Illness Scripts Flashcards
Middle aged man with chest pain of several hours.
List D/Dx +/- Fever
+ Fever: PNA, Pleuritis, MI, Costochondritis
-Fever: ACS- MI, ACS- US, PNA, GERD, Costochondritis
Young man with abrupt SOB
List D/Dx
Pneumothorax Allergic Reaction Panic Attack PE PNA
Importance of pertinent positives and negatives
Positives- Support primary Dx
Negatives- R/o or placed lower on D/Dx list
Woman feeling fatigue
Begin to think possibly anemia
Questions to ask e.g. include…
Menses
Diet- Red meat
No evidence of anemia- Do not include in D/Dx list
D/Dx for depression
Major Depressive d/o
Generalized Anxiety d/o
Hypothyroidism
Somatization d/o
D/Dx for anxiety
Generalized Anxiety d/o
Major depressive d/o
Hyperthyroidism
Somatization d/o
Diagnostic plan for depression and Anxiety
Screening tests for common chronic diseases
e.g. anemia CBC with diff, renal failure, DM, hypothyroidism, chronic liver disease, chronic infection
Basic metabolic panel includes (8)
- Glucose
- Calcium
Electrolytes
- Sodium
- Potassium
- Chloride
- CO2 (Bicarb)
Kidney Tests
- Blood urea nitrogen
- Creatinine
Complete metabolic panel includes (14)
BMP (8) + Additional Test markers (6) = CMP
Liver Tests 1. AST (Function) 2. ALT (Function) 3. Albumin (Synthetic) 4* Alkaline Phosphatase
- Total protein
- Total bilirubin
40 yo man c/o dizziness and hearing loss
Dx
HPI
PMHx
PE findings
W/u
Meniere dz
Dx Meniere dz
HPI Episodic spells of vertigo Fluctuating unilateral hearing loss Aura & ear fullness Nausea & vomiting Tinnitus
PMHx
Hyperlipidemia/MI/DM
FHx hearing problems
PE findings
Sensorineural hearing loss
Normal hearing between attacks
Rinne Test- AC > BC on affected ear
Weber Test- Lateralize to unaffected ear
Gait Problem
W/u Audiometry Vestibular testing Electrocochleography VDRL/RPR/FTA-ab Brain MRI Dix-Hallpike maneuver
40 yo man c/o dizziness and hearing loss
Dx
HPI
PMHx
PE findings
W/u
Otitis Media
Dx Otitis Media
HPI Otalgia Pain behind ear Otorrhea Decreased hearing m/c unilateral
PMHx
Preceding URI
h/o seasonal allergic rhinitis
recurrent otitis media
PE findings Conductive hearing loss Rinne- BC > AC Affected ear Webber- Lateralize to affected ear Erythematous or opacified TM Bulging or perforated TM Fever of facial palsy
W/u
CBC w/ diff
Otomicroscopy
Fiberoptic nasopharyngoscopy
40 yo man c/o dizziness, nausea, and vomiting
Dx
HPI
PMHx
PE findings
W/u
Vestibular neuronitis
Dx Vestibular neuronitis
HPI Vertigo Nausea > with head movements Lasts for days Vomiting Gait problems
PMHx
h/o hearing impairment
h/o vertigo
h/o URI
PE findings
Gait instability
Hearing impairment
Webber and Rinne
W/u
MRI/MRA
35 yo man c/o dizziness
Dx
HPI
PMHx
PE findings
W/u
Labyrinthitis
Dx Labyrinthitis
HPI
Vertigo
Tinnitus
Nausea/vomiting
PMHx
Recent URI
PE findings
Examine ear with otoscope
Check for nystagmus
W/u
Audiometry
Middle-aged c/o pink eye
Dx
HPI
PMHx
PE findings
W/u
Conjunctivitis
Dx Conjunctivitis
HPI Redness and swelling of conjunctiva Sensation of foreign body in eye Skin itching and watery discharge from both eyes Normal visual acuity No photophobia
PMHx h/o seasonal or specific allergies h/o URI h/o STDs h/o Sjogren Syndrome h/o contact lenses h/o swimming
PE findings Purulent discharge from one or both eyes Watery discharge from one or both eyes Diffuse redness of conjunctiva Normal vision and no other eye findings Normal fundoscopic exam
W/u
Rapid test for Adenoviral conjunctivitis
PCR and culture of swabbed specimens
25 yo man c/o facial pain
Dx
HPI
PMHx
PE findings
W/u
Sinusitis
Dx Sinusitis
HPI Thick, green nasal discharge Cough worse at night Dull, constant headache Pain worse when head tilts forward
PMHx
h/o asthma
PE findings
Fever
Tenderness on palpation of sinuses
67 yo man c/o difficulty swallowing
Dx
HPI
PMHx
PE findings
W/u
Esophagitis (Medication induced)
Dx Esophagitis (Medication induced)
HPI Retrosternal pain or heartburn h/o dysphagia h/o odynophagia h/o hematemesis
PMHx h/o GERD h/o H. Pylori Obesity Pregnancy or exogenous estrogen h/o NSAIDs, antibiotics, bisphophonates
W/u
UGI endoscopy
Barium esophagram
67 yo man with difficulty swallowing
Dx
HPI
PMHx
PE findings
W/u
Esophageal cancer
Dx Esophageal cancer
HPI
dysphagia: solids > liquids
sensation of food stuck in throat
Weight loss
PMHx
h/o smoking and alcoholism
h/o GERD
obesity
PE findings
Lymphadenopathy (LAD)
W/u Barium esophagram UGI endoscopy and biopsy CT of chest and upper abdomen PET scan for metastasis CXR
57 yo woman c/o difficulty swallowing
Dx
HPI
PMHx
PE findings
W/u
Plummer-Vinson syndrome
Dx Plummer Vinson syndrome
HPI
Glossitis
Angular Chelitis
Odynophagia
PMHx
h/o Iron deficiency anemia
Post-menopausal
Vegan diet
PE findings
Cheilosis
Pallor
W/u
CBC
Upper endoscopy
18 yo woman c/o sore throat
Dx
HPI
PMHx
PE findings
W/u
Pharyngitis
Dx Pharyngitis
HPI Rhinorrhea Cough Headache Hoarse voice
PMHx
Recent viral infection
PE findings
Fever
W/u
Throat swab
17 yo girl c/o sore throat
Dx
HPI
PMHx
PE findings
W/u
Infectious mononucleosis
Dx Infectious mononucleosis
HPI
Sore throat
Fatigue
Odynophagia
PMHx
LAD
sick contacts
PE findings Fever Pharyngitis HSM LAD
W/u
CBC w/ diff
ESR
Monospot test
35 yo woman c/o palpitations
Dx
HPI
PMHx
PE findings
W/u
Hyperthyroidism
Dx Hyperthyroidism
HPI Heat intolerance Unintentional weight loss Irritability Brittle Hair Diarrhea
PMHx
FHx thyroid disease
PE findings Hand tremor Tachycardia Hyperventilation Increased DTR
W/u
TSH, T3, Free T4
Radioactive iodine Uptake Test
Middle-aged man c/o severe chest pain and SOB
Dx
HPI
PMHx
PE findings
W/u
Pulmonary embolism
Dx Pulmonary Embolism
HPI Sudden dyspnea Orthopnea Dyspnea at rest Cough Hemoptysis Sudden pleuritic pain Calf or thigh pain or swelling
PMHx
h/o smoking
h/o of immoblization or recent long flight
Occupation with prolonged sitting
PE findings HTN/HypoTN Tachypnea Tachycardia Wheezing Calf or thigh swelling
W/u CXR EKG ABG Spiral CT V/Q scan D-dimer (only when it's a low probability)
Middle-aged man c/o acute SOB and agitation
Dx
HPI
PMHx
PE findings
W/u
COPD Exacerbation
Dx COPD Exacerbation
HPI
Acute exacerbation of dyspnea
Chronic h/o dyspnea
Chronic h/o productive cough
PMHx
h/o lung disease
h/o smoking
PE findings Tachypnea Decreased chest excursion Decreased breath sounds Barrel Chest Hyperresonance
W/u CXR Pulse oximetry ABG PFTs
Middle-aged man c/o acute SOB and agitation
Dx
HPI
PMHx
PE findings
W/u
Spontaneous Pneumothorax
Dx Spontaneous Pnuemothorax
HPI
Suddent SOB
Pleuritic Chest pain
PMHx
Previous episode of spontaneous pneumothorax
PE findings Tall thin man Tachypnea Decreased breath sounds Decreased chest excursion on affected side Hyperresonance
W/u
AP and lateral CXR
67 yo woman c/o significant SOB
Middle-aged man c/o acute SOB and agitation
Dx Cor pulmonale
HPI Chronic SOB SOB on exertion Exertional syncope Exertional angina B/l swelling of LE in past several weeks
PMHx
Long standing h/o lung disease
h/o smoking
PE findings
S3/S4
Split S2
W/u CXR ECG Pulse oximetry ABG PFTs Echo
Elderly man c/o worsening dyspnea on exertion
Dx
HPI
PMHx
PE findings
W/u
COPD
Dx COPD
HPI
Chronic h/o SOB
Chronic h/o productive cough
Morning white sputum
PMHx
Long standing h/o smoking
Chronic h/o lung disease
PE findings Tachypnea Prolonged expirations Distant breath sounds Barrel chest
W/u CXR ABG Pulse oximetry PFTs
Elderly man c/o worsening dyspnea on exertion and productive cough
Dx
HPI
PMHx
PE findings
W/u
TB
Dx TB
HPI Chronic h/o SOB Chronic h/o of productive purulent cough h/o hemoptysis night sweats weight loss fatigue
PMHx HIV Immunocompromised Foreign born/travel h/o smoking Exposure to TB (Health care worker)
PE findings
Fever
Tachypnea
Cachexia
W/u CXR PFTs ABG Pulse oximetry TB sputum gram stain and culture Quantiferon test CBC w/ diff Blood culture
Elderly man c/o worsening dyspena on exertion and productive cough
Dx
HPI
PMHx
PE findings
W/u
Chronic Asthma
Dx Asthma
HPI
h/o SOB early in life
Worse at night/early morning
PMHx
Hx of allergies
Hx of smoking
Exposure to second hand smoke
PE findings Tachypnea Prolonged expirations Diffuse wheezing Increased vocal fremitus Intercostal retractions
W/u
CXR
PFTs
ABG
Elderly man c/o worsening dyspnea on exertion and productive cough
Dx
HPI
PMHx
PE findings
W/u
Bronchogenic carcinoma (Central airway obstruction)
Dx Bronchogenic carcinoma (Central airway obstruction)
HPI Cough w/ purulent sputum Slowly progressive dyspnea Purulent sputum Unintended weight loss Hemoptysis
PMHx
h/o smoking
PE findings
Tachypnea
Prolonged expirations
Wheezing
W/u
CXR
PFTs
Bronchoscopy
65 yo man c/o cough
Dx
HPI
PMHx
PE findings
W/u
Lung cancer
Dx Lung cancer
HPI Hemoptysis Dyspnea Unintended weight loss Fatigue Productive cough
PMHx
h/o smoking
FHx of cancer
PE findings
Wheezing on lung exam
W/u
CXR
Sputum gram stain and culture
Chest CT
60 yo man c/o chest pain and cough
Dx
HPI
PMHx
PE findings
W/u
Pneumonia
Dx Pneumonia
HPI Chest pain Cough SOB Purulent Sputum
PMHx
Recent viral prodrome
PE findings Febrile Mild respiratory distress Tachypnea Crackles Areas of lung consolidation
W/u CXR Blood cultures Sputum gram stain & culture CBC w/ diff
Tactile Fremitus
Increased vibration to palpation with 99
Bronchophony
If positive…?
