Kaplan step 2 cs core cases pdf download

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KAPLAN STEP 2 CS CORE CASES routine -knock on door, even for phone cases -identify self -ask who the people are int he room, or on the phone -give them the drape unless on phone, there is a surrogate, they are in street clothes -stress confidentiality -transition bw parts .now id like to ask you about ur health in general .now id like to ask about ur familys health .(OG, sex, sh) i'm going to ask some personal questions. everything we talk about is confidential. .(OE) now id like to do ur physical exam .(closing) let me tell u what im thinking - when they tell you something say 'Thank you, go on ' - NOT 'ok' - ask height and weight ESPECIALLY on phone or interlocutor -ask permission before removing socks -MR/S i'd like to tell uwhat I am thinking. First let me make sure I understand -on ur physical exam I found that -i'd like to have blood tests today to find out the cause -ALWAYS COUNSEL eg weight, abstinence from alcohol, using contraception, hypertension, obesity, diet, smoking -I'd like to see u again to discuss the results and plan treatment. -Do you have any questions ? -I will call u tomorrow with the results and to arrange a follow up -understand ur concerns, will do everything to make them feel better, will do everything to find out what is wrong, will get him best tx available, will remain his doctor, will always be available to help. -multiple chief complaints ? do SQO for each (+ R if pain), then do I + AAA for all the major sx together hx oe ddx ix challenging qs . CC - SIQORAAA PMHRFOSS HPI - (socrates) - previous episodes, triggers PMH - no hospitalizations, surgery or trauma, LMP, htn, cholesterol, DM, Famil Hx - no history of similar illness SH - no recreational drug use, etoh/smoking, CAGE pos/neg alleergies - immunizations ROS - sleep, weight loss, urinary VS - T, BP, HR, RR

GA HEENT Neck Chest - deformity, tenderness. Lungs clear to A. S1, S2 without murmur ABD - soft and non-tender. Tender to palpation and compression of iliac crest Extremity - PT/DP pulse equal 2/4 B/L. able to flex and extend at ankle against resistance bilaterally. Pt able to bend R knee but not he L knee secondary to pain. Neuro - A+O x 3. PERL EOMI. no facial assymetry. motor 5/5. remembers 3 objects, can spell world backward ddx - acute SOB: resp (asthma, COPD, pneumonia, pneumoThx, APO, PE, effusion, cardiac, hypervol airway obstruction (facial injury, burn, anaphylaxis, angioedema, foregin body, epiglottitis, low GCS, aspiration) other (DKA, anemia, anxiety, hyperventilation) ddx - CAP pathogens: strept pneumo, chlamydia pneumo, mycoplasma pneumo, legionella pneumo ddx hemoptysis: bronchitis, bronch carcinoma, bronchiectasis, pneumonia other - pulm infarction, CF, absecess, TB, foreign body, goodpastures, wegeners, SLE cardiac - MS, LVF bleeding diathesis ddx - acute cough
Haematuria RENAL Glomerulonephritis Polycystic kidney disease Pyelonephritis Renal cell carcinoma Analgesic nephropathy Malignant hypertension Renal infarction (e.g. infective endocarditis, vasculitis) Bleeding disorders RENAL TRACT Cystitis Calculi (see Figure ) Bladder or ureteric tumour Prostatic disease (e.g. cancer, benign prostatic hypertrophy) Urethritis Favours urinary tract infection (UTI) Dysuria Fever (prostatitis, pyelonephritis) Suprapubic pain (cystitis) Moderate flank or back pain (pyelonephritis) Favours renal calculi Severe loin pain Favours source that is not glomerular Clots in urine Favours blood not in urine Menstruation Favours immunoglobulin A nephropathy Multiple episodes over months Favours trauma Recent indwelling urinary catheter or procedure Recent back or abdominal injury Favours bleeding disorder Use of anticoagulant drugs Haemoglobinuria Intravascular haemolysis, e.g. microangiopathic haemolytic anaemia, march haemoglobinuria, prosthetic heart valve, paroxysmal nocturnal haemoglobinuria, chronic cold agglutinin disease Myoglobinuria This is due to rhabdomyolysis (muscle destruction): • Muscle infarction (e.g. trauma) • Excessive muscle contraction (e.g. convulsions, hyperthermia, marathon running) • Viral myositis (e.g. influenza, Legionnaires’ disease) • Drugs or toxins (e.g. alcohol, snake venom, statins) • Idiopathic. Causes of acute kidney injury Onset over days = accumulation of nitrogenous wastes + urine flow rate is less than 20 mL/hour or mL/day PRE-RENAL

