as needed; Chronic
back pain.
Medications: Ibuprofen as needed
Allergies: None
Family history: Father died at age 60 of heart attack. Mother and 2 siblings are
healthy.
Social history: You are a postal worker and live with your wife. You have smoked 1
pack a day for the past 25 years. You have consumed 45 beers daily for the past 20
years. You have never used illegal drugs. You have no tattoos.
HEENT: Oropharynx clear
Abdomen: Nontender, nondistended, normoactive bowel sounds, no
hepatosplenomegaly
40YO man with 2 hours of hematemesis with 1 teaspoon of blood
History of GERD relieved with asneeded antacids
One day of midepigastric abdominal pain without radiation associated with nausea
One week of melena
ROS: No changes in appetite, weight loss, fever, chills, shortness of breath, dizziness, or
chest pain
PMHx: GERD; Chronic back pain
PSHx: None
Meds: Ibuprofen, as needed
Allergies: None
FHx: Father died at age 60 of heart attack. Mother and 2 siblings are healthy.
SHx: 1 PPD smoker for past 20 years, 45 beers/day for past 20 years
this encounter.
Vital signs: Temperature, 98.0 F (36.7 C); blood pressure,110/80 mm Hg; heart
hepatosplenomegaly
Diagnosis #1: Bleeding peptic ulcer
History of ibuprofen and excessive alcohol use
Midepigastric pain
Hematemesis and melena
Diagnosis #2: Esophageal variceal bleeding
History of GERD and excessive alcohol use
Midepigastric pain and hematemesis
Melena
Diagnosis #3: Gastritis
History of ibuprofen and excessive alcohol use
Midepigastric pain
Melena
Diagnostic studies
Orthostatic BP and HR measurements
CBC with differential, Basic metabolic panel
Liver function tests and PT/INR
Upper GI endoscopy
55 Yr. O/M Complaining of Chest Pain
Vitals
Pulse78/min
Temp98.7
R.Rate20/min
B.P130/80 mm of Hg.
Make a mental check list for Chest pain
Myocardial Infarction
Unstable Angina
Pulmonary Embolism
Costochondritis
Pleuritis
Pericarditis
Aortic Dissection
G.E.R.D
Esophageal perforation
case22 SP Print
You are a 55yearold man complaining of chest pain.
You are a 55yearold man who comes to the physician with 2 hours of chest pain. The
pain came on suddenly and has progressively worsened to 89/10 severity. You describe
the pain as tightness and squeezing in the substernal area without radiation. It is worse
when walking and moving around. The pain has been fairly constant and is associated
with nausea, 1 episode of vomiting, sweating, and mild shortness of breath.
You have no fever, cough, headache, abdominal pain, diarrhea, constipation, recent
trauma, appetite changes, weight loss, or urinary problems.
High blood pressure for 20 years
Diabetes for 5 years
Cholesterol tested a year ago was 280 (total). You are trying to control your cholesterol
with diet.
Medications:
Atenolol 50 mg a day
Metformin 500 mg a day
Allergies: None
Family history: Father died at age 60 of a heart attack. Mother is living and had a
stroke at age 65. Your brother had a heart attack at age 58.
Social history: You live with your wife and work as a lawyer. You have smoked 1 pack
a day for the past 30 years. You have consumed 1 glass of wine daily for the past 20
years. You eat a lot of fast food. You have never used illegal drugs. You have no
tattoos.
Neck: Supple without JVD or lymphadenopathy, no thyromegaly
Lungs: Clear to auscultation bilaterally. No reproducible chest pain with palpation
55YO man with 2 hours of chest pain described as substernal tightness and
pressure increased with movement and walking. The pain is 89/10 in severity.
There is no radiation.
Nausea, vomiting, sweating, and shortness of breath are associated with pain.
ROS: No fever, cough, headache, abdominal pain, diarrhea, constipation, recent trauma,
appetite changes, weight loss, or urinary problems
PMHx: Hypertension, diabetes, high cholesterol
PSHx: None
Meds: Atenolol 50 mg a day, metformin 500 mg a day
Allergies: None
FHx: Father died at age 60 of heart attack. Mother is living and had a stroke at age 65.
Brother had a heart attack at age 58.
SHx: 1 PPD smoker for past 30 years, 1 glass of wine/day for past 20 years
this encounter.
Neck: Supple without JVD or lymphadenopathy, no thyromegaly
Lungs: Clear to auscultation bilaterally. No reproducible chest pain with palpation
Diagnosis #1: Acute coronary syndrome
Substernal chest pressure No reproducible chest pain with palpation
History of untreated high cholesterol
Nausea, vomiting, diaphoresis
Diagnosis #2: Aortic dissection
History of hypertension No reproducible chest pain with palpation
Substernal chest pain
Sudden onset of symptoms
Sudden onset of chest pain No reproducible chest pain with palpation
Shortness of breath
Diagnostic studies
EKG
Chest xray
Cardiac enzymes
Echocardiogram
70 Yr. O/M complaining of Frequent Falls
Vitals
Pulse78/min
Temp98.7
R.Rate20/min
B.P130/80 mm of Hg.
Make a mental checklist of differential diagnosis for falls
Cerebellar disease [Alcoholic/Tumor]
Parkinson's disease [Idiopathic/drug induced]
Diabetic neuropathy [Sensory ataxia]
Brain tumors
Hyperthyroidism
Fractured hip
Seizure
Vertigo
case23 SP Print
You are a 70yearold man complaining of frequent falls.
You are a 70yearold man who has fallen frequently for the past 2 months. You were
well until 2 months ago when you started having problems with your balance while
standing, leading to falls. These episodes initially occurred once a week but have
increased to twice a week over the last month. You have not fractured any bones but
are concerned that this may happen in the future. You have also noticed a tremor in
your hands that makes it difficult to hold things; it worsens when you reach for an
object. A friend also noticed that your speech has changed. You also have occasional
headache in the morning. There is no numbness of tingling in both legs.
You have no dizziness, vertigo, leg weakness, fever, nausea, vomiting, hair loss, chest
pain, abdominal pain, recent trauma, diarrhea, constipation, or urinary problems.
Past medical history: Diabetes for past 10 years under good control
Medications: Metformin 500 mg a day
Allergies: None
Family history: Father and mother both died of old age. You have no siblings.
Social history: Your wife passed away 5 years ago and you live alone. You do not
smoke. You have consumed 2 beers daily for the past 40 years. You have not used illicit
drugs.
Check for orthostatic vitals
HEENT: Visual acuity testing
Neck: Supple without JVD or lymphadenopathy, no thyromegaly, no bruits
Neurologic: Motor 5/5 bilaterally, sensory grossly intact bilaterally, resting tremor, mild
dysmetria (finger to nose) present, mild dysdiadochokinesia (alternating movements),
DTR 2+ bilaterally
70YO man with 2 months of frequent falls
Has had balance problems while standing up; no syncope
Tremor in hands worse with reaching for objects
Change in speech, occasional morning headache
No sensory symptoms (numbness, tingling) in legs
No dizziness or vertigo
ROS: No fever, nausea, vomiting, hair loss, chest pain, abdominal pain, recent trauma,
diarrhea, constipation, or urinary problems
PMHx: Diabetes
PSHx: None
Meds: Metformin 500 mg a day
Allergies: None
FHx: Father and mother both died of old age.
SHx: No smoking, 2 beers daily for past 40 years
this encounter.
