POPE spring

Question 1

CC: my son won’t stop coughing x3 wks.
6yoM persistant cough. had a cold one month ago that resolved, but continues to cough, esp at night. no recent fever, V/D, no ear/throat pain. stopped playing w friends and is more interested in staying in playing vid games. no one in fam is ill, but colds going around his class. no fam hx of asthma/pneumonia/CF/pulm disorders. father smokes in home.

Answer 1

ddx: post viral cough, asthma, mitral valve stenosis, pneumonia.
PE: GA (resp distress); VS (RR); HEENT (eyes for cobblestoning/shiners, otoscopy, nasoscopy, palpate/percuss sinus, oropharynx); SKIN (atopy); LYMPH (cerv, clav); PULM (I, trach dev, P, P, A, bronchophony); CARDIO (A, extrems for cyanosis, clubbing, cap refil)

Question 2

CC: nephew has a rash and fever x6 hrs.
4yoM fever of 101.5. HA yesterday, did not feel well this AM. no bfast and has been lying around. rash on base of neck that spread to checks. “little red bumps w blisters and pimples.” no V/D, took tylenol for fever, immunizations unknwn

Answer 2

ddx: measles, erythema infectiosum, varicella, meningitis, rubeola, rubella.
PE: GA; VS (T); HEENT (conjunctiva for erythema –Rubeola, oral pharynx for kopeck spots – measles, otoscope for TM injection); LYMPH (cervical and post auricular for rubella); SKIN (face–5th, scalp, upper extrems, trunk/back); PULM/CARDIO (Aus); NEURO (nuchal rigidity/kernig/brudzinski)

Question 3

CC: I’ve got this weird discharge x3 months.
nonsmoking 31yo G2P2 w LMP 3 wks ago, noted nipple discharge from R breast 3 months ago. its whitish in color,does not have odor. only occurred w stimulation, now occurring all the time. no L breast discharge. no tenderness/redness. no vag discharge/dysmenorrhea/dyspareunia. menarche at 12, reg cycles. tubal ligation 3 yrs ago, no fam hx of BC

Answer 3

ddx: hyperprolactinemia, intraductal papilloma, breast cx, fibrocystic breast.
PE: GA (cushingoid, hypothyroid, chronic illness); HEENT (visual field testing, fundoscopic exam for papilledema); NECK (thyroid); LYMPH (axillary, clav); PULM (A); BREAST; ABD (girth/fluid wave, liver size/nodularity); PV (periph edema)

Question 4

CC: my periods last forever x6months.
44yo G3P3 LMP 3 wks ago. continued, persistent heavy vag bleeding. usually reg cycles. now flow is heavy, has to use tampons and adds for 2-3 wks per cycle. soaks 6-8 pads per day at first, then slows to 1-3. large clots. no irritative voiding sxs, but more frequently. fatigue.lightheaded, SOB, gained 15 lbs, no hot flashes.

Answer 4

ddx: uterine fibroid, endometrial polyp, endometrial cx, anemia, hypothyroid.
PE: GA (hypothyroid, pallor); VS (pulse, orthostatic BP); HEENT (MMM, pallor); NECK (thyroid); SKIN (petichiae, purpura, ecchymosis, pallor); PULM/CARDIO (ausc); cyanosis/cap refill; Abd (masses/suprapubic distention, tenderness, spleen size, liver); PELVIC

Question 5

CC: im a wreck, skin bruising and tired all the time x several months.
61yo F w 60packyrhx, increased bruising in UE and LE. when injured, takes longer to heal, skin is thin. new stretch marks on abd. increased hair growth on face/arms. fatigue. muscle weakness, hard to climb stairs. feels more emotional, diminished concentration.

Answer 5

ddx: Cushing, T2D, Anemia, Lung canc, hypothyroidism, alcoholism.
PE: GA (affect, fatigue, chronic illness, moon facies, buffalo hump, central obesity); VS (BP); Skin/Hair/Nails (inspect/palpate hair, skin for thinning/striae/rashes/acne/hirsutism/bruising, nails for clubbing –small cell lung cx); HEENT (visual fields); NECK (thyroid, supraclav fat pads); LYMPH (clav, axillary); PULM/CARDIO (ausc); LE for edema; ABD (striae, kidneys/adrenal masses, liver); neuromusc (digital strength, DTRs –cushing)

Question 6

CC: I’m tired even when i sleep a lot x months.
63 yo retired college prof w fatigue and fluctuating blurry vision. sleeps soundly for 8 hrs/night. no hx of depression or anemia. 3 vag yeast infxns in last 6 months. several skin abscesses in last several weeks. new reading glasses. no wt changes, no changes to hair/nails. no heat/cold intolerance, no altered sensation of extremities.