Fluid loss: blood (haemorrhage), plasma or water and electrolytes (diarrhoea and vomiting, fluid volume depletion) Hypotension: myocardial infarction, septicaemic shock,drugs Renovascular disease: embolus, dissection or atheroma Increased renal vascular resistance: hepatorenal syndrome (liver dz - incr splanchnic vasodilation = less blood to renal = interpreted as low BP = secretion of renin = vasoconstriction) RENAL Acute-on-chronic kidney failure (precipitated by infection, fluid volume depletion, obstruction or nephrotoxic drugs) Acute renal disease:• e.g. primary or secondary glomerulonephritis, connective tissue diseases Acute tubular necrosis secondary to: • ischaemia (hypovolaemia) • toxins and drugs (such as aminoglycoside antibiotics, radiocontrast material, heavy metals) • rhabdomyolysis, haemoglobinuria Tubulointerstitial disease: • e.g. drugs (such as proton pump inhibitors, sulfonamides, cyclosporin A), urate or calcium deposits, phosphate, oxalate, crystal nephropathy Vascular disease: • e.g. vasculitis, scleroderma Myeloma Acute pyelonephritis (rare) POST-RENAL (COMPLETE URINARY TRACT OBSTRUCTION) = stricture, stones, BPH/prostate cancer Urethral obstruction: • e.g. calculus or blood clot, sloughed papillae, trauma, phimosis or paraphimosis (a tight narrowing of the foreskin that prevents it being retracted and that can obstruct the urinary meatus) At the bladder neck:• e.g. calculus or blood clot, prostatic hypertrophy or cancer Bilateral ureteric obstruction: • intraureteric, e.g. blood clot, pyogenic debris,calculi • extra-ureteric, e.g. retroperitoneal fibrosis (due to radiation, methysergide or idiopathic), retroperitoneal/pelvic tumour or surgery, uterine prolapse Causes of rapidly progressive kidney failure (onset over weeks to months) Urinary tract obstruction Rapidly progressive glomerulonephritis Bilateral renal artery stenosis (may be precipitated by angiotensin-converting enzyme [ACE] inhibitor or angiotensin receptor blocker use) Multiple myeloma Scleroderma renal crisis Malignant hypertension Haemolytic uraemic syndrome dialysis qs: 1. What fluid restriction have you been recommended? 2. Have phosphate-binding drugs been prescribed? When do you take these relative to meals? 3. Do you use haemodialysis or peritoneal dialysis? Do you do this at home? How many times a week? 4. Have you had abdominal pain or fever recently? (Peritonitis related to peritoneal dialysis) 5. Have you had any problems with haemodialysis, such as low blood pressure, or with the fistula used for haemodialysis? Have you had any problems with peritonitis with peritoneal dialysis?

6. How much weight do you gain between each haemodialysis? 7. Do you still pass any urine? If so, how much? 8. Are you on a renal transplant list or have you previously had a transplant? 9. Do you follow recommended dietary restrictions? What other medications do you take? Have you had heart or blood vessel problems? Have you had overactive parathyroid glands or parathyroid surgery? I will be helping you today." identify all people in the room - i've schedule time for us today, turned off my pages so that we wont be disturbed, and asked my staff not to interrupt us - would you like your family member to stay or step out while we discuss the results today ? is there anyone else we should call in to discuss the results (would it be allright if she came next visit - id like to talk to you today" - PERCEPTION -what have u been told about your sx -do you remember the colonoscopy/procedure -what did you think the sx was due to -did you think the sx were from something serious - INVITATION - I have the test now - would you like to go through them - would you like all the basic information, or the details as well

- so if it turns out to be something serious - you would like to

know

- KNOWLEDGE - i'm sorry to have to tell you that the pathology reports shows that what you have is serious and will require treatment - what we mean when we say somehing is canc erous is that the growth is uncontrolled - i'm sorry to have to tell you that the report is correct. The pathology reports that you have cancer of the colon - i know that this is serious news - but i want to tell you that there are treatment options available for your condition - the type of cancer you have does have treatment options. you will have a specialist that is an expert in dealing with this sort of cancer and you will get the best care available for your condition - you will be treated by a team of doctors. I will remain your primary physician and I will refer you t a cancer speciality XX with many years of experience managing your condition. I will bring you her number and have already made an appointment for you. I would then like to see you again back here in my office - EMOTION results

- i can see you are upset. I was also upset when I got the

- what you have is serious - but we have medicaitons and treatments available - STRATEGY / SUMMARY - i know I gave u a lot of info to remmeber today. I want to make sure you understand me correctly - can you repeat to me your understanding of the situation - you can call me anytime with questions and of course come to our next appointment. and I'm looking forward to meeting your daughter also. - here is my phone number - please call me at any time if you have questions -

1. ankle pain - ddx + ix fracture, ligament, infection/septic arthritis, gout. vascular (atheroma, raynaud) complex regional pain syndrome (post trauma) = reflex sympathetic dystrophy Osteoid osteoma Diabetic neuropathy Achilles XR ankle (AP, lateral, half oblique mortisse) Would swab - culture and sensitivity Joint aspiration - culture and microscopy CBC + culture and sensitivity Is it fractured or just broken ? when will I play again ? - I will do XR of leg to find out - when we meet again I will have the results and be better able to tell you 2. Backpain ddx, ix, challenging

- first let me summarise - I believes that ddx 1, 2 - results back tomorrow, and will give you a call to see how you are doing - any questions 3. sore throat -

ddx, ix, challenging

ddx - pharyngitis - URTI -infection, bacterial, strep, viral, TB, HiB, Meningococcus - epiglottitis (severe throat + hoarse voice) - peritonsillar abscess (trismus = cannot open mouth completely) - mononucleosis (fever, adenopathy, tummy pain, fatigue) - allergic rhinitis (coryza) CENTOR - cough absent, exudates, nodes, temperature/fever, Old or young if 2 or above = probably bacterial (Group A strept) throat culture, rapid strep testing abx ix - CBC - monospot - throat culture - bilirubin, ALT, AST, PT, PTT challenging - mono - id like you to avoid playing contact sports - why cant i play hockey ? (mono - HS megaly - sports = rupture - hemorrhage) = you might have some swelling in the tummy from the infection that makes it easy to get bleeding fro inside the belly from a minor fall. Just for a few weeks, hold off until you are better. 4. car accident ddx - certical strain - cervical # - ICH