HEENT: PERRLA, EOMI; Visual acuity normal
Neck: Supple without JVD or lymphadenopathy, no thyromegaly, no bruits
Neurologic: Motor 5/5 bilaterally, sensory grossly intact bilaterally, resting tremor,
mild dysmetria (finger to nose) present, mild dysdiadochokinesia (alternating
movements), DTR 2+ bilaterally
Diagnosis #1: Cerebellar disease due to alcohol use
History of chronic alcohol use Dysmetria
Difficulty with balance Dysdiadochokinesia
Diagnosis #2: Parkinson�s disease
Tremor Resting tremor
Balance problems
Diagnosis #3: Brain tumor
Speech difficulties; headache
Balance problems
2 Months of symptom onset
Diagnostic studies
Orthostatic vitals
Brain imaging (CT or MRI)
Thyroid function tests; Vitamin B 12 levels
35 Yr. O/M Complaining of Cough and Chest Pain
Vitals
Pulse94/min
Temp 101.7
R.Rate 24/min
B.P130/80 mm of Hg.
Make a mental check list for Cough and Chest pain
Pneumonia
Pleuritic pain
Pleural effusion
Pulmonary edema
Tuberculosis
Pulmonary embolism
Ca. Bronchus
Infective endocarditis
GERD
case24 SP Print
You are a 35yearold man complaining of cough.
You are a 35yearold man who comes to the physician with 2 days of coughing. You
initially developed malaise followed by productive cough of bloodtinged, yellow sputum.
You subsequently had sharp pain described as 56/10 intensity over the left chest. The
pain is worsened with moving around and deep inspiration and improved with expiration.
You have also had fever, chills, sweating, and mild shortness of breath. One of your
colleagues in the office recently had pneumonia.
You ask: “Is this pneumonia?”
You have no changes in appetite, weight loss, abdominal pain, recent trauma, diarrhea,
constipation, or urinary problems.
Past medical history: Hospitalized once for chest pain 5 years ago with negative
testing
Medications: None
Allergies: Penicillin (rash)
Family history: Father and mother are healthy. You have no siblings.
Social history: You live alone and work as an investment advisor for a local firm. You
have smoked 1 pack a day for the past 15 years. You have consumed 2 shots of liquor
every weekend with friends for the past 10 years. You have not used illicit drugs and
have no tattoos.
Neck: Supple without JVD or lymphadenopathy, no thyromegaly, no bruits, no accessory
muscle use
Lungs: Clear to auscultation bilaterally, fremitus symmetrical bilaterally, resonant to
percussion bilaterally, no bronchophony or egophony
sounds
35 YO male with 2 days of productive cough of yellow bloodtinged sputum
2 days of sharp leftsided chest pain worsened with inspiration and improved with
expiration
Patient has fever, chills, sweating, and mild shortness of breath
Sick contact in office
ROS: No changes in appetite, weight changes, abdominal pain, recent trauma, diarrhea,
constipation, or urinary problems.
PMHx: None
PSHx: None
Meds: None
Allergies: Penicillin (rash)
FHx: Father and mother are healthy
SHx: 1 PPD smoker for past 15 years, 2 shots a week for past 10 years
this encounter.
Vital signs: temperature of 101.7 F (38.7 C), blood pressure of 130/80, heart rate
of 94/min, and respiratory rate of 24/min
Neck: Supple without JVD or lymphadenopathy, no thyromegaly, no bruits, no
accessory muscle use
Lungs: Clear to auscultation bilaterally, fremitus symmetrical bilaterally, resonant
to percussion bilaterally, no bronchophony or egophony
sounds
Diagnosis #1: Bronchitis
Smoking history Fever
Fever
Productive cough of yellow bloodtinged

sputum
Fever and chills Fever
Productive cough of bloodtinged yellow Respiratory rate 24/min
sputum
Pleuritic chest pain
Sick contact at office
Diagnosis #3: Lung cancer
Smoking history
Productive cough of bloodtinged sputum
Diagnostic studies
Chest xray
Sputum gram stain and culture
60yearold male complaining of lower abdominal pain

Vitals:
PR: 98/min
BP: 130/84 mmHg
T: 101 F (38.3 C)
RR: 22/min
Diverticulitis
Renal colic
Appendicitis
Ischemic colitis
Infectious colitis
Leaking aneurysm
Intestinal obstruction from strangulated or incarcerated hernia
case25 SP Print
You are a 60yearold man complaining of lower abdominal pain.
You are a 60yearold man who has had 1 day of lower abdominal pain. You went to
dinner at a restaurant yesterday with family members and later developed left lower
abdominal pain described as 6/10 severity. The pain is episodic and crampy and lasts
1015 minutes at a time. It started slowly and got progressively worse. There is no
radiation or aggravating/alleviating factors. You had nausea with 1 episode of non
bilious and nonbloody vomiting and a low grade subjective fever. You also had 23
episodes of diarrhea with blood but without black stools after the pain started. Your
other family members have no symptoms and are well.
You have no recent travel, sick contacts, chills, or urinary problems.
Hospitalized once 10 years ago for kidney stone that passed spontaneously
Hypertension
Medications: Hydrochlorothiazide 25 mg daily
Allergies: None
Family history: Father died at age 65 of colon cancer. Mother died at age 70 of breast
cancer. You have no siblings.
Social history: You live with your wife and work as a financial planner for a local firm.
You have never smoked. You have consumed 1 beer daily for the past 30 years. You
have not used illicit drugs and have no tattoos.
Abdomen: LLQ tenderness to deep palpation, no rebound tenderness, nondistended, no
hepatosplenomegaly, normoactive bowel sounds, no CVA tenderness
60YO man with 1 day of episodic crampy LLQ abdominal pain lasting 1015
minutes each time without radiation
Pain is 7/10
Ate at a local restaurant with family, but no one else is sick
He has had nausea, 1 episode of vomiting, 23 episodes of diarrhea with blood, and
subjective fever
ROS: No recent travel, sick contacts, chills, or urinary problems
PMHx: Hypertension, kidney stone in past
PSHx: None
Meds: Hydrochlorothiazide 25 mg daily
Allergies: None
FHx: Father died at age 65 of colon cancer. Mother died at age 70 of breast cancer.
SHx: No smoking, 1 beer daily for past 30 years
this encounter.
Abdomen: LLQ tenderness to deep palpation, no rebound tenderness,
nondistended, no hepatosplenomegaly, normoactive bowel sounds, no CVA
tenderness
Diagnosis #1: Acute diverticulitis
Abdominal pain Fever
Fever LLQ abdominal tenderness to palpation
Diarrhea with blood
Diagnosis #2: Infectious colitis
Fever Fever
Ate at local restaurant before symptom onset Abdominal tenderness to palpation
Diarrhea with blood
Diagnosis #3: Ischemic colitis
History of hypertension Fever
Fever
Abdominal pain
Diagnostic studies
Rectal examination with stool guaiac
Abdominal imaging (Xray, CT scan)
Urinalysis
35yearold male complains of fatigue
Vitals:
PR: 82/min
BP: 120/80 mmHg
RR: 16/min
Temp: 96.8 F (36.0 C)
Mental Checklist of DD:
Depression
Anemia
Hypo or Hyperthyroidism
HIV or AIDS
Malingering
Hypochondriasis
Post Traumatic Stress Disorder
Chronic fatigue syndrome
case26 SP Print
You are a 35yearold man complaining of fatigue.
You are a 35yearold man who comes to the physician with 2 months of fatigue. You
were previously well until you were robbed 2 months ago. You have become unable to
fall asleep at night, get tired easily during the day, have nightmares every night, and
generally feel anxious all the time. You have been unable to concentrate at work, have
restricted your daily activities, and feel emotionally distant and lonely. You have also
had 34 months of constipation. You note no increased stress at work or home.