Answer 6

ddx: T2D, hypothyroidism, adrenal insufficiency, cushings, anemia.
PE: GA (affect, fatigue, chronic illness); VS (HR for arrhythmias); SKIN (rashes, abscesses, striae, hirsutism, acanthosis nigricans); HEENT (MM for pallor, visual acuity, fundoscopy, oropharynx for thrush); NECK (thyroid); PULM/Cardio (ausc); ABD (bowel sounds, tenderness/masses); Extremities (LE hair dist/color, feet, temo, cap refill, pulses); NEURO (LE DTRs, distal sensation in feet, vibratory sensation in feet)

Question 7

CC: I’m tired even when i sleep a lot x months.
63 yo retired college prof w fatigue and fluctuating blurry vision. sleeps soundly for 8 hrs/night. no hx of depression or anemia. 3 vag yeast infxns in last 6 months. several skin abscesses in last several weeks. new reading glasses. no wt changes, no changes to hair/nails. no heat/cold intolerance, no altered sensation of extremities.

Answer 7

ddx: T2D, hypothyroidism, adrenal insufficiency, cushings, anemia, colon cancer.
PE: GA (affect, fatigue, chronic illness); VS (HR for arrhythmias); SKIN (rashes, abscesses, striae, hirsutism, acanthosis nigricans); HEENT (MM for pallor, visual acuity, fundoscopy, oropharynx for thrush); NECK (thyroid); PULM/Cardio (ausc); ABD (bowel sounds, tenderness/masses); Extremities (LE hair dist/color, feet, temo, cap refill, pulses); NEURO (LE DTRs, distal sensation in feet, vibratory sensation in feet); RECTAL.

Question 8

CC: I feel like a slug and am gaining wt x6 months.
48yo F w weakness and fatigue getting worse. frequent musc cramps, constipation, menorrhagia for 3-4 days each cycle. skin and hair texture have also changed and fingernails more brittle. she has gained 7 lbs.

Answer 8

ddx: hypothyroidism, peri-menopause, iron def anemia, depression.
PE: GA (hypothyroid facies, vocal changes); VS (HR for bradycardia); SKIN (hair for texture/distribution, skin for dryness/texture, nails for brittleness); HEENT (MM for pallor, tongue for macroglossia, visual fields); NECK (thyroid); PULM/CARDIO (Ausc); LE for edema; ABD (bowel sounds, tenderness/masses); NEURO (DTRs); MSK (musc strength at shoulder girdle/hip and grip/great toe); GU (Pelvic)

Question 9

CC: I can’t sleep at night x2 months.
28yo M w 2 mnth hx of insomnia and wt lost 10 lbs. feels hyper and jittery even though less stress in life than usual. he complains of heat intolerance, episodic diarrhea and hand tremor. drinks only one cup of coffee per day and no stimulants or supps. eats a lot. denies depression, anhedonia, or suicidality.

Answer 9

ddx: anxiety, T1D, testicular cx, hashimoto, graves.
PE: GA (hyperthyroid, vocal changes); VS (HR); SKIN (hair for texture, skin for moisture/texture, clubbing, pretibial edema); HEENT (eyes for exophthalmos/conjunctival chemises; EOMs); NECK (thyroid, thyroid bruits); PULM(ausc); L supraclav node; CARDIO (I, P, PMI, A); ABD (bowel sounds, tenderness/masses); NEURO (extremities for tremor, DTRs); GU (testicular exam).

Question 10

CC: Im so embarrassed –Im leaking x6 months.
58yo G4P3 nonsmoking woman w urinary leakage. occurs when she coughs or strains but also at other times as well. no probs when lying down, but when stands. occasionally a strong urge to go. no dysuria, polyuria, fever/chills, no back pain or loss of sensation in the perineal area. BMs normal.