ddx, ix, challenging

oe -HEENT - pupils, TMJ, pharynx, head + CV spine inspect/palpation -CV, Abd, -Extremities - #, laceration -Neuro - CN + AMS + power + gait - peripheral pulses ix CBC, INR Cspine XR CT brain ECG challenging - i should have taken my coumadin half an hour ago - may i take my own tablet ? Pleast lets get a picture of your head first, then well know (ALWAYS SAME RESPONSE TO WANTING MEDICATION = need to do hx, exam, test, to make sure we give the correct meds) - can I call my wife ? yes certainly, It will take a couple of minutes to finish examining you, then I will call her - my neck is sore when I move it ? provide assistance during the exam (showing concern) 5. left arm weakness ddx

ddx, ix, challenging

stroke - CVA, TIA vascular/claudication MSK spinal cord/ nerve roots oe - CN (pupils, visual fields, facial) - neuro - tone, power, sensation, reflexes - gait - mental status - CV - + dorsalis pedia/posterior tibial ix -non contrast CT brain - CBC, lutes, BUN, Cr, glucose, INR - ECG, CXR - carotid duplex USS challenging - someone has to take care of my wife while i am here - she is helpless ? Yes i can have the visiting nurse or social worker make an emergency visit and help her now 6. positive pregnancy test hx - OG

ddx, ix, challenging

sx pregnancy (nausea, breast tenderness, morning sickness, late period) LMP, menarche, length, cycle day previous varicella/chickenpox, rubeola/german measles immunizations previous pregnancies diabetes fhx - genetic problems domestic violence is the baby coming at a good time for u both have u ever been tested for an sti

ddx - pregnant - ectopic - molar - ovarian cancer oe - height, weight - ask her - thyroid - CV, lungs - abdomen - legs ix - pelvic exam - pap smear - gonorrhea culturfe, chlamydia culture - CBC, blood type, Rh - UA, culture, TSH - VDRL, HIV, rubella - hepatitis B serology

challenging - danger signs of pregnancy - bleeding and abdominal pain, dizzy, headache, visual disturbance, uti - if you feel these please call me - I want you to avoid alcohol and limit caffein - I think I had 4 glasses of wine total when I was pregnant - do u think i hurt the baby ? no - have u ever been tested for an sti ? rememer ervy we talk about is confidential - the more I know the more I can help 7. pre employment physical - ddx, ix, challenging hx - WHY VITALS ARE ABNORMAL + pmhx and oe for preemployment Besides coming for the physical for ur new job - do u have any other health concerns ? CAGE ddx - alcohol withdrawal - alcohol dependence - seizure disorder oe -HEENT mouth,m tongue, palpate -eye sight -hearing -neuro -knee, spine -neuro - mental status, power, gait ix - CBC, INR, lytes, glucose - etoh, urine drug screen - CT brain - bilirubin, AST, ALT - EEG challenging - i don't have any money for tests ? I will have a social worker come and talk to you to help you - also I'd like you to meet our alcohol counselor. You need to stop drinking tin order to imporve ur health. Any other questions ? - you could just give me the note now and ill be on my way - i have the cash to pay you ? I cannot write the note today - i am concerned about ur drinking and falls i believe your put urself and others at risk if you drive a taxi in current state i would like u to see an alcohol counsellor and meet after we have taken a picture of ur head - i'll arrange the pictures now 8. nose bleed - ddx, ix, challenging ddx -dry air, nose picking, truma -polyps, allergies, URTI -cocaine -hemophilia, vWF, warfarin, aspirin, BM failure, liver dz/etoh related, coagulopathy -in alcoholics consider -hypoglycemia etoh/CAGE acetaminophen/tylenol (makes liver worse) oe:

-ear - haemotympanum -inspect palpate head, neck -nose -mental state exam -appearance - jaundice/stigmata -lungs -CV -abd - murphys -neuro - mental status, CN, motor, gait ix -CBC, platelets - Tbili, AST, ALT, NH3 - acetaminophen level, etoh - INR, lytes, glucose - Ultrasound RUQ challenging -r u going to tell the police about my drink driving - i stopped at a bar on the way here - i would test positive and go to jail ? Ni i am not going to call them what we talk about is confidential 9. acute abd pain + syncope - ddx, ix, challenging ddx -vasovagal, SAH, PE, AAA, hypotensive/hemorrhage, alpha blockers, antihypertensives, seizure -female: ruptured cyst, ectopic, missed abortion. hx -blood loss, LMP oe -cva tenderness -abd - reboound tenderness ix challenging -i have finished the exam, thanks for cooperating, i can see u are in a low of pain -am i pregannt ? i am concerned taht this much pain it could be an abnormal pregnancy, a tubal pregnancy - let me get this US for your quickly so we can find out. 40 F vag bleed - ddx, ix, challenging ddx - hypothyroidism, dysfunctional uterine bleeding, endometrial cancer, threatened abortion, incomplete abortion -coagulopathy, liver dz, alcohol -ANEMIA !! hx -LMP, menarche, garvida, para -sex - partners, contraception, STI oe -Abd, chest,