You have no shortness of breath, chest pain, palpitations, sweating, fever, chills, weight
loss, or changes in appetite.
Medications: None
Allergies: None
Social history: You live with your girlfriend and work as a florist. You have smoked 1
pack a day for the past 15 years and drink occasionally. You have not used illicit drugs
and have no tattoos.
HEENT: No pallor, oropharynx clear
Neck: Supple without lymphadenopathy or thyromegaly
Abdomen: No masses or tenderness
Psychiatric: Alert and oriented to person, place, and time.
35YO man with 2 months of fatigue after robbery
He has insomnia, increased daytime fatigue, nightmares every night, generalized
anxiety throughout the day, and inability to concentrate at work.
He feels emotionally alone and distant with no increased stress at work or home.
No hallucinations or delusions.
Constipation for 34 months.
ROS: No shortness of breath, chest pain, palpitations, sweating, fever, chills, weight
loss, or changes in appetite
PMHx: None
PSHx: None
Meds: None
Allergies: None
FHx: Father, mother, and 3 siblings are healthy.
SHx: 1 PPD smoker for 15 years, occasional alcohol use
this encounter.
HEENT: No pallor, oropharynx clear
Abdomen: No masses or tenderness
Psychiatric: Alert and oriented to person, place, and time.
Diagnosis #1: Posttraumatic stress disorder
Symptom onset after robbery 2 months ago
Insomnia
Difficulty concentrating, nightmares
Fatigue
Insomnia
Emotionally feels alone and distant
Diagnosis #3: Hypothyroidism
Constipation for 34 months
Fatigue
Inability to concentrate at work
Diagnostic studies
ESR
65yearold female complaining of loss of hearing
Vitals:
PR: 80/min
BP: 130/86 mmHg
T: 98.0 F (36.7 C)
RR: 16/min

Make a mental check list of DD for loss of hearing:
Conducting hearing loss:
Cerumen impaction
Otitis media with effusion
Tympanic membrane perforation
Otosclerosis
Foreign body in ear canal
Cholesteatoma
Tympanosclerosis
Tumor of the ear canal or middle ear
Sensorineural hearing loss:
Presbycusis (hearing loss with aging)
Ototoxicity
Noiseinduced loss
Meniere's disease
Diabetes
Acoustic neuroma
case27 SP Print
You are a 65yearold woman complaining of hearing loss.
You are a 65yearold woman who comes to the physician with 3 months of reduced
hearing in the left ear. Your hearing was initially decreased in this ear, but it has
progressively worsened. It is difficult for you to hear people with highpitched voices.
You were admitted to the hospital 4 months ago for a kidney infection and treated with
IV antibiotics but can’t remember the name of the drug. Nothing seems to improve or
worsen your hearing difficulties.
You have no discharge from the ear, ringing in the ear, dizziness, facial muscle
weakness, weakness or numbness in other parts of the body, or earache.
Past medical history: Hypertension for the past 30 years
Medications: Hydrochlorothiazide 50 mg daily
Allergies: None
Family history: Father and mother died of old age. Your 2 siblings are healthy.
Social history: You live with your husband and work as a supervisor at a steel factory
where you are exposed to loud noises. You do not smoke but drink occasionally. You
have not used illicit drugs and have no tattoos.
HEENT: PERRLA, EOMI, oropharynx clear, TM clear bilaterally, Rinne with AC>BC,
Weber localizes to the right ear, oropharynx clear
Neurologic: Alert and oriented to person, place, and time. Cranial nerves 212 intact,
except for decreased hearing on the left ear
65YO woman with 3 months of highfrequency hearing loss
Hospitalized for pyelonephritis 4 months ago and treated with unknown antibiotic
Exposed to loud noises at work in steel factory
ROS: No discharge from ear, ringing in the ear, dizziness, facial muscle weakness,
weakness or numbness in other parts of the body, or earache
PMHx: Hypertension
PSHx: None
Meds: Hydrochlorothiazide 50 mg daily
Allergies: None
FHx: Father and mother died of old age, healthy siblings
SHx: No smoking, occasional alcohol use
this encounter.
HEENT: PERRLA, EOMI, oropharynx clear, TM clear bilaterally, Rinne with AC>BC,
Weber localizes to the right ear, oropharynx clear
Neurologic: Alert and oriented to person, place, and time. Cranial nerves 212
intact except for decreased hearing in left ear.
Diagnosis #1: Presbycusis (agerelated hearing loss)
Decreased hearing for 23 months Weber localizing to right ear
Highfrequency hearing loss
Diagnosis #2: Noiseinduced hearing loss
Decreased hearing Weber localized to right ear
Works at steel factory with loud noises
Diagnosis #3: Druginduced hearing loss
History of recent antibiotic use Weber localized to right ear
Diagnostic studies
Audiometric testing
ESR
MRI of brain
A 53yearold male with right knee pain and swelling
Vitals:
PR: 80/min, regular
BP: 130/60 mmHg
RR: 18/min
T: 101.0 F (38.3 C)
Osteoarthritis
Septic arthritis
Pseudogout and gout
Reactive arthritis
Traumatic knee injury
Lyme disease
Monoarticular rheumatoid arthritis
Psoriatic arthritis
case28 SP Print
You are a 53yearold man complaining of right knee pain.
You are a 53yearold man who has had 2 days of worsening right knee pain. You were
well until 1 year ago when you developed right and left knee pain made mildly worse
with walking. Initially you thought that it was due to your heavy weight. You also have
stiffness in multiple joints every morning for 1015 minutes that resolves spontaneously.
The pain worsened acutely 2 days ago in the right knee. You describe it as a throbbing
sensation of 7/10 severity with no radiation. You took ibuprofen without relief. There
are no aggravating or relieving factors and no recent trauma.
You have no fever, chills, nausea, vomiting, diarrhea, constipation, rashes, travel
history, sick contacts, insect bites, or urinary complaints.
Past medical history: Hypertension for the past 10 years
Medications:
Ibuprofen 600 mg as needed
Hydrochlorothiazide 25 mg a day
Allergies: None
Family history: Father has hypertension and mother has pseudogout. You have no
siblings.
Social history: You live with your wife and work as a librarian. You do not smoke but
drink beer occasionally. You have not used illicit drugs and have no tattoos.
HEENT: PERRLA, EOMI, no conjunctival hemorrhage
Musculoskeletal: Right knee is tender to palpation. ROM is decreased. There is no
redness or warmth. There are no other joint deformities.
Skin: No rashes or lesions
53YO man with 1 year of bilateral knee pain now with 2 days of worsening right
knee pain described as throbbing and constant
Pain is 7/10 and no relief with ibuprofen
Has 1520 minutes of morning stiffness in multiple joints each day that resolves
spontaneously
No H/O trauma
ROS: No fever, chills, nausea, vomiting, diarrhea, constipation, rashes, travel history,
sick contacts, insect bites, or urinary complaints
PMHx: Hypertension for 10 years
PSHx: None
Meds: Hydrochlorothiazide 25 mg daily, ibuprofen 600 mg as needed
Allergies: None
FHx: Father has hypertension and mother has pseudogout.
this encounter.
HEENT: PERRLA, EOMI, no conjunctival hemorrhage
Musculoskeletal: Right knee is tender. ROM is decreased. There is no swelling or
warmth. There are no other joint deformities.
Skin: No rashes or lesions.