Increased clarity of 99 with Auscultation (+ loud and clear) (- soft and muffled)
If positive
Perform whispered pectoriloquy
Whisper 123 and auscultate (+ if clear) (-if faint and muffled)
Egophony
Say “EEE”
- soft muffled eeee
(+ “aaa” heard)
66 yo man c/o chest pain and cough
Dx
HPI
PMHx
PE findings
W/u
Pleural effussion
Dx Pleural Effusion
HPI
Pleuritic chest pain worse with deep inspiration or motion
Cough
SOB
PMHx
Recent viral prodrome
PE findings Febrile Mild respiratory distress Dullness Egophony
W/u CXR Chest U/S Pleurocentesis Pleural fluid cell count/cytology, histology/culture LDH/pH Sputum culture
Viral prodrome
Fever cough chills malaise myalgias fatigue SOB
53 yo man c/o recurrent chest pain, dyspnea, anxiety
Dx
HPI
PMHx
PE findings
W/u
Myocardial infarction
Dx MI
HPI Diaphorsis Crushing retrosternal pain > 20 min Chest, neck, mandible, down left arm FHx of heart dz SOB
PMHx
smoker
h/o of angina or MI
PE findings
Pale and diaphoretic
Tachycardia
Hemodynamic instability
W/u ECG CXR Cardiac troponins CK-MB Echo
53 yo man c/o recurrent chest pain, dyspnea, and anxiety
Dx
HPI
PMHx
PE findings
W/u
Angina pectoris/stable angina
Dx Angina pectoris/stable angina
HPI Pain <20 min Gradual onset Discomfort center or left of chest Worse with exertion Better with rest No change with respiration of position
PMHx
h/o high cholesterol
h/o HTN
PE findings
Levine sign (clenched fist on chest)
High BP
S3 or S4
W/u
ECG
Troponins
Stress Test
Angina pectoris/stable angina
Middle age man c/o severe chest pain
Dx
HPI
PMHx
PE findings
W/u
Aortic dissection
Dx Aortic dissection
HPI
Tearing chest pain
Back pain
Acute onset
PMHx
h/o HTN
h/o Cocaine use
Congenital factors- Marfan, Turner, Noonan Syndrome
PE findings HTN UE BP Assymetry UE Pulselessness Hemodynamic instability
W/u CXR TEE CT scan Urine toxicology
Middle aged man c/o severe chest pain
Dx
HPI
PMHx
PE findings
W/u
Cocaine-induced ACS
Dx Cocaine-induced ACS
HPI
Chest pain
Agitation
PMHx
Cocaine myocarditis
Vasculitis
PE findings
HTN
Arrhythmia
Nasal Septum perforation
W/u EKG Troponins I/T CK-MB Urine toxicology
67 yo woman c/o significant dyspnea
Dx
HPI
PMHx
PE findings
W/u
CHF/Pulmonary edema
Dx CHF/Pulmonary edema
HPI SOB paroxysmal nocturnal dyspnea orthopnea Pink Frothy sputum cough Noncompliant w/ medication LE pitting edema x several weeks
PMHx
HTN
MI
PE findings JVD LE Edema Rales S3 gallop
W/u ECG Echo BNP Troponins CXR
67 yo woman c/o significant dyspnea
Dx
HPI
PMHx
PE findings
W/u
Myocarditis
Dx Myocarditis
HPI
Chest pain
Fatigue
LE edema x several weeks
PMHx
h/o URI
PE findings
Tachypnea
Gallop
Peripheral edema
W/u CBC w/ diff ESR/CPR ECG CXR Echo
67 yo woman c/o significant dyspnea
Dx
HPI
PMHx
PE findings
W/u
Atrial Fibrillation
Dx Atrial Fibrillation
HPI
Palpitations
Light headed
Anxiety
PMHx
Cardiomyopathy
HTN
PE findings Pallor Diaphoresis Irregular heart rate Dyspnea
W/u
ECG
Holter monitor
Event recorder
60 yo man c/o chest pain and cough
Dx
HPI
PMHx
PE findings
W/u
Pericarditis
Dx Pericarditis
HPI
Sharp pleuritic chest pain
Better when leaning forward
Persistent fever
PMHx
Recent viral prodrome
PE findings Febrile Mild respiratory distress Pericardial friction rub Rash on skin
W/u ECG ECHO CXR Blood cultures
Middle aged man c/o palpitation and chest pain
Dx
HPI
PMHx
PE findings
W/u
Mitral valve prolapse
Dx mitral valve prolapse
HPI chest pain palpitation dyspnea chest pressure exertion intolerance Dizziness Anxiety d/o
PMHx
HTN
Arrhythmia
Pulmonary edema
PE findings
Systolic murmur and non-ejection click
Narrow AP chest diameter
Scoliosis and loss of kyphosis of spine
W/u ECG/CK-MB Troponin I/T TTE ECHO CV magenetic resonance
Middle age man c/o dizziness
Dx
HPI
PMHx
PE findings
W/u
Drug induced orthostatic hypotension
Dx Drug induced orthostatic hypotension
HPI
Dizziness
Syncope
Sx onset after standing or eating
PMHx
angina, stroke
supine HTN
HTN medications
PE findings Pallor Diaphoresis Hypotension Tachycardia
W/u
Monitor orthostatic/supine/and sitting BP
Tilt Table
69 yo man c/o lightheadedness
Dx
HPI
PMHx
PE findings
W/u
Orthostatic hypotension from dehydration
Dx Orthostatic hypotension from dehydration
HPI Fatigue Palpitations Profuse seating Nausea
PMHx
Diarrhea
Excessive exercise
decreased fluid intake
PE findings
Orthostatic hypotension
pale
W/u
BUN and Creatinine
CBC
Electrolytes
patient c/o palpitation and anxiety
Dx
HPI
PMHx
PE findings
W/u
Insulinoma
Dx Insulinoma
HPI Severe episodes of fasting or postprandial hypoglycemia Palpitations, diaphoresis, tremulousness Weight gain Confusion Visual changes Unusual behavior
PMHx
FHx of MEN 1
PE findings
Peripheral tremor
W/u
Blood glucose
Plasma GLP-1 level and insulin
Abd CT/MRI/US
Patient c/o palpitations and anxiety
Dx
HPI
PMHx
PE findings
W/u
Hypoglycemia
Dx Hypoglycemia
HPI Tremor palpitations anxiety seating hunger paraesthesia
PMHx similar episodes during fasts Insulin or other DM Tx alcohol use hormone deficiency (cortisol, glucagon, epinephrine) insulinoma
PE findings
peripheral tremor
W/u Blood glucose level Insulin level C-peptide level Beta-hydroxyurate level Secretatogue screen
38 yo c/o vaginal discharge
Dx
HPI
PMHx
PE findings
W/u
Bacterial vaginosis
Dx Bacterial vaginosis
HPI
grayish-white watery discharge
malodorous
Post-menstrual onset
PMHx IUD Douching Recent antibiotics menopause multiple sex partners unprotected sex
W/u pelvic exam Wet prep Vaginal pH Whiff test
38 yo woman c/o vaginal discharge
Dx
HPI
PMHx
PE findings
W/u
Trichomonal vaginitis
Dx Trichomonal vaginitis
HPI Copious green/yellow frothy discharge Malordorous Pruritic Dysparenuia Dysuria Post-coital bleeding
PMHx
Unprotected sex
Multiple partners
IUD/smoking
W/u
Pelvic exam
Wet prep
Vaginal pH
38 yo woman c/o vaginal discharge
Dx
HPI
PMHx
PE findings
W/u
Candida vaginitis
Dx Candida vaginitis
HPI White, thick, cheesy, discharge Odorless Pruritic Dyspareunia Dysuria
PMHx Previous episodes of Abx DM Pregnant HIV OCP
W/u
Pelvic exam
KOH prep
Vaginal pH
48 yo woman c/o vaginal discharge
Dx
HPI
PMHx
PE findings
W/u
Atrophic vaginitis
Dx Atrophic vaginitis
HPI Vaginal dryness dysuria/urgency/frequency hot flashes post-coital bleeding
PMHx sleep disturbance osteoporosis pelvic organ prolapse tamoxifen/lupron menopause
W/u pelvic exam FSH Estradiol Vaginal smear
38 yo woman c/o heavy vaginal bleeding
Dx
HPI
PMHx
PE findings
W/u
abnormal uterine bleeding
Dx Abnormal uterine bleeding
HPI AUB > 6months (frequency/regularity/duration/volume) brown-stain bleeding color dysmenorrhea reproductive age not pregnant fatigue
PMHx AUB > 6months thyroid disease not on local or systemic gonadosteroids not on any medication OCP Systemic disorders of hemostasis Ovulatory disorders primary disorders of endometrium
PE findings
Tachycardia
Pallor
W/u Pelvic exam CBC Extraction of HB (alkaline hematin method) Pictorial blood loss assessment chart
38 yo woman c/o heavy vaginal bleeding
Dx
HPI
PMHx
PE findings
W/u
Endometriosis
Dx Endometriosis
HPI Abn bleeing pelvic pain infertility urinary urgency/frequency dypareunia dysmenorrhea dyschezia
PMHx
FHx endometriosis
FHx infertility
W/u Pelvic exam Abd U/S Transvaginal U/S Abd CT
38 yo woman c/o heavy vaginal bleeding
Dx
HPI
PMHx
PE findings
W/u