Answer 10

ddx: stress incont, atophic urethritis, cauda equina, urge incont, ___cele.
PE: GA; ABD (I, palpate for masses/tenderness, suprapub area for distension, percuss for CVA tenderness); GU

Question 11

CC: my stomach hurts x24 hrs.
22 yo G0P0 LMP 1 wk ago. lower abd and pelvic pain which began day after menses stopped, and is ass’d w scant whitish vag discharge. has been feeling unwell, low grade fever, uncomfortable to have sex. uses depo proverb for contraception. last inj was 4.5 months ago. no reg condom use.

Answer 11

ddx: PID, cervicitis, STI, extopic preg, endometriosis.
PE: GA (illness/pain); VS (T); PULM/CARDIO (ausc); ABD (I, ausc for bowel sounds and hepatic rubs, palpate 4 quadrants and suprapubic area, McBurneys, palpate liver, rebound tenderness, CVA tenderness); PELVIC

Question 12

CC: my roommate had a fit earlier today.
HPI: 22yoM brought in by roommate after fit (pt was watching tv, cried out, stood up, fell to floor..out of it and unaware of what was happening. included spasmodic movements and loss of bladder control. lasted 5 mins. had cold 2 wks ago, otherwise, no sig PMH.

Answer 12

ddx: grand mal seizure (d/t tumor, drugs, infxn, epilepsy, hypoglycemia, arrhythmias).
PE: VS: temp; HEENT: HEAD (trauma, fundo for papilledema, mouth for bites); SKIN (injuries/echymosis); HEART/LUNG (ausc); NEURO (A&Ox4, recent/remote hx, romberg, RAM, CN test (vision, EOMS, pupillary rxn, face jaw sens, accommodation, facial expressions, gross hearing, gag/swallow, speech sounds, trap/scm, tongue strength), DTRs,distal strength, babinski, distal sens, nuchal rigidity/kernig/brudz)

Question 13

CC: I feel like I’m going to throw up when i turn my head x4days.
HPI: 45 yo F felt dizzy when turns head, similar to being on a boat, feels unsteady and as though the room is spinning. sxs occur primarily when turns head to R. nausea ,but no vomitting/palpitations/falls/ or trauma. no numbness/weakness/visual or hearing changes. had similar episode years ago, resolved on own. no sig PMH. had cold 2 wks ago.

Answer 13

ddx: vestibular neuronitis, drug induced, BPPV, labrynthitis, hypotension, arrhythmia, migraine ass’d.
PE: VS: ortho BP, HR for regularity, NEURO (romberg, gait, RAMs, CNs, EOMS chk for nystagmus, distal strength), HEENT (mucus memb for pallor, VA, fundosc for papilledema, gross hearing, weber/rinne, otoscope bilat), cardio (ausc)

Question 14

CC: my wife is worried bc i fell.
HPI: 79 yo w hx of htn, hyperlipidemia, DM who is here w wife. he fell yesterday and doesn’t know why. denies losing consciousness. has lightheadedness, worse when moving around, but no falls/LOC.

Answer 14

ddx: fall d/t vision impairment (presbyopia, glaucoma, mac degen), hypotension/orthostatic, diabetic neuropathy, arrythmia, hypoglycemia, environmnetal hazard, gait impairment (arthritis, sens ataxia), neuromusc (Parkinsons, MS), seizure, aortic sten.
PE: VS (orthostat BP), Skin (turgor, for injuries from fall), HEENT (face symmetry, conjunctival pallor, VA, fundoscop exam, otoscopy), cardio/PV (ausc, carotid bruits, nail beds for pallor/cyanosis, cap refill), pulm (ausc), MSK (gait, feet for abnormalities, grip/toe strength, get up and go), NEURO (A&O, CNs, EOMs, Romberg, finger-nose, heel-shin, RAMs, sens testing, LE DTRs)

Question 15

CC: my legs are burning and numb and i have had some cramping in my calves x 6wks”
HPI: 49yo russian woman who immigrated to us 3 months ago and is being seen for first time. no instigating events and states she gradually became aware of the discomfort at night time. it now bothers her at daytime. pain in both feet and ankles. the cramping in calves happens at night and the pain wakes her up. nothing helps other than getting up and walking around. she denies trauma and has not begun any new activities. taking med for “energy” , 35# wt gain.