Diagnosis #1: Osteoarthritis flare
History of chronic knee pain Decreased ROM in right knee
Acute worsening of right knee pain
Diagnosis #2: Septic joint
Acute onset of right knee pain Fever
Decreased ROM in right knee
Diagnosis #3: Acute crystal arthritis (gout or pseudogout)
History of diuretic use Fever
Acuteonset right knee pain Right knee with decreased ROM
Family history of pseudogout
Diagnostic studies
Right knee arthrocentesis
Right knee xray
ESR
A 50yearold man with blurred vision
Vitals:
BP: 160/90 mmHg
Temp: 98.0 F (36.7 C)
Pulse: 70/min
RR: 16/min
Make a mental checklist of DD for blurry vision:
Diabetes mellitus
Cataract
Hypertensive retinopathy
Glaucoma
Macular degeneration
Brain lesions
Hyperviscosity syndromes (polycythemia)
Illegal drugs
Temporal arteritis (usually starts unilateral)
Trauma or infections to the eye (if unilateral)
case29 SP Print
You are a 50yearold man complaining of blurry vision.
You are a 50yearold man who has had blurry vision in both eyes for 2 months. You
have also had a 10pound weight loss, increased urination, excessive thirst, and
increased appetite. You can still see objects without any halos around them, but the
objects are becoming more blurry. You bought overthecounter reading glasses but still
have some difficulty seeing. You have not seen a doctor for the past 10 years.
You have no nausea, vomiting, headache, arm/leg weakness, eye discharge, eye pain,
dizziness, loss of consciousness, or numbness or tingling in the extremities.
Medications: None
Allergies: None
Family history: Father has hypertension and mother has diabetes. You have no siblings.
Social history: You live with your wife and work as a truck driver. You have smoked a
pack a day for 30 years and drink occasionally. You have not used illicit drugs and have
no tattoos.
HEENT: PERRLA, EOMI, fundi without hemorrhages or AV nicking
Neck: Supple without lymphadenopathy, thyromegaly, or bruits
Neurologic: Motor 5/5 bilaterally, sensory grossly intact bilaterally
50YO man with 2 months of blurry vision, polyuria, polydipsia, polyphagia, and 10
pound weight loss
Has not seen a doctor in 10 years
Objects blurry without complete loss of vision or halos around light
ROS: No nausea, vomiting, headache, arm/leg weakness, eye discharge, eye pain,
dizziness, loss of consciousness, or numbness or tingling in the extremities
PMHx: None
PSHx: None
Meds: None
Allergies: None
FHx: Father has hypertension and mother has diabetes.
SHx: 1 PPD smoker for past 30 years, occasional alcohol use
this encounter.
HEENT: PERRLA, EOMI, fundi without hemorrhages or AV nicking
Neck: Supple without lymphadenopathy, thyromegaly, or bruits
Neurologic: Motor 5/5 bilaterally, sensory grossly intact bilaterally
Diagnosis #1: Diabetic retinopathy
Polyuria, polydipsia, polyphagia
Weight loss
Blurry vision
Diagnosis #2: Hypertensive retinopathy
Blurry vision BP 160/90 mm Hg
Diagnosis #3: Glaucoma
Decreased vision
Diagnostic studies
Fasting blood sugar and hemoglobin A1C
Eye examination to measure pressure
Lipid profile
32yearold female with multiple bruises
Vitals:
PR: 90/min
BP: 120/80 mmHg
RR: 16/min
Temp: 99.4 F (37.4 C)
Accident
Physical assault
Spousal abuse
Bleeding disorders
Collagen vascular disorders
case30 SP Print
*If the doctor asks you anything other than these, just say 'no,' or say things
You are a 32yearold woman
You have a bruise on the right arm between your shoulder and your elbow
You are accompanied by your husband
When the doctor asks you how you sustained the injury, you tell him that, "My
husband told me that I fell down the stairs."
On further questioning by the doctor, you say that you have been hit by your
husband
You have been married for 7 years
Your husband is a truck driver
Your husband hits you whenever he has his rage episodes usually once a week
You have 2 children, a boy (age 6) and a girl (age 5). He does not hit them. He
loves them, but they are afraid to go near him when he has his rage episodes.
Your husband is an alcoholic, and he almost always has a bottle of bourbon by his
side
Both your parents are living in the same town as you are and neither of them is
aware of the abuse that you are subject to
You feel that your husband loves you
You love your husband, but you are always on the edge when he is around
You feel that it is very difficult for you to leave him
You have never reported the matter to any agency
You do not feel safe at home, especially when he is around
You have felt at least on two occasions that he might kill you
You do not have an emergency plan to leave home if the need arises
You do not wish the matter to be reported to the authorities
You have a satisfying sexual relationship with him, and you are monogamous
You do not smoke, drink, or use recreational drugs
There is a shotgun at your house. You think your husband might use it.
When the doctor persuades you that you need not endure such a relationship in
which you are always in mortal fear, you say that you are going to think about
reporting it to the social welfare agencies
If you have been persuaded enough by the doctor, take his phone number and tell
him that you are going to call him if the need arises.
A 20yearold woman with burning urination
Vitals:
PR: 82/min
BP: 110/80 mmHg
RR: 16/min
Temp: 101.0 F (38.3 C)
Cystitis
Pyelonephritis
Urethritis
Vulvovaginitis
Noninflammatory dysuria (trauma, irritant, allergy)
case31 SP Print
You are a 20yearold woman who complains of burning with urination.
You are a 20yearold woman who comes to the physician with 4 days of burning with
urination. You were well before but then had onset of fever to 38.3 C (101 F), chills,
rigors, and burning with urination. You are urinating 1012 times a day, sometimes with
increased urgency and little urine. There is also a dull intermittent pain in the lower
pelvic area, greenish vaginal discharge, and occasional blood in the urine. You had a
similar episode 1 year ago diagnosed as chlamydia and treated with doxycycline. Your
last menstrual period was 2 weeks ago, and you have had a new sexual partner for the
past 2 months. You do not use condoms and have no pain during intercourse.
You have no back pain, nausea, vaginal bleeding, vomiting, diarrhea, or constipation.
Medications: Birth control pills
Allergies: None
Family history: Father and mother are healthy. You have no siblings.
Social history: You live alone and are a college student. You do not smoke but do drink
occasionally. You have not used illicit drugs and have no tattoos.
Vital signs: T 101 F (38.3 C), BP 110/80 mm Hg, HR 82/min, RR 16/min
Abdomen: Mild suprapubic discomfort with deep palpation, nondistended, normoactive
bowel sounds, no CVA tenderness
20YO woman with 4 days of dysuria, increased urinary frequency and urgency,
fever, chills, and episode of hematuria
New sexual partner 2 months ago without condom use
Treated for chlamydia cervicitis 1 year ago with similar symptoms
Intermittent suprapubic pain with green vaginal discharge
ROS: No back pain, nausea, vaginal bleeding, pain with intercourse, vomiting, diarrhea,
or constipation.
PMHx: None
PSHx: None
Meds: Birth control pills
Allergies: None
FHx: Father and mother are healthy.
this encounter.
Vital signs: Temperature, 101 F (38.3 C); blood pressure, 110/80 mm Hg; heart
Abdomen: Mild suprapubic discomfort with deep palpation, nondistended,
normoactive bowel sounds, no CVA tenderness
Diagnosis #1: Cystitis
Increased urinary frequency and urgency Suprapubic discomfort
Fever, chills Fever
Hematuria, dysuria
Diagnosis #2: Pyelonephritis
Increased urinary frequency and urgency Fever
Fever, chills
Hematuria, dysuria
Diagnosis #3: Cervicitis
Fever Fever
Vaginal discharge
New sexual partner with no condom use
History of previous cervicitis
Diagnostic studies
Pelvic examination
Nucleic acid amplification tests for Chlamydia
and Gonorrhea
Urinalysis
Urine culture
A 50yearold male with difficulty swallowing
Vitals:
BP: 130/90 mmHg
PR: 85/min
Temp: 98 F (36.7 C)
RR: 16/min
Make a mental checklist of DD:
Oropharyngeal dysphagia:
Neuromuscular (CVA, Parkinsonism, multiple sclerosis)
Mechanical obstruction (Zenker diverticulum, thyromegaly)
Skeletal muscle disorders (myasthenia gravis, muscular dystrophies, polymyositis)
Miscellaneous (medications, radiation)
Esophageal dysphagia:
Mechanical obstruction [carcinoma esophagus, benign strictures, webs and rings
(Schatzki)]
Achalasia cardia (achalasia, scleroderma)
Gastroesophageal reflux disease
Miscellaneous (diabetes, alcoholism)
case32 SP Print
You are a 50yearold man complaining of difficulty swallowing.