Spontaneous abortion
Dx Spontaneous abortion
HPI Confirmed pregnancy Suddent onset of vaginal bleeding Abd pain and contractions NSAID use
PMHx Advanced maternal age smoking cacaine Previous abortion prolonged time to conceive maternal infection
PE findings
fever
W/u pelvic exam abd U/S Beta hCG Folate level RhD level CBC w diff
45 yo woman c/o abnormal vaginal bleeding
Dx
HPI
PMHx
PE findings
W/u
Cervical cancer
Dx Cervical Cancer
HPI Pelvic pain Dyspareunia Bleeding after sex weight loss anorexia
PMHx
HPV infection
smoker
multiple partners
occ condom use
OC{ use over 10 years
W/u
Pelvic exam
Pap smear
18 yo woman c/o irregular menses
Dx
HPI
PMHx
PE findings
W/u
Stress induced amenorrhea
Dx Stressed induced amenorrhea
HPI
no menses for 3 months
Started college 3 months ago
PMHx
mother also with stress
W/u
bhCG
Testosterone and estrogen levels
Abd U/S
30 yo woman c/o amenorrhea
Dx
HPI
PMHx
PE findings
W/u
Prolactinoma
Dx Prolactinoma
HPI Galactorrhea Oligo/Amenorrhea Loss of axillary and pubic hair Headache
PE findings
Loss of peripheral vision
W/u
Prolactin level
Brain MRI
48 yo woman c/o amenorrhea for few hours
Dx
HPI
PMHx
PE findings
W/u
Menopause
Dx Menopause
HPI Amenorrhea for 12 mos Hot flashes Vaginal dryness Sleep disturbances Mood imbalance New onset depression Decline in cognitive function Dyspareunia joint pain Breast pain/tenderness
PMHx
irregular cycles > 4 years before final prd >12mo ago
Progressive course of decreased of very heavy bleeding
FHx of early menopause
hysterectomy with ovarian conservation
menstrual migraine
PE findings
increased age and wrinkling of skin
W/u Pelvic exam inhibin B FSH and LH Estradiol level AMH level AFC (ovarian antral follicular count) Transvaginal and pelvic U/S TSH
Middle aged woman c/o amenorrhea for few weeks
Dx
HPI
PMHx
PE findings
W/u
Pregnancy
Dx Pregnancy
HPI
amenorrhea, N w/wo V, breast enlargement/tenderness, increased frequency w/o dysuria, fatigue, mild uterine cramping/discomfort without bleeding
constipation, heart burn, nasal congestion, sexually active, reproductive age, physiologic pruritus, hirsutism, androgenic alopecia, increased salivation, food craving or aversion, mood changes
PMHx
new onset GERD
Hx of previous pregnancy
PE findings increased pigmentation (face, linea alba, areola), nevi, melasma, striae gravidarum
Vascular- spider angiomata, palmar erythema, varicositis, vascular tumors, hemorrhoids
Enlarged uterus on abd palpation
gigivitis
W/u
urine and blood bhCG
serum ALT/AST, bilirubin
Abd, pelvic, transvaginal U/S
Pelvic exam
Fetal HR with Doppler
CBC
26 yo woman c/o difficulty getting pregnant
Dx
HPI
PMHx
PE findings
W/u
Polycystic ovary syndrome
Dx Polycystic ovary syndrome
HPI
Dysmenorrhea
Unintentional weight loss
Hirsutism
PMHx Pelvic pain DM II OSA Ovarian cysts Similar Sx with female family members G0P0 excessive acne
PE findings facial acne patches of thin, darker, velvety skin Obese abdomen Hirsutism
W/u Pelvic exam serum hCG pelvic U/S Androgen levels Serum insulin Homocysteine level
30 yo c/o dysuria
Dx
HPI
PMHx
PE findings
W/u
Urethritis
Dx Urethritis
HPI Urinary urgency, frequency, starting itching pain, burning, and discomfort in urination and genitalia dysmenorrhea vaginal d/c
PMHx
active with multiple partners
occ condom use
PID
W/u
pelvic exam
U/A
55 yo woman c/o urinary incontinence
Dx
HPI
PMHx
PE findings
W/u
urge incontinence
Dx urge incontinence
HPI
Sudden uncontrolled urine loss associate with strong desire to void
PMHx UTI DM BPH (man) C-section, prostate surgeries Pregnancy/delivery
PE findings
No abd tenderness
No CVA tenderness
W/u Genital and pelvic exam U/A cystometry Post void residual volume Pelvic of abd U/S
55 yo woman c/o urinary incontinence
Dx
HPI
PMHx
PE findings
W/u
Stress Incontinence
Dx stress incontinence
HPI
involuntary urine loss while coughing, laughing, lifting, sneezing
PMHx constipation, urinary incontinence multiple gestations smoking prostatectomy
PE findings
No abd tenderness
No CVA tenderness
W/u genital and pelvic exams U/A Cystometry Post-void residual volume Pelvic or abd U/S
70 yo man c/o nocturia
Dx
HPI
PMHx
PE findings
W/u
Benign prostatic hyperplasia
Dx Benign prostatic hyperplasia
HPI
urgency, hesitancy, frequency, incontinence, weak urine stream, straining to void, sense of incomplete emptying, terminal dribbling
PMHx
family hx
PE findings
abd exam WNL
W/u
Prostate exam
PSA
Transrectal U/S
70 yo man c/o hematuria
Dx
HPI
PMHx
PE findings
W/u
Prostate Cancer
Dx Prostate cancer
HPI
back pain, fatigue, weight loss, urinary frequency and urgency, difficulty starting and maintaining stream of urine, nocturia, dysuria
PMHx
diet high in processed meat
father with prostate cancer
PE findings
obese
abd exam WNL
W/u
Prostate exam
PSA
Transrectal U/A
60 yo man c/o hematuria
Dx
HPI
PMHx
PE findings
W/u
Bladder cancer
Dx Bladder cancer
HPI
dysuria, increased frequency, urgency
PMHx
smoker (many years)
hair dresser
PE findings
WNL abd exam
W/u
U/A
urine cytology
cystoscopy
60 yo man c/o hematuria
Dx
HPI
PMHx
PE findings
W/u
renal cell carcinoma
Dx renal cell carcinoma
HPI
flank pain
unintentional weight loss
fatigue
PMHx
smoker, FHx of kidney cancer, x.s. acetaminophen use
occupational exposure- asbestos
HTN
PE findings
Obesity
Abd mass
W/u
U/A
Abd CT
37 yo man c/o groin pain
Dx
HPI
PMHx
PE findings
W/u
Testicular torsion
Dx Testicular torsion
HPI young man sudden onset unilateral radiates to lower back N/V
PMHx
onset during physical exertion
PE findings
fever
CVA tenderness
W/u
genital exam
Doppler U/S of scrotum
37 yo Man/Woman c/0 increasing flank pain
Dx
HPI
PMHx
PE findings
W/u
nephrolithiasis
Dx nephrolithiasis
HPI sudden back/flank pain restlessnes (colicky pain) radiation to groin or abdomen N/V Anorexia Dysuria
PMHx kidney stone dehydration high protein and sodium diet overweight
PE findings
fever
CVA tenderness
W/u
Helical renal CT
U/A for Ca2+, oxalate, uric acid
renal U/S
37 yo Man/Woman c/o flank pain and fever
Dx
HPI
PMHx
PE findings
W/u
Pyelonephritis
Dx Pyelonephritis
HPI
dysuria, FEVER, N/V, polyuria, urgency, hematuria, chills
PMHx
recurrent UTO
BPH (man)
PE findings
Fever
CVA Tenderness
W/u
U/A
urine culture
renal U/S
45 yo womanc/o right sided abdominal pain
Dx
HPI
PMHx
PE findings
W/u
Acute cholecystitis (biliary colic)
Dx acute cholecystitis (biliary colic)
HPI acute, persistent RUQ pain Pain related to fatty foods Radiation to RIGHT scapula N/V Fever
PMHx OCP use Fat DM FHx gb dz multiparity
PE findings uncomfortable overweight fever RUQ tenderness Murphy sign Tachycardic
W/u CBC w/ diff Abd U/S AST/ALT/ALP, bilirubin ERCP HIDA
41 yo woman c/o acute painful abdominal distress
Dx
HPI
PMHx
PE findings
W/u
Pancreatitis
Dx Pancreatitis
HPI persistent epigastric pain radiates to back alleviated by sitting up or bending forward N/V
PMHx
binge alcohol
gallstones
PE findings appears ill and uncomfortable epigastric tenderness rebound guarding cullen/gray turner sign febrile tachycardia
W/u serum lipase/ amylase CRP/ALT/AST Abd xray Abd U/S Abd CT trypsinogen activation peptide
53 yo man c/o recurrent chest pain, dyspnea, anxiety
Dx
HPI
PMHx
PE findings
W/u
GERD
Dx GERD
HPI
postprandial discomfort, worse supine, heartburn, regurgitation, dysphagia, chest pain, nausea