Answer 15

ddx: spinal compression/stenosis; GBS; B12 deficiency; diabetic periph neurop; dehydration/electrolyte imbalance; drugs; hypothyroid.
PE: GA, VS (wt), thyroid, ausc heart/lungs, NEURO (gait, cerebellar - romberg/RAM, distal sensation, great toe proprioception, vibratory sensation LE, DTR at ankle/knee), MUSC (inspect back, blunt percuss spine, inspect LE for wasting/skin changes/structural abnormalities, palpate LE for warmth/tenderness/nerve thickening, musc strength at hip/knee/ankle/foot, distal pulses)

Question 16

CC: I’ve had a HA x6 hrs”
HPI: 49 yo F with a hx of ht. who reports the abrupt onset of severe HA. pain is diffuse/throbbing/worsened when out in sunlight, she’s never had a HA this bad and its not responding to ibuprofen or acetaminophen. no nausea/vomitting/phonophobia or recent URI sxs.

Answer 16

ddx: migraine, subarachnoid hemorrhage, HTN crisis, MOH, dehydration/withdrawal, meningitis.
PE: GA, VS (rechk BP), ausc heart/lungs, NEURO (A&Ox4, romberg, RAM/heel to shin, CNs, distal strength, DTRs, distal sens, kernig/brudzinski), HEENT (fundo to eval for papilledema, palpate/percuss sinus, palpate temporal artery).

Question 17

CC: “my bro made me come in but i can hear just fine.”
HPI: retired 71yo has come in at insistence of his brother bc of changes in hearing for several months. his bro wants him to get checked bc he has a hard time getting his attention when they are in a noisy environment and he has to repeat himself a lot. he is also annoyed that the TV vol is loud at home. the pt doesn’t think theres anything wrong w his hearing other than a buzzing sound he hears frequently. but he’s stopped playing poker bc too frustrating and no longer fun.

Answer 17

ddx: presbyacusis, cerumen impaction, excessive noise exposure, otosclerosis, acustic neuroma, dementia/cog impairment, choliasteatoma.
PE: GA, NEURO (A&Ox4, recent and remote hx, sensation testing over facial nerve-3 areas), HEENT (nasoscopy, oropharynx, external ear, gross hearing, weber/rinne, otoscopy)

Question 18

CC: my eye is all red and goopy x 2 days”
16 yo F w red/irritated eye. it started out feeling “itchy/scratchy” and she’s now noticing discharge, esp in morning. her lashes have been glued shut and she has to use a washcloth to soak eyelids to open them. denies visual loss except for blurriness d/t discharge. recently had a cold. no facial pain/swelling/fever/chills. her L eye is now starting to develop the same sxs.

Answer 18

ddx: viral or bacterial conjunctivitis, blepharitis, keratitis, allergic conjunctivitis, anterior uveitis.
PE: GA, HEENT (VA, inspect ocular adnexa, palpate ocular adnexa, inspect conjunctiva w pen light, EOMs, pupillary rxn testing, fundo bilat, otoscope bilat, nasoscopy, oropharynx), LYMPH (cervical LAD including pre-auricular), Ausc heart/lungs.

Question 19

CC: my right eye isn’t working right x2 days.
HPI: 32 yo african american M w unilateral vision loss in R eye. his vision is diminished in the center where he reads, but seems fairly normal in the perish areas. the area around his R eye aches and the pain is worse when he moves his eyes around. episodic “double vision” for a week. no change in color vision. last eye exam was 3 yrs ago and normal. uses magnifiers for reading. has had lightheadedness for 6 months on and off. no falls, loc, wt changes, facial pain, HA, swelling, fever, or chills. no hx of thyroid dz, diabetes, htn, or glaucoma.

Answer 19

ddx: acute glaucoma, foreign body/corneal abrasion, stroke, optic neuritis, mac degen, hypothyroid.
PE: GA, HEENT (inspect face for weakness/focal deficits/asymetry/abnormal gaze, VA, visual field testing, I/P ocular adnexa, palpate globe tension, swinging flashlight test for APD, conjunctiva, anterior chamber depth, EOMs, pupillary rxn, fundo for optic nerve atrophy, otoscopic exam, nasoscopy, oropharynx), thyroid, ausc heart/lungs, NEURO (CNs, cerebella - RAM/romberg, gait, vibratory sensation for UMN dz, distal sens, DTRs, grip strength and great toe strength)

Question 20

CC: “my baby is sick since this morning”
HPI: 6 mo infant F in ED w hx of fever ranging from 101.5-103.8 for 2 days. she was doing ok until she had a “spell” 1 hr ago. it lasted a couple of minutes, and she had some jelly movements and was unresponsive to her parents. since then she has become more interactive, but still sleepy and lethargic. parents are concerned about meningitis. she been taking tylenol, which helped at first but it hasn’t fully resolved her fever for the last couple of doses. her last stool was yesterday and was normal. has refused feeding the last 8 hrs. no recent illness. last visit was at 4 months.