-CVA pain ix -pelvic USS -pelvic exam -rectal exam -CBC, TSH, lytes, BSL -HCG -AST, ALT, albumin, INR -PT, PTT -pap smear -gonorrhea + chlamydia culture -mammogram challenging -i can tell you now that i want you to practice safe sex every time. that means use a condom every time. it is still possible fo ru to get pregnant or contract a sexually transmitted disease -should i go back on the pill to regulate my periods ? i need to see the results of the blood test to decide the best medicine for you. can you come back tomorrow so we can discuss the results. 60 F vag bleed - ddx, ix, challenging ddx - endometrial cancer (smoking, obesity, estrogen replacement, nulliparity) -cervical cancer, uterine polyps, HRT, -perineal, vaginal, cervical trauma -atrophic vaginitis, endometritis -rectal, urinary bleeding -coagulopathy/warfarin/liver ix pelvic exam rectal exam CBC, UA, INR, P pelvic USS pap smear endometrial biopsy challenging -Dr Im really bothered by the dryness during sex. Is there anything I can do about it - like taking hormones ? hormones would not be a good idea right now, with the healing blood clot and bleeding - have u tried a vaginal lubricant - contraindications to estrogen HRT (stroke, clotting/PE, breast cancer, cardiovascular) personal problem - ddx, ix, challenging ddx - STI -psych, addiction, genitals, rectum, std oe -septic arthritis/joints, eyes ix chlamydia, gonorhea - culture, NAAT/pcr genital exam

challenging hypertension - ddx, ix, challenging ddx -medication noncompliance -medications/decongestants (phenylephrine) -renovascular -nephrotic -hyperaldo -essential hypertension -SYMTPOMS - HF, kidney failure, PVD, retinopathy, angina, ERECTILE DYUSFUNCTION oe - weight -Pupils/ retinopathy / papillodemea, fundoscopy - HEENT,eyes, ears, throat - THYROID - chest - lungs - CV - HS, PMI, JVD, edema, peripheral pulses - neuro, power, gait ix -CXR, ECG, UA -CBC, lytes, BUN, Cr, glucose -fasting cholesterol, HDL, LDL, TG -arterial doppler USS, lower extremities challenging -do I have a bad heart ? it is possible that the BP has caused the heart to elnarge. I need to have you complete the tests to know. If you do, there are medicines to treat you. TELEPHONE - ACE-I Medications refill ddx -hypertension -ACE-I cough -heart failure

ddx, ix, challenging

hx -ALWAYS AS IF THERE ARE ANY CONCERNS I CAN HELP YOU WITH 'ANY OTHER HEALTH PROBLEMS' -htn .how affecting ur life, what is ur BP, when did it start, what makes it lower, higher ? .associated symptoms - end organ affects - heart disease, stroke -refill meds .name .WHY DO THEY NEED IT REFILLED NOW ? 'chest pain' = i want you to call and go to the hospital and I will meet you there and examine you after we finish the phone call .dose .route .number times per day .side effects .compliance ix -PHYSICAL EXAM

-CBC, glucose, BUN, Cr, lytes -ECG, CXR, UA -fasting cholesterol, HDL, LDL, trigylcerides - BNP, echocardiogram -BSL,HbA1c challenging -telephone cases - request they come and see you for physical exam and investigations but -tell patients you will refill their medications UNLESS DANGEROUS MEDICAL CONDITION - 'need to see them for an exam to determine the best way to manage his condition - you are always available'- they should come to see you immediately - if too sick to travel on his own - tell them to call an ambulance call and you will meet them at the hospital. - seeking narcotics ? request physical exam immediately - so that can treat condition effectively. - bone cancer patient requesting opioid refill ? this is appropriate - on ACEI, htn, now SOB, swelling, cough ? I am concerned that you have some fluid on ur lungs - I'd like you to come into the office today so that I can examine youand talk more with you. I'd also like to take some picture of ur chest and heart and do a blood test for cholesterol and talk to you about ur diet and exercise. do you have any questions. - I dont have health insurance - i cant afford any tests - cant you refill my pills ? I need to see u because you may need different or more medicines. Ill keep ur concerns in mind but I am recommeding for what is best for your help. I can arrange our counselor to talk to you about health insurance. DO NOT PROMISE THAT THE COUNSELOR WILL GET THEM HEALTH INSURANCE Estrogen Menopause drug refill - ddx, ix, challenging ddx -menopausal sx hx -OG = menarche, menopause, gravida, para, LMP, bleeding, amount/pads, discharge, associated pain/smell, side effects of menopause (hot flashes, vaginal atrophy, night sweats), sexual activity, contraception -HRT = name, why now, dose, frequency, side effects (vaginal bleeding, HA, vaginitis), compliance, contraindications (stroke, PE/DVT/clotting, breast cancer/uterine cancer, CVD, CAD, liver dysfunction, pregnancy, allergy) -other sx menopause = osteoperosis ix -physical exam + pelvic exam -rectal exam -bone density scan (DEX scanning) -ECG -mammogram -pap smear -chlamydia + gonorrhoea challenging -my broken wrist was just because i slipped over, do i need a test ? yes it would be wise to test ur bone density - you may need more than calcium tablets fever + wt loss + cheesy rash in mouth - no safe sex ddx -HIV -pneumocystiis pneumonia -esophageal candidiasis

ddx, ix, challenging

hx -sexual partners - have you told them you are sick ? ix -CXR, pulse Ox, sputum -lytes, BUN, Cr, BSL, blood culture, UA -HIV ab (ELISA) -CD4, PPD -upper endoscopy challenging -r u going to tell my employer ? I work with children ?? - what we discuss is confidential - I do want you to tell ur sexual partners to come in and be tested I'll have the nurse come and taken the sample now and we can arrange a chest picture now - sooner we have the results sooner we can treat - any other questions Broken nose ddx - broken nose / - substance use - seizure - cardiogenic /