PMHx
obesity
smoking
PE findings
wheezing
W/u
EGD
Esophageal pH
41 yo woman c/o acute painful abdominal distress
Dx
HPI
PMHx
PE findings
W/u
Peptic ulcer disease
Dx Peptic Ulcer Disease
HPI epigastric pain and fullness Persistent N/V Hematemesis Melena
PMHx
NSAIDs
H. pylori
PE findings
uncomfortable, epigastric tenderness
W/u
EGD
FOBT
46 yo woman c/o abdominal pain and nausea
Dx
HPI
PMHx
PE findings
W/u
Gastritis
Dx Gastritis
HPI Epigastric pain worse with food better with ant-acids N/V
PMHx
H. pylori
infections and AI dz
PE findings
epigastric tenderness
W/u GUI endoscopy H. pylori testing Serum pepsinogen Antibodies to IF, parietal cells, and H. pylori
68 yo woman c/o chills, nausea, and abdominal pain
Dx
HPI
PMHx
PE findings
W/u
Gastroenteritis (Norovirus)
Dx Gastroenteritis
HPI nonbloody diarrhea V/N crampy abd pain onset in winter season malaise
PMHx
sick contacts
PE findings appears frail and uncomfortable fever diffuse abd tenderness dehydration
W/u blood culture FOBT fecal leukocyte fecal lactoferrin
68 yo woman c/o chills, nausea, abdominal pain
Dx
HPI
PMHx
PE findings
W/u
Hepatitis A
Dx Hepatitis A
HPI fatigue malaise anorexia N/V gradual onset
PMHx
sick contacts
travel to endemic areas
PE findings low grade fever RUQ pain HSM jaundice LAD
W/u AST/ALT Bilirubin AlkP/GGT LDH Serum IgM/IgG Anti-HAV
68 yo woman c/o chills, nausea, abd pain
Dx
HPI
PMHx
PE findings
W/u
Acute cholangitis
Dx acute cholangitis
HPI
abd pain
jaundice
N/V
PMHx
choledocholithiasis
PE findings uncomfortable FEVER RUQ pain jaundice
W/u CBC w/ diff CRP ALT/AST/GGT AlkP Blood cultures Transabd U/S
70 yo man c/o abd pain
Dx
HPI
PMHx
PE findings
W/u
pancreatic cancer
Dx pancreatic cancer
HPI upper abd pain unintentional weight loss light colored stool dark urine loss of apetite
PMHx
smoker
DM
heavy alcohol use
PE findings
jaundice
FHx cancer
W/u
Abdominal CT
CA 19-9
LFT
Elderly man c/o increasing abdominal pain
Dx
HPI
PMHx
PE findings
W/u
Diverticulitis
Dx Diverticulitis
HPI LLQ abd pain several days duration gradually increasing diarrhea and constipation
PE findings restless LLQ tenderness guarding rebound
W/u
CT scan
Abd x-ray
CBC w/ diff
65 yo c/o bloody stools
Dx
HPI
PMHx
PE findings
W/u
Diverticulosis
Dx Diverticulosis
HPI painless rectal bleeding constipation weak and fatigue dizziness
PMHx no fiber supplements HTN IBS FHx diverticulosis no FHx of colon cancer
W/u rectal exam with FOBT CBC w/diff CT abdomen Colonoscopy
65 yo man c/o bloody stool
Dx
HPI
PMHx
PE findings
W/u
Colon cancer
Dx Colon cancer
HPI painless rectal bleeding change in bowel habits weak and fatigue unintentional weight loss
PMHx no screening colonoscopy anemia FHx colon cancer smoking
PE findings
abdominal tenderness
abdominal mass
W/u rectal exam with FOBT CBC w/ diff CT abd Colonoscopy
65 yo man c/o bloody stool
Dx
HPI
PMHx
PE findings
W/u
Angiodysplasia
Dx Angiodysplasia
HPI painless rectal bleeding stool black and tarry fatigue no weight loss no hx of bruising
PMHx
anemia
no FHx of colon cancer
W/u rectal exam w/ FOBT CBC w/ diff PT/PTT/INR CT abdomen Colonoscopy EGD
70 yo man c/o acute abdominal pain
Dx
HPI
PMHx
PE findings
W/u
mesenteric ischemia
Dx mesenteric ischemia
HPI acute abd pain pain with meals pain out of proportion to exam weight loss N/V blood in stool
PMHx
arrhythmia, cardiac valvular disease, infective endocarditis, recent MI, ventricular aneurysm, aortic aneurysm, aortic athersclerosis
h/o metabolic acidosis
PE findings
diffuse abd pain on palpation
abd guarding
Rovsing sign/rebound
W/u abd xray CBC ABG Lactate Abd CT angiography
Man c/o abdominal pain
Dx
HPI
PMHx
PE findings
W/u
large bowl obstruction
Dx large bowel obstruction
HPI severe cramping and pain diffuse and poorly localized abdominal distention constipation vomiting unable to pass flatulus
PMHx
prior abdominal surgery
PE findings
restless, fever, abd distention, bowel sounds, normal or quiet, hyperresonance on abd percussion, tenderness on palpation
W/u CBC w/ diff Electrolytes/anion gap Barium enema Abd xray colonoscopy abd CT
20 yo man c/o abdominal pain and diarrhea
Dx
HPI
PMHx
PE findings
W/u
Lactose intolerance
Dx lactose intolerance
HPI
bloating, diarrhea, nausea, flatulence, borborygmi,
Sx start 2 hrs after ingestion of lactose, abdominal cramps
PMHx
stomach problems
W/u hydrogen breath test stool acidity test fecal lactoferrin levels calprotectin levels
20 yo man c/o abdominal pain and diarrhea
Dx
HPI
PMHx
PE findings
W/u
Traveler’s diarrhea
Dx Traveler’s Diarrhea
HPI abd cramps nausea bloating malaise anorexia
PMHx
recent trip overseas
use of antacids for heartburn
PE findings
fever
W/u
FOB
Stool culture
Stool ova for parasites
46 yo man c/o abdominal pain and diarrhea
Dx
HPI
PMHx
PE
W/u
Chron disease
Dx Chron disease
HPI Prolonged diarrhea w/or w/o gross bleeding Crampy abdominal pain Steatorrhea Aphthous ulcers or pain in mouth or gums Odynophagia Dysphagia Weight loss Fatigue fever
PMHx Fhx IBD PMHx eye problems (uveitis, irits, episcleritis), joint problems (sacroiliitis or ankylosing spondylitis), erythema nodosum and pyoderma gangrenosum Recurrent UTI Primary sclerosing cholangitis Pulmonary manifestations
PE
Febrile
Abd tender to palpation
Abd mass
W/u Abd x-ray Rectal exam w/ FOBT CBC ESR and CRP PANCA and ASCA Electrolytes Colonoscopy Capsule endoscopy UGI Series MRE
36 yo woman c/o abdominal pain
Dx
HPI
PMHx
PE
W/u
IBS
Dx IBS
HPI
Diarrhea w/ alternating constipation
Abd cramps better with defecation
Diffuse abdominal pain
PMHx Anxiety Excessive stress FHx Child abuse
PE
Generalized abd tenderness
46 yo man c/o abdominal pain and diarrhea
Dx
HPI
PMHx
PE
W/u
Psuedomembranous colitis
Dx Psuedomembranous colitis
HPI
Watery diarrhea
Abd pain and cramps
No blood in stool
PMHx
Allergies
Abx therapy
Hospitalization
PE
Diffuse abdominal tenderness to palpation
W/u CBC w/ diff Stool assay for C. difficile Rectal exam and FOBT Stool for ova and parasites
30 yo woman c/o sudden onset abdominal pain
Dx
HPI
PMHx
PE
W/u
Appendicitis
Dx Appendicitis
HPI Periumbilical/sharo Progressive to RLQ Anorexia/fever N/V Diarrhea Malaise Indigestion/flatulence
PMHx
IBD
PE Fever Psoas/obturator sign Rovsing sign McBurney point tenderness
W/u
CBC w/ diff
Abd U/S; if negative or inconclusive then abd CT
40 yo woman c/o abdominal pain
Dx
HPI
PMHx
PE
W/u
Polycystic kidney disease
Dx Polycystic kidney disease
HPI
Headache
Hematuria
Polyuria
PMHx
FHx of kidney disease
HTN
UTI
PE
HTN
W/u
Abd U/S
Abd CT
Bun and Creatinine
33 yo woman c/o sudden onset severe abdominal pain
Dx
HPI
PMHx
PE
W/u
Ectopic pregnancy
Dx Ectopic pregnancy
HPI Sudden LLQ/RLQ pain Severe, progressive Unilateral Amenorrhea Vaginal bleeding/spotting N/V Breast fullness Weakness
PMHx Previous ectopic Fallopian tube pathology and surgery Abdominal surgery In-utero DES exposure PID/ infertility Uterine anomalies Smoker Progesterone contraception/IUD
PE
Tenderness
Gaurding
W/u
Pelvic exam
Serum quantitative bhCG
Transvaginal U/S
33 yo woman c/o sudden onset severe abdominal pain
Dx
HPI
PMHx
PE
W/u
PID
Dx PID
HPI Lower abd pain Gradual or sudden Dull and achy b/l Progressive Fever Purulent vaginal discharge N/V Anorexia/malaise Onset following menses