You are a 50yearold man who has had difficulty swallowing for 3 months. You were
previously well but began having problems swallowing solids. Food would get stuck in
the middle of your chest before slowly going down. This has progressed slowly and you
have had difficulty swallowing liquids for the past 3 weeks. You could previously gulp
water but are unable to do so now. Food also regurgitates into your chest 23 hours
after eating. You have no problem chewing or transferring food out of your mouth into
your throat. You have lost nearly 10 pounds (4.53 kg) in the past 3 months and have had
a decreased appetite for the past 3 weeks.
You have no weakness in the arms or legs, shortness of breath, nausea, vomiting, chest
pain, diarrhea, constipation, or urinary problems.
Past medical history: Gastroesophageal reflux disease you have had symptoms 23
times a week in the past relieved with antacids for the past 25 years.
Medications: Overthecounter antacids as needed
Allergies: None
Family history: Father and mother are healthy. You have 2 healthy siblings.
Social history: You live with your wife and are a stock broker. You have smoked 1
pack a day for the past 30 years and drink wine occasionally. You have not used illicit
drugs and have no tattoos.
HEENT: Oropharynx clear, difficulty swallowing water
Neck: Supple without lymphadenopathy
Lymph nodes: No axillary or supraclavicular adenopathy
hepatosplenomegaly, no CVA tenderness
50YO man with 3 months of dysphagia initially with solids and now with liquids for
the past 3 weeks
No problem with chewing and transferring food to throat, but feels food getting
stuck in middle of chest
Decreased appetite and 10pound (4.53kg) weight loss
Food regurgitates 23 hours after eating
ROS: No weakness in the arms or legs, shortness of breath, nausea, vomiting, chest
pain, diarrhea, constipation, or urinary problems
PMHx: GERD for 25 years relieved with OTC antacids
PSHx: None
Meds: OTC antacids
Allergies: None
FHx: Father, mother, and 2 siblings are healthy.
this encounter.
Vital signs: Temperature, 98 F (36.7 C); blood pressure,130/90 mm Hg; heart
HEENT: Oropharynx clear; patient has difficulty swallowing water
Lymph nodes: No axillary or supraclavicular adenopathy
Diagnosis #1: Esophageal cancer
Dysphagia with solids and then liquids
Weight loss with decreased appetite
Smoking history
Diagnosis #2: Achalasia
Dysphagia with solids and liquids
Weight loss
Diagnosis #3: Reflux esophagitis/Stricture
History of GERD
Food regurgitates 23 hours after eating
OTC antacid use
Diagnostic studies
Chest xray
Barium swallow
Upper GI endoscopy (EGD)
30 Yr. O/M came to HIV drug refill
Vitals
Pulse78/min
B.P120/75 mm of Hg
Temp98.8F
R.rate16/min
case33 SP Print
You are a 30yearold man requesting a refill for your HIV medications.
You are a 30yearold man who comes to the physician for a refill of HIV medications.
You were diagnosed 1 year ago with HIV and your partner at the time terminated the
relationship. You initially were sad but have slowly recovered and currently have a
positive outlook. You have been compliant with your medications for the past 6 months,
and your last CD4 count was 480 with an undetectable viral load 3 months ago. You have
had normal appetite and no weight loss.
You have no numbness or tingling in the extremities, weakness, chest pain, shortness of
breath, abdominal pain, skin rashes, cough, diarrhea, constipation, genital lesions, fever,
chills, or night sweats.
Past medical history: HIV screened 1 year ago by ELISA test and confirmed by Western
blot
Medications: HAART medications
Allergies: None
Family history: Your father and mother are healthy. You have 1 healthy sister.
Social history: You live alone and work as a truck driver. You have had multiple male
sexual partners in the past but have not had a relationship in the past year. You do not
smoke or drink. You have not used illicit drugs and have no tattoos.
HEENT: Oropharynx clear, fundi without papilledema or lesions
Extremities: No rash or edema
30YO man for refill of HIV medications
Diagnosed 1 year ago and has no stable support system
Initially felt sad but now has positive outlook
Compliant with meds
No weight loss; appetite normal
ROS: No numbness or tingling in extremities, weakness, chest pain, shortness of breath,
abdominal pain, skin rashes, cough, diarrhea, constipation, genital lesions, fever, chills,
or night sweats
PMHx: HIV diagnosed 1 year ago last CD4 count 480 with undetectable viral load 3
months ago
PSHx: None
Meds: HAART therapy
Allergies: None
FHx: Father, mother, and 1 sister are healthy.
SHx: No smoking or alcohol use
this encounter.
HEENT: Oropharynx clear, fundi without papilledema or lesions
Extremities: no rash or edema
Diagnosis #1: HIV medication refill
HIV diagnosis 1 year ago Normal examination findings
Recent stable CD4 and viral load
Compliant with medications
Diagnostic studies
CD4 count and viral load
16yearold female with amenorrhea
Vitals:
PR: 76/min
BP: 120/70 mmHg
RR: 16/min
Temp: 98.0 F (36.7 C)
Mental checklist of DD:
Primary amenorrhea
Secondary amenorrhea
Pregnancy
Anorexia nervosa
Hyperprolactinemia
Thyroid dysfunction
Polycystic ovarian syndrome
Stress
Post pill amenorrhea
Hypothalamic pituitary ovarian axis problems

Note: Both hypothyroidism and hyperthyroidism can present with amenorrhea.
case34 SP Print
You are a 16yearold girl who complains of having no periods for 2 months.
You are a 16yearold girl who has had no menstrual period for 2 months. You started
having periods at age 13. They were regular and you had no missed periods until the
last 2 months. Your cycle usually lasts 2830 days with moderate bleeding for 34 days
requiring 34 fully soaked pads a day. You have been under a lot of stress at school for
the past 4 months and are currently studying for upcoming midterm examinations in 2
weeks. You have a good appetite but have unintentionally lost 10 pounds (4.53 kg) in the
past 4 months. You are anxious during the interview.
You have no palpitations, diarrhea, constipation, hair loss, skin changes, breast
tenderness, nipple discharge, vaginal discharge, or urinary problems.
During the interview you ask “Do you think I'm pregnant? I can't be pregnant right
now. My parents will not be happy.”
Past medical history: G0P0
Medications: None
Allergies: None
Family history: Father and mother are healthy. You have 1 healthy sister.
Social history: You live with your parents and are currently a junior in high school. You
are doing well in school academically and participate in many extracurricular activities.
You have a boyfriend and have been sexually active for the past 6 months but don't
always use condoms. You do not smoke or drink. You have not used illicit drugs and
have no tattoos.