+ LOC -

ddx, ix, challenging

blunt head trauma with LOC disorder - alcohol vasovagal

hx -visual disturbance, weakness in limbs -incontinence, tongue bite, jerking/shaking, vomiting, confusion, trauma/head strike oe -trauma to one part of body = suspect elsewhere -inspeciton and palpation to uncover additional injuries -bruises, tenderness - spine/cervical, CVA ix - CT-brain, head - alcohol blood level - eeg - XR nose - CBC, INR - T bili, ALT, AST, EtOH, albumin challenging -drinking alcohol and working with electricity is a dangerous combination - i would like for you to see our alcohol counselor TELEPHONE - Adolescent weight loss ddx -depression -eating disorder - anorexia -hyperthyroid -drug use -diabetes -neoplastic -sport hx oe

ddx, ix, challenging

ix -physical exam -TSH -CBC, lytes, BUN, Cr, Glu -UA, BHCG challenging -do you think she will need to be hospitalised ? I need to see hr first and the test results to decide for sure - nothing u told me makes met thinks she needs to be in hospital today - but I do need to examie her ASAP TELEPHONE - Adolesecent depression ddx -depression MSIGECAPS -hypothyroid -drug effects -primary sleep disorder -pregnancy

ddx, ix, challenging

hx -CONFIDENTIAL -MSIGECAPS ix -physical exam -mental status exam (psychiatrist) -hypothyroid screen (TSH) -CBC, glucose, TSH -BHCG challenging - what should i tell carol about coming oto the doctor - should i say its for the school physical ? Ithink you should tell her you are concerned and want the doctor to find out if anything is wrong TELEPHONE - 7 F noctural enuresis - ddx, ix, challenging ddx -primary nocturnal enuresis -secondary - constipation, stress, diabetes hx -dysuria, constipation, polyuria, polydipsia, polyphagia -attempts to solve -pediatric hx - prenatal (drugs, Csection/NVB, weeks/term_, perinatal - (length of stay in hospital, jaundice, problems breathing, problems eating), growth and development, immunisations, self esteem, depression, feeding. -counselling -snoring, -family history -diet -UTIs -neurogenic bladder (meningomyelocele - gait disturbance) -psychologial stress ix -physical exam -UA

-BSL -bladder scan, voiding cystourethrogram challenging TELEPHONE - 9 F SOB - ddx, ix, challenging ddx -probability = pharyngitis, pneumonia, asthma -airway - obstruction, anaphylaxis -lungs - asthma, CF -cardiac - CCF, nephrotic -metablolic acidosis (sepsis, infection/UTI, fever) hx asthma -# use of reliever -night time sx -imapct on ADL/function/exercise -triggers - sport, cold, dander, pollen, drugs/ACEI/aspirin -pediatric ix -physical exam -CXR -pulse oximetry -LFT - spirometry, challenge -swabs challenging -I have no health insurance and cannot pay for counselling - I take him to church and we can get help there ? In addition to church, I believe mental health counselors can help. I can have you speak with our social worker, who can help arrange financial aid 50F Cancer checkup ddx -

ddx, ix, challenging

hx -CVD RF - diabetes, age, cholesterol/lipids, previous stroke/clotting, alcohol/tobacco -cardiac (SOB, swelling, CP, PND) oe -cardiac ** pulses, HS, carotid, PMI, edema, JVD -HEENT pharynx, THY, adenopathy -skin -Extrem - ROM, gait ix -pelvic and breast exam -stool FOBT -mammography + colonoscopy -CBC, BUN, Cr, Glu, Cholesterol, HDL, LDL, TG -PSA -lipid panel -ecg -BSL

-renal function ? (BUN, GFR, Cr) -stress testing -pap smear challenging -counsel wrt limit etoh, tobacco, salt, exercise, diet -now im nervous, colonoscopy was how they found my fathers cancer ? colonoscopy is good bc it can easily find treatable polyps long before they turn cancerous - I will call u with the results immediately so you wont be worried. Health fair referral - abdominal pain - ddx, ix, challenging ddx -GORD -biliary colic, cholelithiasis -pancreatitis hx -ALSO I WOULD LIKE TO KNOW IF YOU HAVE ANY OTHER PROBLEMS ix -rectal exam -FOBT -T bili, AST, ALT,, ALP -USS gallbladder, HIDA scan -upper endoscopy -amylase, lipase -CBC, CRP, lytes, BSL challenging -i FIND IT DIFFICULT TO LOSE WEIGHT and have tried different diets - anything else i can do ? yes i know it can be difficult - incr fruits/vegetable and exercise is the first stp. Avoid hi fat and hi sugar food. I'll have u speak with our nutritionist and develop a plan for diet and exercise with you. TELEPHONE - Crying baby - ddx, ix, challenging ddx -too hot, too cold, hungry, bored, overstimulated, uncomfortable, colic -inconsolable ? = AOM, pneumonia, UTI, acute abdomen hx -confidentiality -stress, harming baby, shaking - prenatal, birth, perinatal, feeding, growth and development, immunizations, checkups -feeding, sleep, stooling, uination, fever, rash, breathing, urinating, alertness/crying ix -physical examination -reassurance challenging -can u give her medicine to maker her stop crying ? how about benadryl I can get it without perscription ? please dont give her medicine right now - I would like to examine her first to see what will be best for her. -sometimes i feel like shaking the baby to quiet her ? I understand that caring for her is stressful and can be frustrating, but it is important not to shake her or