PMHx Multiple partners Unprotected sex Bacterial vaginosis Recent gyn procedure HIV PE Abd- Tenderness, Guarding
W/u Pelvic exam NAAT/cultures for chlamydia and gonorrhea Vaginal secretions KOH Transvaginal U/S
30 yo c/o sudden onset severe abdominal pain
Dx
HPI
PMHx
PE
W/u
Ovarian torsion
Dx Ovarian torsion
HPI Sharp, intermittent, unilateral, worsening lower abd pain Precipitated by exercise Radiates to flank, back, and/or groin Fever N/V
PMHx
Previously resolved episodes
Pelvic surgery
Ovulation induction
W/u
Pelvic exam
Pelvic U/S Doppler
30 yo woman c/o sudden onset abdominal pain
Dx
HPI
PMHx
PE
W/u
ovarian cyst rupture
Dx ovarian cyst rupture
HPI Unilateral onset Diffuse Exercise precipitated Vaginal bleeding N/V Shoulder pain
PMHx
LMP 2 wks ago (midcycle)
PE
Cullen sign
W/u
Pelvic exam
Pelvic U/S Abd CT
55 yo man c/o vomiting blood
Dx
HPI
PMHx
PE
W/u
Mallory-Weiss syndrome
Dx Mallory-Weiss syndrome
HPI
Bright red blood w/ gastric content after lots of alcohol
Lightheadedness
Epigastric abdominal pain
PMHx
Smoking
Heavy alcohol use
PE
Pallor
Diaphoretic
Alcohol breath
W/u
CBC w/ diff
EGD
Middle-aged c/o difficulty swallowing
Dx
HPI
PMHx
PE
W/u
Achalasia
Dx Achalasia
HPI Progressive dysphagia both liquid and solid a/w regurgitation of undigested food a/w retrosternal pain a/w coughing when lying flat
PE
Thin
CV exam WNL
W/u
Esophageal manometry
Barium esophagram
Endoscopy
Young man c/o headache
Dx
HPI
PMHx
PE
W/u
Meningitis
Dx Meningitis
HPI Severe headache Photophobia Nuchal rigidity Fever
PMHx
Rash or recent URI
recent travel
PE
Brudzinski sign
Kernig sign
Nuchal rigidity
W/u CBC w/ diff serum glucose electrolytes blood cultures CT head lumbar puncture
Middle-aged man c/o headache
Dx
HPI
PMHx
PE
W/u
Subarachnoid hemorrhage
Dx Subarachnoid hemorrhage
HPI Severe headache sudden onset photophobia nuchal rigidity LOC confusion vomiting
PMHx
recent h/o head injury
PE
nuchal rigidity
MMSE altered
W/u
Head CT
Young woman c/o headache
Dx
HPI
PMHx
PE
W/u
Migraine
Dx Migraine
HPI Unilateral headache pulsating photophobia visual disturbances associated with food, menses nausea precipitated by stress, hunger, fatigue
PMHx
OCP use
FHx of similar headaches
W/u
—-
45 yo woman c/o headache
Dx
HPI
PMHx
PE
W/u
Tension headache
Dx Tension Headache
HPI pain in lower back of head on both sides radiates to neck constant pressure mild to moderate pain
PMHx
increased stress
sleep deprivation
recent eye strain
PE
tense neck and shoulder muscles
45 yo man c/o headache
Dx
HPI
PMHx
PE
W/u
Cluster headache
Dx Cluster headache
HPI
unilateral orbital pain
recurrent w/ periods of spontaneous remission
severe
associated rhinorrhea and nasal congestion
No aura
PMHx
prior episodes of same headache
W/u
—
65 yo man c/o forgetfulness
Dx
HPI
PMHx
PE
W/u
Alzheimer Disease
Dx Alzheimer Disease
HPI progressive memory loss confusion occupational functioning impairment personality and mood changes progressive deterioration falls urinary incontinence fatigue and weakness
PMHx
Fhx of Alzheimer
PE
MMSE
FND
Gait disturbance
W/u
Brain MRI
Brain PET scan
65 yo man c/o forgetfulness
Dx
HPI
PMHx
PE
W/u
Vascular dementia
Dx Vascular dementia
HPI
cognitive deficits and memory
social and occupational functioning impairment
personality and mood changes, abulia, apathy
step-like decline
falls
urinary incontinence
fatigue and weakness
PMHx
HTN
strokes or CVA/dz
high cholesterol
PE MMSE FND Gait disturbance Hyperreflexia Babinski Pseudobulbar palsy (CN 5,7,9,10,11,12)
W/u
Brain CT and MRI
65 yo man c/o forgetfulness
Dx
HPI
PMHx
PE
W/u
Prion Disease
Dx Prion Disease
HPI
rapid progression of psychiatric Sx
Depression, agitation, apathy, insomnia, irritability, social withdrawal, psychotic features (delusions and hallucinations)
PMHx
FHx of prion disease
FHx psychiatric
PE abnormal sensation gait ataxia involuntary movements immobility paresis of upward gaze cognitive impairment startle response and mutism
W/u EEG LP Examination of tonsillar tissue Brain CT and MRI
65 yo man c/o vertigo
Dx
HPI
PMHx
PE
W/u
Benign positional vertigo
Dx Benign positional vertigo
HPI
episodic (seconds) with loss of balance
N/V
Sudden onset with change in head position
PMHx --- PE --- W/u Dix-Hallpike test CBC w/diff CT of head Audiogram
65 yo man with headache and confusion
Dx
HPI
PMHx
PE
W/u
Cerebrovascular accident
Dx Cerebrovascular accident
HPI
FND < 24 hrs
sudden
PMHx HTN DM high cholesterol A-fib not compliant with Warfarin FHx of early CAD smoking
PE
FND
W/u Head CT Brain MRI ECG CBC w/diff PT/PTT/INR Electrolytes Fasting blood lipids and glucose
70 yo woman c/o severe headache and stiff neck
Dx
HPI
PMHx
PE
W/u
Subdural hematoma
Dx Subdural hematoma
HPI headache confusion somnolence N/V head trauma falls with progressive FNDs Seizures
PMHx
frequent fall
alcoholism
h/o anticoagulant medication
PE FNDs gait abnormalities nuchal rigidity Brudzinsky/Kernig Babinski Hemiplegia (R or L) Bruises from falls
W/u Head CT Brain MRI LP-CSF analysis CBC w/diff PT/PTT/INR Urine toxicology
70 yo woman c/o severe headache and facial pain
Dx
HPI
PMHx
PE
W/u
Trigeminal neuralgia
Dx Trigeminal neuralgia
HPI
Headache
Sharp facial pain electric, shock-like, or stabbing
repetitive episodes ( at least three)
lacrimation, conjunctival injection, and rhinorrhea
facial muscle spasm
PMHx migraine HTN chronic facial pain dull continuous pain in the jaw
PE
no FNDs except some sensory loss
precipitation of painful attack by tactile stimulation of facial trigger zone
W/u
Brain CT and MRI
60 yo woman c/o severe headache
Dx
HPI
PMHx
PE
W/u
Temporal arteritis
Dx Temporal arteritis
HPI right or left temporal headache tongue claudication jaw claudication blurred vision acute tinnitus
PMHx
recurrently diagnosed with PRP
PE Fever Tenderness on scalp over temporal area jaw claudication decreased visual acuity
W/u ESR Biopsy of temporal artery LFT CRP Platelet
58 yo woman c/o sudden onset back pain
Dx
HPI
PMHx
PE
W/u
lumbar muscle strain
Dx Lumbar muscle strain
HPI lower back pain sudden after cleaning house dull and achy b/l no radiation numbness tingling or weakness
PMHx similar episode in apst smoking weight gain and sedentary life style during heavy work and strenuous exercise FMHx back pain
PE
paraspinal tenderness and spasm
no sensory deficits and motor impairments in LE
W/u
L-spine x-ray
L-spine MRI
58 yo woman c/o progressive onset pain in the legs
Dx
HPI
PMHx
PE
W/u
lumbar spinal stenosis
Dx Lumbar spinal stenosis
HPI progressive onset back pain and b/l leg pain alleviate by sitting and bending forward aggravated by walking and standing
PMHx
back pain
b/l pain in buttocks and posterior thighs
FM hx back pain
PE antalgic gait wide based gait abnormal romberg vibration deficits No SLR
W/u
L-S spine x-ray
L-S spine CT
L-S spine MRI
58 yo woman c/o progressive onset pain in the legs
Dx
HPI
PMHx
PE
W/u
Disc herniation
Dx Disc herniation
HPI
severe back pain radiation down to buttock, leg foot, and ankle
Associate numbness and paraesthesia
worse with cough, sneezing, and prolonged sitting
precipitated by heavy lifting
bowel and bladder Sx if b/l disc herniation
PMHx
back pain
occupation- labor job
sciatica