HEENT: PERRLA, EOMI, oropharynx clear
hepatosplenomegaly
16YO girl presents with 2 months of amenorrhea
Menarche at age 13 with regular and no missed periods until 2 months ago
Sexually active with boyfriend and does not always use condoms
Increased stress at school
Unintentional 10pound (4.53kg) weight loss in past 4 months with good appetite
ROS: No palpitations, diarrhea, constipation, hair loss, skin changes, breast tenderness,
nipple discharge, vaginal discharge, or urinary problems
PMHx: G0P0
PSHx: None
Meds: None
Allergies: None
SHx: No smoking or alcohol use
this encounter.
HEENT: PERRLA, EOMI, oropharynx clear
hepatosplenomegaly
Diagnosis #1: Pregnancy
Amenorrhea
Sexually active, sometimes not using condoms
Amenorrhea
Increased anxiety
Weight loss with good appetite
Diagnosis #3: Hyperprolactinemia
Amenorrhea
Diagnostic studies
Pregnancy test
TSH and T4
Pelvic and breast examination
Prolactin level
35yearold female with acute right lumbar and lower abdominal pain
Vitals
PR: 100/min
BP: 110/70 mmHg
Temp: 38.3 C (101 F)
RR: 16/min
Renal colic
Ovarian torsion
Urinary tract infection and pyelonephritis
Mittelschmerz
Appendicitis
Threatened abortion
Ectopic pregnancy
Dysmenorrhea
Endometriosis
Fibroids
case35 SP Print
You are a 35yearold woman complaining of low back and abdominal pain.
You are a 35yearold woman who has had 1 day of right low back and lower abdominal
pain. You were previously well and then had sudden onset of sharp right lower back pain
of 7/10 severity that radiates to the pelvic and lower abdominal area. The pain is
progressively worsening without relief and is unaffected by positional changes. You also
have had fever, chills, nausea without vomiting, burning with urination for 23 days, and
occasional blood in the urine. Your last menstrual period was 3 weeks ago. You are
sexually active with your boyfriend but do not use condoms.
You have no vaginal discharge, chest pain, shortness of breath, diarrhea, or constipation.
At the end of interview you say “I am in a lot of pain. Please make it stop.”
G2P2
Pelvic inflammatory disease 2 years ago
UTI twice 2 years ago treated with antibiotics
Medications: None
Allergies: None
Family history: Father and mother are healthy. You have 1 healthy sister.
Social history: You live alone and work as a bank teller. You have smoked 1 pack a
day for the past 15 years and drink occasionally. You have not used illicit drugs and
have no tattoos.
Abdomen: Diffuse abdominal discomfort without focal tenderness, nondistended,
normoactive bowel sounds, no hepatosplenomegaly, mild CVA tenderness on the right,
negative Psoas test
35YO woman presents with 1 day of sharp right flank pain radiating to the right
pelvis and lower abdomen
Pain is 7/10
Progressive, worsening pain without relief and not affected by position
Has dysuria, fever, chills, nausea, and occasional hematuria
ROS: No vaginal discharge, chest pain, shortness of breath, diarrhea, or constipation
PMHx: G2P2, PID 2 years ago, UTI 2 years ago
PSHx: None
Meds: None
Allergies: None
this encounter.
Abdomen: Diffuse abdominal discomfort without focal tenderness, nondistended,
normoactive bowel sounds, no hepatosplenomegaly, mild CVA tenderness on the
right, negative Psoas test
Diagnosis #1: Nephrolithiasis with hydronephrosis
Flank pain radiating to lower abdomen Fever, CVA tenderness
No comfort with any position change
Diagnosis #2: Pyelonephritis
Dysuria CVA tenderness
Hematuria Fever
Fever
Diagnosis #3: Pelvic inflammatory disease
Previous PID
Sexually active without condom use
Lower abdominal pain
Diagnostic studies
Pregnancy test
Pelvic examination
CT of abdomen
Urinalysis and urine culture
70yearold male with insomnia
Vitals:
PR: 58/min
BP: 130/90 mmHg
RR: 16/min
Temp: 98 F (36.7 C)
Depression
Posttraumatic stress disorder
Anxiety disorder
Chronic pain syndromes
Drug induced
Age related sleep changes
Thyroid problems
Sleep apnea
Restless leg syndrome
case36 SP Print
You are a 70yearold man complaining of insomnia.
You are a 70yearold man who comes to the physician with 2 months of insomnia. You
were well until 3 months ago when you were admitted to the hospital with chest pain and
diagnosed with coronary artery disease. You had a cardiac catheterization and
angioplasty and were placed on medications. You were very anxious throughout the
hospitalization and were given lorazepam for anxiety. You have since had difficulty
falling asleep and stay asleep for only 23 hours before getting up and pacing around.
You have no nightmares and do not drink alcohol or caffeine before you go to bed. You
feel very tired in the morning and throughout the day. You have also had decreased
appetite and a 5pound (2.27kg) weight loss during this time. Your son lives in town
and feels that you have become more isolated and not interested in any activities.
You have no chest pain, shortness of breath, voice changes, tremor, hair loss, diarrhea,
constipation, palpitations, dizziness, or recent trauma.
Past medical history: Coronary artery disease
Medications:
Aspirin 325 mg daily
Metoprolol 50 mg twice daily
Nitroglycerin sublingual as needed
Allergies: None
Family history: Father died of heart attack at age 75. Mother died of breast cancer at
age 68. You have 1 healthy sister.
Social history: You live alone since your wife's death 2 years ago and are a retired
accountant. You have smoked 1 pack a day for the past 50 years and drink beer
occasionally. You have not used illicit drugs and have no tattoos.
hepatosplenomegaly
Neurologic: Motor 5/5 bilaterally; alert and oriented to person, place, and time; DTR 2+
bilaterally
70YO man with 2 months of insomnia after hospitalization for CAD with angioplasty
Has difficulty falling asleep and staying asleep
Decreased appetite and 5pound (2.27kg) weight loss
Family thinks the patient feels isolated and lost interest in activities
ROS: Fatigue present. No chest pain, shortness of breath, voice changes, tremor, hair
loss, diarrhea, constipation, palpitations, dizziness, or recent trauma
PMHx: CAD
PSHx: None
Meds: Aspirin, metoprolol, nitroglycerin as needed
Allergies: None
FHx: Father died of MI, mother died of breast cancer
this encounter.
rate, 58/min; respiratory rate, 16/min
hepatosplenomegaly
Neurologic: Motor 5/5 bilaterally; alert and oriented to person, place, and time;
DTR 2+ bilaterally
Diagnosis #1: Anxiety disorder
Recent hospitalization
Difficulty falling asleep and staying asleep
Previous anxiety requiring medications
Decreased appetite and weight loss
Decreased interest in activities
Insomnia; fatigue
Diagnosis #3: Druginduced
Recently started on metoprolol Bradycardia
Insomnia
Diagnostic studies
TSH
65yearold male patient with difficulty urinating
Vitals:
PR: 92/min, regular
BP: 130/80 mmHg
RR: 16/min
Temp: 99 F (37.2 C)
Benign prostatic hyperplasia
Carcinoma of prostate
Stone in the urinary tract (obstructive)
Strictures of urethra
Carcinoma bladder
Sphincter dysfunction
Infection
Neurological dysfunction, like spinal cord trauma and diabetes
Drug induced (anticholinergics)
case37 SP Print
You are a 65yearold man complaining of difficulty with urination.
You are a 65yearold man who has had difficulty urinating for 2 months. You were
previously well and developed difficulty with initiating urination, decreased intermittent
urinary flow, increased straining, and increased urinary frequency during the day. You
also are getting up 56 times at night to urinate and feel that your bladder does not
empty properly. There is mild burning with urination and 1 episode of blood in the urine.
You also have a decreased appetite and have lost 10 pounds (4.53 kg) over the last
year.