harm her. Let me arrange a counselor to talk to you about how you are feeling. Also I would like to se if we can arrange some home help to give you some respite for your sleep and rest. ELDERLY + AMS - ddx, ix, challenging ddx dementia with alzheimers dementia from stroke pseudodementia from depression -alzeheimer, depression, stroke, THY, cardiac, metabolic -medication SE -etoh, drugs hx -impact - carer stress -ADL/iADL = DEATH (dressing, eating, ambulation/falls, toilet, hygiene) (shopping, housekeeping, accounting, food, transportation) ix -physical exam -CT brain -CBC, lytes, BUN, Cr, glu -TSH -B12, folate challenging -will my dad need a nursing home ? thank you for bringing it up - id like to fully evaluate ur dad tomorrorw to determine what help he needs\ -id like my father to stay home but i work - i dont want to leave him alone - I will have our social worker call u. She may be able to arrange for some in home help for ur father. Are you able to take care of him tonight, or should we make other arrangements today Diabetic checkup - ddx, ix, challenging ddx -diabetes mellitus -ischemic heart disease/CAD -peripheral neuropathy -diabetic retinopathy -peripheral vascular disease / erectile dysfunction / stroke - diabetic nephropathy - gastroparesis - macro (CAD, PAD, stroke), micro (nephropathy, neuropathy, retinopathy) - ulcers/foot hygiene hx -sx diabetes -assoc CVD - CP, SOB, headache, claudication, edema -assoc nephro - frequency, hematuria oe -eyes / HEENT / neuro -feet -cvs / pulses - abd -neuro - sensation -erectile

ix -CBC, lytes, BUN, Cr, glucose -HbA1c, UA microalbuminia -fasting cholesterol, HDL, LDL, TG -ECG, cardiac stres test challenging -i'd like to get into better shape fo mountain climibing - can I start running up hills ? I'm glad you want to be in shape, before u begin, let me do a heart test to be sure its safe to being strenuous activity. abdominal pain, fatigue, malaise (Domestic violence) ddx

ddx, ix, challenging

-domestic violence -hemopneumothorax -traumatic injury spleen oe -HEENT, THY ix -pelvic and rectal exam -TSH -CBC, lytes, Glu,INR -CXR, UA -CT abd challenging -during PE - i see a lot of bruises on ur side -Ms T, I have finished ur phys exam. I'd live to review our meeting. You tol me abd pain. On exam I found u r tender in the tummy and have large bruises. I am concerned that u were injred u may have hurt ur chest o belly -Ms T, many women are victims of domestic violence. If anyone is hurting u, I can help keep u safe. -I know its difficult to talk about. Remember, I am here to help -no one has the right to hurt u -I'd like u to see our counselor to help. Also I want to be sure u have a safe place to go when u feel u are in danger. -I'lll bring u a list of shelters - and thank you for telling me. -Of course the important this is to be safe in the future. -I also want to take an xr of ur chest and belly to look for any bleeding in ur body -then we will meet again to siscuss the results to see how u r doing with counselor -do you have any questions ? -ok i;ll call tomorrow with the results. INTERLOCUTOR - Child 18 mo F - vomiting/ diarrhoea ddx -dehydration -gastroenteritis -diarrhoea from amoxicillin -antibiotic - clostridium difficile -food poisoning -food intolerance

ddx, ix, challenging

-obstruction ix -physical exam (hydration status) -stool - rotavirus + C-diff -(hydration) - lytes, glucose, BUN, Cr, UA -CRP, ESR -CXR, AXR challenging -in peds - you want to see the child for illness TODAY -counsel caregiver the need to call an ambulance if the child sounds sick and that u will meet them at the hospital -counsel mother to stop feeding cows milk as it will make the diarrhoea worse -reassure that the child is receiving adequat fluid replacement - pedialyte -need ot evaluate the child soon -I have no transportation and cant come today - Itr sounds like i need to see ur child today - I need a stool sample to check for infection and blood test to check for dehydration. Can you take a taxi or ask someone to drive you -otherwise ring an ambulance and bring u to the ED and I will meet u there Life insurance exam ddx -obesity -diabetes -peripheral neuropathy

ddx, ix, challenging

hx -diabetes qs -hypertension, obesity oe -height and weight -diabetes and hypertension = eyes, feet, cardiac ix -physical exam - rectal and prostate -CBC, lytes, BUN, Cr - UA - HbA1c - fasting glucose challenging -MAKE SURE ASK - aside from the insurance form, are there any other health concerns I can help you with? - could u just put down that everything is normal - i really need the insurance ? I'm afrain i cant do taht. How about working together to make your health better ? - (obesity counselling) - id like u to eat 5 serving of veges per day and minimise the fatty food and hi sugar foods in ur diet. Sometimes its difficult to know how much fatg is in takeout and fast foods so its best to avoid them. - also for you ronoging health i recommend you stop smoking. It can be difficult so here is a phone number for a stop smoking class that many people find helpful in quitting. It is the single most important thing you can do for your health as it prevent s many health conditions - here is the insurance form i need u to fill out ? thank you , ill fill it out and send it in after our visit INTERLOCUTOR - 15 F - Obesity ddx

ddx, ix, challenging

-

obesity lifetstyle depression hypothyroid night time eating disorder binge eating disorder, nighttime eating disorder, bulimia

- insulinoma, cushing, PCOS hx -body image, eating disorders, education, friends, drugs, sex, smoking, depression obesity oe - height and weight - cardiac - knees and spine - abd - gall stones (RUQ tender) - HEENT thyroid ix - physical exam - TSH, CBC, lutes, BUN, Cr, Glu - FSH, LH, prolactin - USS ovaries challenging - DONT TALK ABOUT OBESITY OR BEING FAT - say overweight - she wont want to see u. Should I lie to her and trick her into coming ? No honesty is the best policy. Just tell her I want to help her with her weight. Tell her that she can talk to me confidentially. - weight loss pills prescirption ? i dont know if that medicine would be right for shirley withou a physical exam and a blood test. Letme know if she refuses to come to the appointment. I can call her at home, or perhaps set up some counseling for her. 70M Parkinsons disease + fever + htn + tachypnoea ddx -decongestant meds (phenylephrine) -essential hypertension -aspiration pneumonia -anticholinergic SE (HR, dryness) - NMS (fever, rigit, cannot move, change in meds) -complications of parkinsons ? dysphagia/aspiration depression sleep disorders constipation falls (subdural hematoma) SE to much meds too little meds non compliance