PE loss of sensation in L5-S1 distribution SLR ipsilateral Crossed straight leg test Loss DTRs Impaired ankle reflex ankle dorsireflexion weakness great toe extensor weakness
W/u L-S spine x-ray L-S spine CT L-S spine MRI lower extremity EMG
35 yo woman c/o numbness and tingling in her legs
Dx
HPI
PMHx
PE
W/u
Multiple Sclerosis
Dx Multiple Sclerosis
HPI
relapsing remiting sensory weakness and visual disturbances
pain, light touch, and proprioceptive loss
b/l sensory loss in limb and face from certain level down
vertigo
fatigue
urinary incontinence
heat sensitivity
gait disturbance, incoordination, balance problems
headache
painful spasms
PMHx epilepsy anxiety, depression, cognitive impairment anemia sleep d/o and sleep apnea thyroid d/o and infxns mobility limitations trigeminal neuralgia back pain restless leg syndrome
PE weakness associated with spasticity, hyperreflexia, and clonus Lhermitte phenomenon monocular vision/visual field loss (scotoma) and difficulty discerning color Marcus gunn pupils internuclear ophthalmoplegia horizontal nystagmus spastic paraparesis limb ataxia
W/u brain MRI spinal MRI CS analysis for oligo-clonal bands visual evoked potential somatosensory evoked potential
55 yo man c/o numbness in hands and feet
Dx
HPI
PMHx
PE
W/u
Diabetic peripheral neuropathy
Dx Diabetic peripheral neuropathy
HPI numbness and tingling in hands and feet for few mos pain in legs >6 mo constipation Impotence vision problems
PMHx DM alcoholism HTN otitis media
PE
decreased soft vibratory and position sense
sores on feet
W/u Glucose level HbA1c nerve conduction study EMG
66 yo man c/o forgetfulness
Dx
HPI
PMHx
PE
W/u
Parkinson disease
Dx Parkinson disease
HPI feeling slow in processing information and thinking for last few months loss of dexterity (noted when dressing) slight tremor malaise sleep disturbances decreased sense of smell bradykinesia constipation
PMHx
occupation: e.g. farmer
PE soft spoke, slow speech, hypomimia (masked facies) resting tremor bradykinesia rigidity
30 yo woman c/o headache
Dx
HPI
PMHx
PE
W/u
Idiopathic intracranial hypertension
Dx Idiopathic intracranial hypertension
HPI throbbing headache headache worse in morning and with coughing/sneezing N/V Pulsatile tinnitus Double vision
PMHx
Isotretinoin for acne
PE
CNS examination
Fundoscopy
Obese
W/u
Brain CT
LP w/ CSF analysis
35 yo woman c/o pain in left hand
Dx
HPI
PMHx
PE
W/u
Carpal tunnel syndrome
Dx Carpal tunnel syndrome
HPI
1- 3th phalange and wrist
Numbness and tingling
Pain radiated up forearm
PMHx
occupation involves repetitive movement
hypothyroidism
multiple pregnancies
PE tenderness to palpation of 1st digits and wrist decreased muscle strength of left hand decreases sensation in first 3 digits Phalen or Tinel sign
W/u
Left hand x-ray
EMG
Nerve conduction study
Middle-aged woman c/o joint pain
Dx
HPI
PMHx
PE
W/u
Rheumatoid arthritis
Dx Rhematoid Arthritis
HPI Morning stiffness < 1 hr 6 wks improved w/ motion swelling of hands low-grade fever fatigue for several mos
PMHx
FHx of RA
PE
rheumatoid nodules
decreased ROM on hands and fingers
tender joints with ROM
W/u
anti-CCP
ANA, RF
Hand/wrist x-ray
Middle-aged woman c/o joint pain
Dx
HPI
PMHx
PE
W/u
SLE
Dx SLE
HPI photosensitivity oral ulcers alopecia weight loss swelling and redness of affected joints fatigue
PMHx
FHx of immune disease
PE Malar/discoid rash low grade fever petechiae decreased ROM on affected joints tender joints w/ ROM
W/u ANA anti-dsDNA Ab Anti-smith Ab Complement level antiphospholipid Ab INR
Middle-aged woman c/o joint pain
Dx
HPI
PMHx
PE
W/u
Lyme disease
Dx Lyme disease
HPI erythema migrans rash arthralgias/myalgias onset: migratory/ polyarticular tick bite lives in northeast, mid atlantic, upper midwest swelling and redness of affected joints fatigue
PMHx
hx of tick bite or walking in woods
PE bell palsy bradycardia heart block target rash not present at this stage low grade fever decreased ROM on affected joints tender joints w/ ROM
W/u
Lyme titer: ELISA/Western blot
Middle-aged woman c/o pain in left hip
Dx
HPI
PMHx
PE
W/u
Osteoarthritis
Dx Osteoarthritis
HPI Morning stiffness < 30 min monoarticular/polyarticular asymmetric insidious progression worse with exercise relieved by rest
PMHx FHx of OA obesity trauma/ repetitive stress previous surgery
PE
< ROM
W/u
Hip x-ray
Middle-aged woman c/o pain in left hip
Dx
HPI
PMHx
PE
W/u
Polymyalgia rheumatica
Dx Polymyalgia rheumatica
HPI morning stiffness > 30 min Distal extremities Fatigue Anorexia/weight loss Fever Headache Scalp tenderness
PMHx
carpal tunnel
temporal arteritis
PE
PIP affected
nodules
W/u
ESR
CRP
MRI or U/S of involved joint
multiple-aged woman c/o pain in left hip
Dx
HPI
PMHx
PE
W/u
multiple myeloma
Dx multiple myeloma
HPI bone pain: spine, long bones, skull, pelvis, chest severe/intermittent worse with movement relieved by rest fatigue/generalized weakness weight loss
PMHx
anemia
recent bacterial infection
PE
back pain
W/u serum protein electrophoresis U/A bence jones proteins & albumin peripheral smear skeletal survey serum Ca
45 yo man c/o worsening joint pain and morning stiffness
Dx
HPI
PMHx
PE
W/u
psoriatic arthritis
Dx psoriatic arthritis
HPI joint pain with polyarthriris oligo arthritis (asymmetrical but at multiple joints) morning stiffness > 30 min worse with prolonged immobility better with physical exercise back pain h/o skin disease
PMHx FHx psoriasis FHx RA spondyloarthritis enthesitis and tenosynovitis arthritis mutilans CV diseases or stroke achilles tendinitis and planter fasciitis gout
PE stress pain,, joint line tenderness and effusion in affected joint DIP join pain and deformity sausage digits decreased ROM in affected joints dactylitis skin lesions over joint pressure points nail pitting, onycholysis hyperkeratosis splinter hemorrhages pitting edema conjunctivitis and uveitis
W/u CBC ESR CRP FR ANA anti-CCP HLA B27 xray and MRI of affected joint Arthrocentesis and sinovial fluid analysis BUN/uric acid U/A
patient c/o pain in left foot
Dx
HPI
PMHx
PE
W/u
gout
Dx gout
HPI acute swelling of ankle joint monoarticular or oligoarticular asymmetric increased with purines (foods) increased with exercise low-grade fever
PMHx prior episode trauma/diuretics alcohol nephrolithiasis metabolic syndrome
PE
podagra
erythema
W/u
joint aspiration with synovial fluid analysis
angle x-ray for crystal
uric acid level in blood
45 yo man with worsening joint pain and morning stiffness
Dx
HPI
PMHx
PE
W/u
disseminated gonococcal infection
Dx disseminated gonococcal infection
HPI c/o tenosynovitis asymmetric mono or poly-arthralgia dermatitis fever, chills generalized malaise multiple partners unprotected sex
PMHx
congenital or acquired complement deficiency
SLE
STI
PE
purulent arthritis
pustular or veiculopustular dermatitis
tenosynovitis with redness and warmth around tendon sheath
W/u CBC w diff synovial fluid analysis blood culture on tayer-martin media PCR for gonoccocal DNA skin lesions specimens
45 yo man c/o worsening joint pain
Dx
HPI
PMHx
PE
W/u
Lateral epicondilitis
Dx lateral epicondilitis
HPI elbow pain,swelling, loss of motion repetitive elbow movement numbness and tingling in the hand cervical neck pain
PMHx trauma smoking gout gonorrhea IBS
PE
local tenderness, swelling, redness at affected jiont