You have no increased urinary urgency, abdominal pain, flank pain, fever, chills,
diarrhea, constipation, leg weakness, or trauma.
Ask the doctor: “Do you think I have prostate cancer?”
Past medical history: Diabetes mellitus for the past 10 years
Medications: Metformin 500 mg daily
Allergies: None
Family history: Father died of prostate cancer at age 75. Mother died of kidney
problems at age 78. You have 1 healthy sister.
Social history: You are an accountant and live with your wife. You have never smoked
and have consumed 2 beers a day for the past 35 years. You have not used illicit drugs
and have no tattoos.
Neurologic: Motor 5/5 bilaterally, DTR 2+ bilaterally
65YO man presents with 2 months of difficulty initiating urination, decreased
urinary flow, nocturia, increased urinary frequency, and incomplete emptying of
bladder
1 episode of hematuria
Decreased appetite and 10lb (4.53kg) weight loss over the past year
ROS: No increased urinary urgency, abdominal pain, flank pain, fever, chills, diarrhea,
constipation, leg weakness, or trauma
PMHx: Diabetes for past 10 years
PSHx: None
Meds: Metformin 500 mg a day
Allergies: None
FHx: Father died of prostate cancer, mother died of kidney problems
SHx: Denies smoking; 2 beers daily for 35 years
this encounter.
Neurologic: Motor 5/5 bilaterally; DTR 2+ bilaterally
Diagnosis #1: Benign prostatic hyperplasia
Difficulty with urinary initiation
Incomplete emptying of bladder
Nocturia, decreased urinary flow
Diagnosis #2: Prostate cancer
Family history of prostate cancer
Decreased urinary flow, nocturia
Weight loss
Diagnosis #3: Bladder cancer
Gross hematuria
Incomplete emptying of urine
Weight loss
Diagnostic studies
Rectal examination
Urinalysis with urine culture
PSA
35yearold female complains of breathlessness and anxiety

Vitals:
PR: 94/min, regular
BP: 130/80 mmHg
RR: 22/min
Temp: 97 F (36.1 C)
Anxiety secondary to medical condition, e.g., hyperthyroidism, arrhythmias,
pheochromocytoma
Substance abuse
Panic disorder
Generalized anxiety disorder
Adjustment disorder with anxious mood
Acute stress disorder or post traumatic stress disorder
Hypochondriasis
Malingering
case38 SP Print
You are a 35yearold woman complaining of shortness of breath.
You are a 35yearold woman who has had shortness of breath for 3 months. You
remember that you may have had slight problems previously, but the symptoms became
worse 3 months ago. You develop episodes of shortness of breath lasting 30 minutes
associated with palpitations, sweating, and a feeling that you are going to die. The
episodes occur about 23 times a week at any time but are worse in crowded places
outside the house. The symptoms seem to improve with slow breathing and relaxation,
but you have stopped going to outdoor activities to prevent the episodes. You have been
to the emergency department many times, but all the tests come back normal without
any clear diagnosis. You also have occasional diarrhea alternating with constipation.
You drink 1 cup of coffee a day.
You have no chest pain, headache, nausea, vomiting, tremors, neck swelling, or
abdominal pain.
Ask the doctor: “Do you think that this is anxiety like my mother has?”
Medications: None
Allergies: Penicillin causes a rash.
Family history: Father is healthy. Mother has generalized anxiety disorder. You have 1
healthy sister.
Social history: You are a homemaker and live with your husband and 2 children. You
have never smoked and drink a glass of wine occasionally. You used marijuana in
college but have not used any since. You have no tattoos.
Neck: Supple without thyromegaly or lymphadenopathy
Heart: Regular rhythm without murmurs, rubs, or gallops
Neurologic: No tremor in extremities
35YO woman presents with 3 months of episodic shortness of breath, palpitations,
diaphoresis, and feeling of impending death.
Episodes last 30 minutes and occur more frequently outside of house in crowded
places
Symptoms improve with slow breathing and relaxation
Has been to ED multiple times with normal investigation and no definitive diagnosis
ROS: Occasional diarrhea with alternating constipation present. No chest pain,
headache, nausea, vomiting, tremors, neck swelling, or abdominal pain
PMHx: None
PSHx: None
Meds: None
Allergies: Penicillin causes a rash.
FHx: Father is healthy. Mother has generalized anxiety disorder.
SHx: Denies smoking; occasional glass of wine
this encounter.
Heart: Regular rhythm without murmurs, rubs, or gallops
Neurologic: No tremor in extremities
Diagnosis #1: Generalized anxiety with panic attacks
Episodes of palpitations with dyspnea
Family history of anxiety
Symptoms worse in crowded places
Symptoms relieved with slow breathing
Episodes of palpitations
Shortness of breath and diaphoresis
Diagnosis #3: Cardiac arrhythmia
Palpitations
Shortness of breath and diaphoresis
Diagnostic studies
EKG
TSH, T4
Event monitor
53yearold male with a long history of epigastric pain
Vitals:
PR: 84/min
BP: 120/70 mmHg
RR: 16/min
Temp: 97 F (36.1 C)
Peptic ulcer
Gastritis
Esophagitis (GERD)
Carcinoma of esophagus, stomach, and pancreas
Chronic pancreatitis
Cholecystitis
Hepatitis
case39 SP Print
You are a 53yearold man complaining of abdominal pain.
You are a 53yearold man who presents with 2 years of abdominal pain. You were
previously well and developed midepigastric pain that occurs on and off for months
before decreasing and then recurring. The midepigastric pain is sharp, 7/10 intensity,
made worse by food, and is sometimes relieved with antacids. The pain also occurs in
the middle of the night and sometimes radiates to your back. You have also had
decreased appetite, the feeling of a full stomach, abdominal bloating, occasional black
stools, and a 15pound (6.8kg) weight loss in the past 6 months.
You have no jaundice, fever, chills, vomiting, shortness of breath, diarrhea, or
constipation.
Ask the doctor: “Can you please stop this pain? Is it curable?”
Past medical history: Osteoarthritis of the knee for past 10 years
Medications:
Overthecounter antacids as needed
Ibuprofen 600 mg 3 times a day as needed
Allergies: None
Family history: Father is healthy. Mother died at age 60 from pancreatic cancer. You
have 1 healthy brother.
Social history: You are a stockbroker. You live with your wife and have 2 children. You
have never smoked but have consumed 2 beers a day for the past 25 years. You have
never used illicit drugs and have no tattoos.
53YO man presents with 2 years of episodic midepigastric pain worse with food
and sometimes relieved with antacids.
Pain also occurs at night and sometimes radiates to the back.
Pain is 7/10.
Has also noticed decreased appetite, the feeling of a full stomach, abdominal
bloating, occasional black stools, and a 15pound (6.8kg) weight loss in the past 6
months
ROS: No jaundice, fever, chills, vomiting, shortness of breath, diarrhea, or constipation
PMHx: Osteoarthritis of the knee for past 10 years
PSHx: None
Meds: Overthecounter antacids as needed, ibuprofen 600 mg 3 times a day as needed
Allergies: None
FHx: Father healthy, mother died at age 60 of pancreatic cancer.
SHx: Denies smoking; 2 beers a day for past 25 years
this encounter.
Diagnosis #1: Peptic ulcer disease
Midepigastric pain
Relieved with antacids
History of NSAID use
Diagnosis #2: Chronic pancreatitis
Chronic midepigastric pain
Pain radiates to back
History of alcohol use
Diagnosis #3: Gastric cancer
Midepigastric pain increased with food
Nighttime pain
Weight loss
Diagnostic studies
Upper GI endoscopy
45yearold male complaining of bloody vomiting
Vitals:
PR: 90/min, regular
BP: 100/60 mmHg
RR: 18/min
T: 98.0 F (36.7 C)
Gastric ulcer
Duodenal ulcer
Esophageal and gastric varices
MalloryWeiss tears
Gastritis
Erosive esophagitis
GI malignancy
Vascular ectasia
case40 SP Print
You are a 45yearold man complaining of bloody vomiting.