ddx, ix, challenging

oe: -GA -HEENT - fall trauma, plapation tender, pharynx -chest - cardiac, inspection, resp excur, tactile fremitus, percussion, auscultation -abd palpation -neuro AMS, orinteaiton, motor, gait, check neck for meningitis

ix -CBC, BC, sputum culture -CXR, UA, urine culture -lytes, BUN, Cr -CPK. challenging -an u going to die ? what u have may be serious, but I am going to get u the appropriate treatment and will do everything i can to help. breaking bad news BREAKING BAD NEWS: SPIKES setup, perception, invitation, knowledge, emotions, strategy and summary - SETUP - "my name is john-paul oshea. I will be helping you today." identify all people in the room - i've schedule time for us today, turned off my pages so that we wont be disturbed, and asked my staff not to interrupt us - would you like your family member to stay or step out while we discuss the results today ? is there anyone else we should call in to discuss the results (would it be allright if she came next visit - id like to talk to you today" - PERCEPTION -what have u been told about your sx -do you remember the colonoscopy/procedure -what did you think the sx was due to -did you think the sx were from something serious - INVITATION - I have the test now - would you like to go through them - would you like all the basic information, or the details as well - so if it turns out to be something serious - you would like to know - KNOWLEDGE - i'm sorry to have to tell you that the pathology reports shows that what you have is serious and will require treatment - what we mean when we say somehing is canc erous is that the growth is uncontrolled - i'm sorry to have to tell you that the report is correct. The pathology reports that you have cancer of the colon - i know that this is serious news - but i want to tell you that there are treatment options available for your condition - the type of cancer you have does have treatment options. you will have a specialist that is an expert in dealing with this sort of cancer and you will get the best care available for your condition - you will be treated by a team of doctors. I will remain your primary physician and I will refer you t a cancer speciality XX with many years of experience managing your condition. I will bring you her number and have already made an appointment for you. I would then like to see you again back here in my office - EMOTION results

- i can see you are upset. I was also upset when I got the

- what you have is serious - but we have medicaitons and treatments available - STRATEGY / SUMMARY -

- i know I gave u a lot of info to remmeber today. I want to make sure you understand me correctly - can you repeat to me your understanding of the situation - you can call me anytime with questions and of course come to our next appointment. and I'm looking forward to meeting your daughter also. - here is my phone number - please call me at any time if you have questions challenging - dont tell my husband he has cancer -? why do you feel that way - we have found that if we dont tell pt they have cancer - they eventually find out anyway - then they are often angry and resentful toward their doctors and family - its best to get the news out int he open. If he gets depresed I can helpt treat that also - ill ask Mr X if he wants to knw the test results - if he doesnt i will speak only with you about it. If he does want to know, I need to tell him and we both can help support himz 48 M, wants to quit Smoking, tachypnoea ddx -emphysema -chronic bronchitis -lung cancer

ddx, ix, challenging

hx -when started, packs/d, years smoked, previous attempts to quit - how, associated sx - SOB, wt wloss, hemoptysis, hoarseness, previous pneumonias, productive cough oe -HEENT - colour, adenopathy, pharynx -resp - palp, excur, fremitus, percussio, auscult -cardiac - jvp, hs, cyanosis, edema, clubbing ix -CXR -CBC -PFT -PPD -chest CT -pulse oximetry -arterial blood gases -CRP challenging -too late to stop ? no every day is a good day to be smoke free. I'd like u to start attending the smoking cessation classes here at the hospital immediately. WHen the tests are back, ill call u. Its great that ur r here today. It shows u are serious about stopping and ill help however i can.\ -but ive failed so many times before ? its better to think positively. Now u have another opportunity, with help from me and the stop smoking classes. Schizophrenia ddx -schiz -bipolar 1 oe

ddx, ix, challenging

-neuro, psych -do not give the drape if wearing street clothes -psych = GA, orientation,speech,memory, attention/conc, mood/affect, process, halluc/del/paranoia, suicidal/homicidal ideations, insight speech - normal, pressured, rapid, volume, rate, tone, accent, stuttering mood - subjective patient - how do u feel affect - objective - euthymic, neutral, euphoric, dysphoric, flat, blunted process - logical, loose associations, flight of ideas, tangential, circumstantial halluc - do u see/hear tings not really there ? do they tell u things del - do people ever tell u that u have very unusual ideas about urself or the worl insight - what do u think about ur symptoms ix -physical exam -CBC, lytes, BUN, Cr, Ca, glucose -lipid screen -LFTs -TSH -drug screen -EtOH -Lithium/valproate elevels challenging -i dont want any tests - i dont want u to inject me with any monitoring devices ? I am here to help u and would never do anything to harm u. I'll ha e the counselor come and speak to u now. Do u have any questions ? INTERLOCUTOR - 24 mo Child - temper tantrum / emotional problems- ddx, ix, challenging ddx -tired, hungry, bored, physical discomfort/dirty, cold, hot, overstimulated. - if > 4 yr = depression, autism, attention deficit disorder - assoc feinting = seizures, arrhythmias, (EEG required, ECG) - breath holding spells (blue) hx -peds hx prenatal/drugs/date/term/delivery perinatal/birth weight + APGARS/time spent in hospital/jaundice/breathing/feeding/stooling/surgeries/fevers/ infant - sleep, feed, stool, wetting, ear infections, toothaches, tantrums growth and devleopment risk harm to baby primary caregiver smoking in household smoke detectors firearms in house car seats poisons out of reach WHAT IS CARERS RESPONSE immunisations ix -physical exam -no test indicated challenging -what can we do about them ? They happen when a child is tired, hungry or out of routine. All u can do is to sit quietly with her until it passes. Punishment doesnt work to prevent tantrums. Usually they grow out of them. Would it help to know that