impaired ROM
sensory loss
W/u CXR X-ray and MRI of affected joint arthrocentesis CBC uric acid level
43 yo woman c/o hip pain
Dx
HPI
PMHx
PE
W/u
Hip dislocation
Dx hip dislocation
HPI
fall
PMHx
long term smoker
recent hip replacement surgery
PE
tenderness to palpation of hip
limited ROM
W/u
hip-x-ray
MRI of affected hip
82 yo woman c/o inability to bear weight
Dx
HPI
PMHx
PE
W/u
hip fracture
Dx hip fracture
HPI
fall
hip pain
PMHx
osteoporosis
PE
tenderness on palpation of hip
W/u
hip-x-ray
MRI of affected hip
45 yo woman c/o muscle weakness
Dx
HPI
PMHx
PE
W/u
myasthenia gravis
Dx myasthenia gravis
HPI worse at night/exertion- weakness weakness better with rest diplopia dysphagia and difficulty chewing slurred speech droopy eyelids progressive fatigue jaw weakness w/ chewing difficulty walking up stairs no muscle pain
PMHx
FHx of hypothyroidism and RA
PE slurred speech drooping eyelids decreased muscle strength decreased flexes in UE and LE b/l
W/u ACH receptor Abs muscle specific tyrosine kinase Abs anti-striated muscle Abs EMG nerve conduction study
45 yo man c/o muscle weakness
Dx
HPI
PMHx
PE
W/u
Guillain-Barre syndrome
Dx Guillaine-Barre syndrome
HPI ascending symmetrical weakness numbness and tingling progressive fatigue diplopia slurred speech
PMHx
recent URI
PE low BP and high HR ptosis loss of DTR in LE b/l decreased muscle strenth in LE b/l
W/u
EMG, nerve conduction study
PFTs (FVC, negative inspiratory force)
Dx
HPI
PMHx
PE
W/u
cellulitis
Dx cellulits
HPI ankle area extending up LLE +/- puncture wound welling/erythema/unilateral fever/chills/malaise no drainage
PMHx trauma few days ago skin disorder at site DM or HIV Surgery
PE
Lymph nodes
Erythema
W/u
CBC w/ diff
patient c/o pain in left lower leg
Dx
HPI
PMHx
PE
W/u
Peripheral arterial disease
Dx Peripheral arterial disease
HPI worse with ambulation worse when climbing stairs better with rest intermittent/cramping/claudication
PMHx hyperlipidemia DM MI HTN smoker Fhx
PE diminished/absent pulses shiny skin/absent hair cold feet thickened toe nails impaired sensation
W/u
ankle/brachial arterial pressure
57 yo woman c/o significant pain and swelling of her left leg for past several days
Dx
HPI
PMHx
PE
W/u
deep vein thrombosis
Dx deep vein thrombosis
HPI
pain w/ leg swelling (difference of 3 cm circumference)
OCPs and smoking
sedentary lifestyle
dyspnea of sudden onset, chest pain, fatigue if complicated with PE
PMHx malignancy prior DVT immobilization >3days surgery > 30 min pregnancy estrogen Tx smoking obestiy h/o venous thromboembolism
PE localized tenderness entire leg swollen pitting edema collateral superficial veins increased warmth at affected side tachypnea
W/u doppler U/S of LE D-Dimer CTA ant-phospholipid ABs Factor V leiden Protein C S INR, PT, PTT Homocysteine level antithrombin III Factor VIII CXR ABG ECG
50 yo man c/o pain in heel and bottom of foot
Dx
HPI
PMHx
PE
W/u
Plantar fascitis
Dx plantar fascitis
HPI
sharp unilateral pain
worse at period of rest and in morning
PMHx
smoking
runner
PE
Obese
pain reproduced by bending foot and toes up toward shin
45 yo man c/o gradual onset of localized chest pain
Dx
HPI
PMHx
PE
W/u
Costochondritis
Dx costochondritis
HPI region pain syndrome stinging pain pain reproducible multiple areas of chest tenderness absence of cough
PE
tenderness at upper costal cartilage of costochondral or costosternal junctions
localized muscle tension
no heat erythema or localized swelling
W/u
CXR
patient c/o dizziness
Dx
HPI
PMHx
PE
W/u
panic disorder
Dx panic disorder
HPI
unexpected episodes of palpitations, SOB, dizziness
associated w/ sweating, trembling, chest pain, palpitiations, and circumoral numbness
persistent concern about future attacks
PMHx
anxiety
no substance use d/o
caffeine use
W/u
—
patient c/o dizziness
Dx
HPI
PMHx
PE
W/u
acute alcohol intoxication
Dx acute alcohol intoxication
HPI dizziness euphoria ataxia slurred speech vomiting confusion
PMHx
alcohol abuse
alcoholism
stressful job
PE alcohol scent on breath unstable gait slurred speech MMSE
W/u
serum ethanol level
urine tox
serum glucose level
25 yo man c/o visual hallucinations
Dx
HPI
PMHx
PE
W/u
substance-induced psychosis
Dx substance-induced psychosis
HPI
disorientation
acute intoxication of alcohol
PMHx
alcoholic
cannabis use
W/u
urine tox
23 yo man c/o restlessness
Dx
HPI
PMHx
PE
W/u
Schizophrenia
Dx Schizophrenia
HPI
> 6 mo delusions, hallucinations (auditory), social dysfxn, disorganized speech
interferes with normal functioning
PMHx
FHx
PE
MMSE
impaired judgement
blunt affect
W/u urine tox head CT brain MRI brain PET scan
18 yo man c/o difficulty concentrating
Dx
HPI
PMHx
PE
W/u
Schizoaffective disorder
Dx Schizoaffective disorder
HPI delusions hallucinations alogia avolition anhedonia irritable mood excessive agitation
PMHx
anxiety
risk taking behavior
PE
disorganized speech
blunt affect
W/u CBC w/ diff electrolytes serum glucose cortisol urine tox serum alcohol TSH
25 yo woman c/o fatigue
Dx
HPI
PMHx
PE
W/u
Bipolar disorder
Dx Bipolar disorder
DIG FAST
HPI sad mood > 2wks early morning wakefulness anhedonia loss of concentration decreased appetite suicidal ideation associated with periods of increased energy, excessive spending, and increased promiscuous sexual activity
PMHx
FHx similar Sx
PE
affect depressed
mood c/w affect
W/u CBC w/ diff electrolytes serum glucose cortisol urine tox serum alcohol level TSH
20 yo woman c/o depressed mood
Dx
HPI
PMHx
PE
W/u
Adjustment disorder
Dx Adjustment disorder
HPI loss of interest feeling of hopelessness better with removal of stressors sadness anhedonia difficulty concentration
PMHx
loss of job 1mo ago
PE
depressed affect
affect c/w mood
W/u CBC w/ diff electrolytes serum glucose cortisol urine tox serum alcohol level TSH
25 yo woman c/o fatigue
Dx
HPI
PMHx
PE
W/u
Major depressive disorder
Dx Major depressive disorder
HPI
(5/9) SIGECAPS + depressed mood or anhedonia
PMHx
Fhx psych conditions
PE decreased concentration of MMSE depressed affect mood c/w affect lack of eye contact
W/u CBC w/ diff electrolytes serum glucose cortisol urine tox serum alcohol level TSH
35 yo woman c/o fatigue
Dx
HPI
PMHx
PE
W/u
Normal bereavement (<6mo)
vs
persistent complex bereavement disorder (>12mo)
Dx Normal bereavement
HPI anhedonia anorexia trouble concentrating trouble sleeping
PMHx
loss of husband 6 mo ago
W/u
—
20 yo woman c/o fatigue
Dx
HPI
PMHx
PE
W/u
social anxiety disorder (social phobia)
Dx social anxiety disorder
HPI
persistent fear of one or more social or performance situations
diaphoresis, tremors, palpitations, nausea in public places
avoidance of public spaces
PMHx
anxiety
PE
anxious affect
mood c/w affect
W/u CBC w/ diff electrolytes serum glucose cortisol urine tox serum alcohol level TSH
mother c/o child becoming irritable
Dx
HPI
PMHx
PE
W/u
lead poisoning
Dx lead poisoning
HPI anorexia abd pain/constipation poor attention span distractability impulsiveness/hyperactivity pica/lethargy vomiting headache
PMHx
old building
low socioeconomic status
PE --- W/u physical exam blood lead level CBC
mother c/o child becoming irritable lately
Dx
HPI
PMHx
PE
W/u
Iron deficiency anemia
Dx Iron deficiency anemia
HPI anorexia lethargy fatigue pallor irritability poor feeding pica mainly milk