You are a 45yearold man who has had 2 hours of bloody vomiting. You were
previously well until 2 hours ago when you developed burning epigastric pain of 8/10
severity radiating to the back. This was immediately followed by vomiting with a cupful
of bright red blood. You had a second episode 30 minutes ago similar to the first and
decided to come to the emergency department. You are also dizzy.
You have had 2 years of heartburn symptoms with midepigastric pain 34 times a week
after eating that lasts 1015 minutes. Your symptoms were relieved with antacids but
have been getting worse over the past 2 months. The pain was also made worse with
drinking caffeine and alcohol. You have had occasional black stools for 1 month.
You have no jaundice, fever, chills, shortness of breath, weight loss, urinary symptoms,
diarrhea, or constipation.
Ask the doctor: “Will I die from this bleeding? Is it cancer?”
Hypertension
Tension headaches
Medications:
Hydrochlorothiazide 50 mg daily
Ibuprofen 400 mg 3 times a day as needed
Allergies: None
Social history: You are a sales manager at a marketing company and are under a lot of
stress. You live with your wife and 2 children. You have smoked 2 packs a day for the
past 25 years and have consumed 2 beers a day for the past 25 years. You have never
used illicit drugs and have no tattoos.
HEENT: No jaundice or pallor, oropharynx clear
Heart: Regular rhythm and rate without murmurs, gallops, or rubs
45YO man presents with acute onset of 2 episodes of hematemesis with a cupful of
bright red blood and dizziness.
Also has midepigastric pain radiating to the back
Has had 2 years of heartburn and chronic midepigastric pain after meals lasting 15
20 minutes and relieved with antacids
Symptoms are worse with caffeine and alcohol intake
Occasional black stools in the past month
ROS: No jaundice, fever, chills, shortness of breath, weight loss, urinary symptoms,
diarrhea, or constipation
PMHx: HTN, tension headaches
PSHx: None
Meds: Hydrochlorothiazide 50 mg daily, ibuprofen 400 mg 3 times a day as needed
Allergies: None
FHx: Father, mother, and siblings are healthy.
SHx: 2 PPD smoker for 25 years; 2 beers a day for past 25 years
this encounter.
HEENT: No jaundice or pallor, oropharynx clear
Heart: Regular rhythm and rate without murmurs, gallops, or rubs
Diagnosis #1: Bleeding gastric ulcer
Hematemesis Hypotension
Midepigastric pain
Occasional black stools
NSAID use
Diagnosis #2: Gastritis
Hematemesis
Midepigastric pain
History of NSAID use
Diagnosis #3: Esophagitis
History of heartburn
Hematemesis
Chronic tobacco/alcohol use
Diagnostic studies
Upper GI endoscopy
Coagulation studies
60yearold male complains of dizziness
Vitals:
PR: 80/min
BP: 140/90 mmHg
RR: 16/min
Temp: 97.0F(36.1)
TIA or stroke
Drug induced
Coronary artery disease
Autonomic dysfunction
Postural hypotension
Arrhythmias
Hypoglycemia
Intracranial pathology
Ear problems
Anemia
case41 SP Print
SP's Notes
You are Robert, 60yearsold
Having dizziness for past 4 days
Occurs occasionally
Lasts for 25 minutes
More on getting up from sitting position
Lying down will help reduce the dizziness
Sometimes associated with palpitations or sweating
No chest pain
Never lost consciousness during these episodes
This time noticed weakness in right lower leg and lasted for 10 minutes and
resolved spontaneously; no headache, nausea, or vomiting
No change in bowel or bladder habits
Other medical problems:
You have diabetes for 15 years and take glyburide twice daily; you check blood
sugar twice daily, and it is in the range of 120160 mg/dL.
You have high BP from the past 10 years. One week back, medication for BP
control was changed from atenolol to terazosin (alfa blocker).
So far, no heart problems and never had any strokes.
Social history:
Smoker for 30 years, 2 packs/day
Not an alcoholic
Exercise regularly
Occupation clerk in food store
Lives with wife; she is healthy
Medications:
Only terazosin and glyburide
Taking medication regularly, as prescribed
Allergies:
You have no known drug allergies
Ask this question, 'Doc, did I have stroke?'
30yearold male with new onset of seizure

Vitals:
PR: 82/min, regular
BP: 120/80 mmHg
RR: 18/min
T: 99.0 F (37.2 C)
Seizures (secondary to head trauma, infections, drugs, metabolic disorders)
Hypoglycemia
Syncope
Migraine
Stroke
Space occupying lesions
Alcohol or drug withdrawal
case42 SP Print
You are Keith, age 30 years
Had an episode of seizure a few hours ago; the episode lasted around 3 minutes,
but you were unconscious probably about 20 minutes. You felt a little nauseous
before the onset of seizures, and then you don't know what happened, but your co
workers told you that you had jerky movements for a couple of moments.
Did not pass urine or feces during the episode
You bit your tongue during the episode
You have been noticing some weakness in the right hand for the past 3 months
Once in a while, you get very mild headaches, but these days your headache is
constant and more in severity
Having mild fever, cold and flulike symptoms for the past couple of days
No history of ear discharge or sinusitis
No pain in the neck
No history of head trauma
Other medical problems:
You have type1 diabetes and have been on insulin for the past few years. You do
not think this is an episode of hypoglycemia, because you know how that looks
like.
No other medical problems
Social history:
Occasionally drinks alcohol. Last drink was 2 days ago.
No smoking history
Never used any illicit drugs
Occupation Clerk in postal department
Family history:
There is no family history of seizures
Medications:
Insulin NPH type 10 units in AM and 8 units at PM. Usually checks blood sugar 2
times a day.
Allergies:
No known drug allergies
Ask this question, 'Doc, do I have a brain tumor?'
A 23yearold male with rectal bleeding
Vitals:
PR: 90/min, regular
BP: 110/60 mmHg
RR: 18/min
T: 101.0 F (38.3 C)
Differential diagnosis of lower GI bleed in an young patient:
Anal fistula/fissure
Infectious colitis
Neoplasm
Vascular ectasia
Gonococcal proctitis
Hemorrhoids
Differential diagnosis of lower GI bleed in an elderly patient:
Diverticulosis
Angiodysplasia
Malignancy/polyp
Ischemic colitis
case43 SP Print
You are Steve, age 23 years
Having bleeding per rectum for past 3 days
Started mildly with blood streaks in stools for past one month; progressed over 3
days to frank blood in stools; never had black stools.
Associated with mild (23/10), crampy lower abdomen pain
Suffered from chronic constipation for past 5 years. Have to strain a lot while
defecating. Also, you use to have severe pain sometimes when defecating, but the
bowel movements increased in frequency to 3 times a day recently.
No nausea or vomiting
Having mild fever (100 F) without chills for the past 45 days
No recent change in weight or appetite
No similar episodes in the past. Never admitted in the hospital before.
Do not eat much vegetables or fruits
You are working at local restaurant. No illicit drug use.
Multiple female sexual partners; no homosexual activity; does not always use
condoms.
Not a smoker; not an alcoholic.
Father died from colon cancer at the age of 65
Not using any medications chronically
You have no known drug allergies

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Place the tips of your index fingers directly in front of the tragus of each ear. Ask

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