Answer 20

ddx: febrile seizure, ideopathic seizure, electrolyte abnormality, UTI infxn/bacteremia/meningitis/URI, roseola, measles, ALL.
PE: GA, VS (resp, HR, temp), HEENT (fontanels, fundoscopy, nasoscopy, otoscopy, oropharynx), SKIN (turgor, rashes, echymosis, injuries), LYMPH (cervical, inguinal), ausc heart/lungs, ABD (palpate for tenderness, distended bladder), NEURO (inspect for decorticate/decerebrate posturing, nuchal rigidity, kernig/brudz, CNs, reflexes, musc tone in extremities), MSK (general survey for swollen/erythematous joints).

Question 21

CC: “my knee hurts x3 wks”
HPI: 11 yo African American M w right knee pain. has been liming and states the pain comes and goes but is getting worse. he does not recall any specific initiating incident or hx of trauma. the pain radiates up into thigh occasionally. also trouble w stiffness that makes it diff to tie his shoes and has stopped playing bball.

Answer 21

ddx: osgood schlatter, slipped cap-femoral epiphysis, patellar tendonitis, septic arthritis, tendonitis.
PE: GA, VS (temp to r/o sepsis), NEURO (gait, distal DTRs, distal sens, distal pulses), MSK HIP (inspect/palpate, active ROM, passive ROM, strength against resistance), MSK KNEE (inspect for swelling, valgus/varus, palpate, active and passive ROM, ROM against resistance, joint effusion, patellar apprehension test, ant/post drawer sign, lachmans, mcmurray, varus/valgus stress), MSK ANKLE (inspect/palpate, active ROM).

Question 22

CC: my mom made me come in bc she is worried about my periods x3 months.
HPI: 17yo F w mom who hasn’t had period for 3 months. pt denies sexual activity. has been oligomenorrheic in past after menarche at age 12. tired and difficulty sleeping. has been losing more hair than usual, but feels like arms are becoming hairier. lost interest in activities and stopped doing things w friends. hx of cutting w razor blade. no illicit drug or alc use. no rx drugs. smokes 10 cigs/day. fam hx of depression, obesity, alcoholism.

Answer 22

DDX: eating disorder, pregnancy, hypothyroid, anemia, depression, PCOS, contraception.
PE: GA, VS (ht, BMI, pulse for brady), HEENT (dentition erosion, parotid gland for edema, thyroid exam), SKIN/HAIR/NAILS (scars, cutting sites, self harm, xerosis, face for acne/hirsutism, scalp for alopecia, forearms for lanugo), HEART/LUNGS (ausc), GU (inspect vulva/vagina for signs of estrogen deficiency).

Question 23

CC: Tired and stressed x2 months.
HPI: 43 yo F w demanding, high stress job as exec mgr. unusually fatigued for 2 months, increasingly difficult to concentrate at work. sleeps 10-12 hrs but still tired. feelings of worthlessness, fear d/t inability to perform at work and dissatisfied w life. 8 lb wt gain in a few months. no suicidal thoughts, no hallucinations, fevers, night sweats, bowel changes, palpitations, SOB. lack of libido. more irritable/withdrawn. LMP was 6 wks ago and normal.

Answer 23

DDX: MDD, bipolar, perimenopausal, hyper/hypothyroid, pregnancy, anemia, OSA.
PE: GA (hypothyroid and cushing facies, affect), VS (wt), SKIN (hair text/distribution, skin dryness/text/myxedema, ecchymosis/signs of injury), HEENT (mucus memb for pallor, tongue for macroglossia, oropharynx), NECK (goiter, buffalo hump, neck circc, thyroid, supraclav fat pads), PULM/HEART (ausc), abd (inspect for central obesity and striae), NEURO (A&Ox4, DTRs), PSYCH (eye contact, body post, expressions, speech, though process, judgement).