PMHx
low birth weight
blood loss
systolic murmur
PE --- W/u Physical exam peripheral smear serum iron/ferritin TIBC/FEP reticulocyte count FOBT CBC/MCV/RDW
mother c/o child becoming irritable lately
Dx
HPI
PMHx
PE
W/u
ADHD
Dx ADHD
HPI inattention/hyperactive impulsive multiple settings <12 yo > 6 mo distracted/disorganized forgetful constant fidgeting short attention span tasks not completed
PMHx
FHx psychiatric d/o
W/u
physical exam
psychiatric mental status evaluation
Parent c/o 7 yo child with irritability
Dx
HPI
PMHx
PE
W/u
oppositional defiant disorder
Dx oppositional defiant disorder
HPI patterns of argumentative behavior > 6 mo often loses temper/angry argues with authority annoys classmate blames others for his mistakes
PMHx --- PE --- W/u physical exam
Mother c/o child with fever and rash
Dx
HPI
PMHx
PE
W/u
Measles
Dx Measles
HPI cough, coryza, and conjunctivitis recent travel or exposure to sick persons transient respiratory Sx Fever Malaise, anorexia diarrhea lethargy
PMHx
otitis media
missed vaccinations
PE fever maculopapular rash koplik spots keratitis or corneal ulcerations non-purulent conjunctivitis LAD
W/u Physical exam serum measles IgM and IgG Abs RT-PCR for measles virus RNA CBC w/ diff
Mother c/o newborn with fever and lethargy
Dx
HPI
PMHx
PE
W/u
Neonatal sepsis
Dx Neonatal sepsis
HPI fever lethargy poor feeding poor tone irritability seizures
PMHx inherited metabolic disorders hypoxia acidosis GBS infection maternal chorioamnionitis intrapartum-fetal tachycardia APGAR <6 Meconium ileus
PE respiratory distress: tachypnea, flaring, grunting, and use of respiratory muscles tachycardia hypotension fever
W/u physical exam cbc w/ diff blood cultures LP CXR (if respiratory distress)
Mother c/o newborn with irritability and crying
Dx
HPI
PMHx
PE
W/u
colic
Dx colic
HPI irritability paroxysmal crying (esp. at night) relieved by flatus or bowel movement normal feeding
PE face of baby flushed distended and tensed abdomen clenched fingers stiff and extended arms otherwise NL PE
W/u
bring child for PE
Mother c/o newborn who is irritable and cries inconsolably
Dx
HPI
PMHx
PE
W/u
intussusception
Dx intussesception
HPI progressive intermittent cramping sudden every 15-20 min inconsolable cry bilious emesis lethargy alerted consciousness
PMHx
reactive lymphoid hyperplasia
gastroenteritis
FHx GI problems: Meckel, Chron, celiac, cystic fibrosis
PE
drawing legs to abdomen
distension
palpable sausage-shaped abd mass
W/u bring child for PE FOBT for gross blood and currant jelly stool abd U/S abd plain x-ray
Mother c/o newborn to pass stool
Dx
HPI
PMHx
PE
W/u
Hirschsprung disease
Dx Hirschsprung disease
HPI
a/w brown vomit
abd swelling
flatulence
W/u
Physical exam
16 yo girl c/o cold intolerance
Dx
HPI
PMHx
PE
W/u
anorexia nervosa
Dx anorexia nervosa
HPI
weight loss
food restriction
excessive exercise
PMHx use of laxatives amenorrhea brittle hair fatigue FHx of eating d/o
PE
thin appearance
lanugo
HYPOTENSION
W/u
electrolytes
cbc
patient c/o fatigue
Dx
HPI
PMHx
PE
W/u
hypothyroidism
Dx Hypothyroidism
HPI weight gain cold intolerance dry skin brittle hair/puffy face/sleepiness constipation depressed mood muscle weakness decreased mood muscles weakness decreased sweating hoarseness lower extremity edema impaired memory tongue enlargement
PMHx potential drug induced- lithium hypothalamic-pituitary axis damage menstrual abnormalities carpal tunnel h/o autoimmune disease FHx of hypothyroidism
PE loss of eye brows periorbital edema DTR: delayed relaxation edema
W/u
TSH
Free T3
patient c/o fatigue
Dx
HPI
PMHx
PE
W/u
B12 deficiency
Dx B12 deficiency
HPI weight loss decreased appetite unsteady gait numbness/tingling of feet and hands perception of wearing stockings or gloves constipation or diarrhea sore tongue/weakness psychosis/memory loss pallor palpitations dyspnea on exertion
PMHx vegan diet alcoholic pernicious anemia chron disease/celiac GI resection acid suppressing drug metformin bacterial overgrowth
PE
Romberg sign
altered gait
W/u cbc peripheral smear serum b12 methylmalonic acid homocysteine
patient c/o fatigue
Dx
HPI
PMHx
PE
W/u
iron deficiency anemia
Dx iron deficiency anemia
HPI angular chelitis pica lethargy/pallor palpitations/dyspnea on exertion poor exercise tolerance lightheadedness leg cramps glossitis/koilonychia
PMHx GI bleed menorrhagia celiac sprue recent infections bacterial overgrowth systolic murmur
PE
pallor
tachycardia
W/u ferritin serum iron TIBC/CBC peripheral smear
patient c/o fatigue
Dx
HPI
PMHx
PE
W/u
Non-Hodgkin Lymphoma
Dx Non-Hodgkin Lymphoma
HPI fever/night sweats/ weight loss skin rash, pruritis anorexia/weight loss N/V complex regional pain abd fullness early satiety headache lethargy seizure
PMHx
PMHx or FHx lymphoma or hematopoietic malignancy
radiation or chemoTx
exposure to agricultural pesticides and hair dyes
PE painless, peripheral lymphadenopathy HSM fever FNDs
W/u cbc w/diff serum LDH and uric acid serum Ca peripheral smear serum protein electrophoresis CXR CT abd PET/CT brain LN Bx
35 yo woman c/o fatigue
Dx
HPI
PMHx
PE
W/u
PTSD
Dx PTSD
HPI
flashbacks
nightmares
Sxs > 1 mo
PMHx
major stressor
67 yo man with personal problem
Dx
HPI
PMHx
PE
W/u
drug-related erectile dysfunction
Dx drug-related erectile dysfunction
HPI
h/o ED
non compliant with DM or HTN medications
PMHx
HTN, DM, MI
radical prostatectomy
PE abn peripheral sensation on LE abn femoral/peripheral pulse alopecia, gynecomastia visual field defects
W/u genital examinations nocturnal penile tumescence test MRI brain glucose level and hgbA1c Testosterone and prolactin duplex doppler of penis Lipid profile
patient c/o tremor, palpitations, anxiety
Dx
HPI
PMHx
PE
W/u
DM
Dx DM
HPI poly- uria/dipsia/phagia h/o hypoglycemia Sx weight gain or loss (DM I) sedentary lifestyle high fat diet h/o claudication
PMHx CV dz HTN high cholesterol PAD obesity smoking
PE
obese
diminished LE peripheral pulses
decreased LE sensation
W/u blood glucose hgbA1c fasting lipid profile urine albumin AST/ALT serum creatinine TSH (if type DM 1)
41 yo woman c/o insomnia
Dx
HPI
PMHx
PE
W/u
Domestic violence
Dx domestic violence
HPI h/o abd pain depressed mood difficulty falling asleep pain on bruised area abd pain or other Sx
PMHx
depression
visiting the clinic multiple times w/o a clear dz
PE
bruises
inspection of other skin or body parts with traces of trauma in different stages of healing
W/u
x-ray skeletal survey
Fast U/S for soft tissue damage
41 yo woman c/o insomnia
Dx
HPI
PMHx
PE
W/u
stress induced insomnia
Dx stress induced insomnia
HPI issue falling asleep and staying asleep anxiety fatigue unreasonable worries and tension impaired daytime function inability to concentrate weight loss or gain memory problems h/o x.s coffee
PMHx FHx of bipolar disorder or other psychiatric disorder h/o starting new medication anxiety d/o very stressful situation complex regional pain using recreational drugs and alcohol
PE
nl thyroid exam
DTR intact b/l
motor 5/5 b/l
W/u
cbc
TSH, T3, free T4
35 yo woman c/o fatigue
Dx
HPI
PMHx
PE
W/u
obstructive sleep apnea
Dx obstructive sleep apnea
HPI
snoring
morning headaches
excessive daytime sleepiness
PMHx
smoker
PE
obese
hypertensive
W/u
polysomnography