they are part of growing up. -whenever it happens, i send them to bed without dinner ? we have found that punishment doesnt work for temper tanturms. It would be better if you just put them in time out for a minute. Once the tantrum and the time out are over, forget about it and pretend it never happened. -should i take her to a child psychologist ? no - but i'd liek ot examine amy. Can u bring her in tomorrow. -to tell the truth, I did scare myself (worried she might shake/hurt the child) a few times 30 F - Asthma attack - ddx, ix, challenging ddx -asthma exacerb - meds non compliance -asthma exacerb - trigger 1 and trigger 2 SOB acute -resp .copd, asthma, effusion, penumonia, edema/ards/apo, pe, pthx -obstruction .foregin body, facial inj, angioedema/anaphyl, epiglottis/quinsy, gcs, aspiration .thoracic outlet -cardiac failure -nephrotic/swelling -drugs .pe - tamoxifen, ocp, raloxifene .apo - hczt / non compliance with antihypertensives .effusion - MTX, phenytoin -other .anemia, dka, hypervol -thoracic outlet obs (goiter) - pembertons hx -medicine non compliance -triggers -infection -SOB ddx (airway obstruction, lung/asthma, cardiac, traumatic/PThx/dissection/) -frequency of sx -sx SOB - cought, sputum, hemoptysis, dys/SOB, wheeze, CP, fever, hoarse, n oe -Cap refill !!, cyanosis, HEENT, percussion/fremitus -speaking in short sentences. -check swelling !!!!! - cor pulmonale/ DVT - check for cardiac, clotting, kidney ix -pulse O2 - CXR -arterial blood gas -?ECG -peak flow challenging -i'm scared ? i can see u r SOB. I am here to make u feel better -counseling wrt compliance + triggers - I think all of these have contributed to asthma attac. I will take an CXR, measure ur oxygen level, get a peak flow now and start tx RIGHT NOW (emergency)

. When u r feeling better, I want to make an asthma action plan with you which invovles - check ur peak flow every day, take ur medicines as presecribed and call me if u r running low on meds. I dont want u to run out of medicine and i want to hear first thinkg if ur peak flow is less than baseline. Also I'd like to outline for you what to do int he case of an emergency. 36M - Back pain ddx -renal colic -biliary colic -testicular torsion

ddx, ix, challenging

-AAA -pancreatitis -prostate mets -strain -spondylosis -spondyloisthesis -sciatica -pleuritic source of backpain hx -sexual history oe -lungs (pleuritic source of back pain) -sclera/jaundice ix -genital exam -PR -inguinal hernia exam -BUN, Cr, ALP, T bili, D Bili -CT Abd, pelvis -UA hemo, UA, Urine MCS -PSA challenging -do i have hi blood pressure ? is this the first time you've had an elevated reading ? It's likely ur reading is hi bc of pain. I'll check it again once u feel better 55 M - chronic Diarrhoea + current fever + tachypnoea ddx -giardiasis -amebiasis -crohn chronic -HIV itself or immune compromised - cryptosporidium -blood + mucus = UC -crohns + ulcers -travellers -overflow -IBS -pancreatic -medications -Food intolerance -food poisoning

ddx, ix, challenging

-infectious - giardia hx -watery, blood/black, mucus, volume, frequency, travel, sick contacts -food, intoleracnces, pancreatic, medicaitons, IBD, IBS -assoc abd pain oe -hydration status -abd -jaundice ix -stool for ova parasites -stool for fecal leukocytes -CBC, lytes -enteric pathogens -colonscopy challenging -my aide will be in contact with you ? I can talk to your aide about your helath if u give permission -You look a little young. Id like to see a more senior physician ? I can arrange that for you. I am here now and would like to help. How about I finish seeing u today and arrange that for your follow up visit. 30 F, Chest pain - GERD ddx -gord -pud -pancreatitis

ddx, ix, challenging

Acute CP ddx - 4 Hs 4 Tshx - Hypo-VOGET (volemia, oxygen, glycemia, electrolytes/kalemia, thermia) - PThx, dissection, trauma/MI, thrombus - stroke, thrombus - PE, tamponade, toxins - Booerhaaves hx -SOB, vomit, radiation, PR blood - DM, htn, cholesterol, cardiac, trauma, surgx, admissions, lmp, d=a oe -jaundice vs liver/variceal ix -PR exam -FOBT -esophago-gastro-duodenoscopy -CBC, amylase, lipase -T -bili, ALP, ALT, AST -esophageal pH monitoring challenging - something else before a procedure ? lose weight, stop smoking, avoid large meals before lying down - id like u to attend the smoking cessation clinic here at the hospital - that is the place to start - i can see ur reluctant about the endoscopy - why dont we talk in a couple of days

when i call you back with the blood work results - cant you give me a prescription for the purple pill ? Its important to be sure what is wrong first. We will talk more about treatment when i get the test results back 65 M - Hearing loss ddx - AOM wax, firearm discharge, neoplastic (occurs over a long time), infection, congenital, toxin (gentamicin, chemo - toxins will damage bilaterally) hx - complications inclu mastoiditis Rinne - BC>AC = cond that side Weber - one side louder = .if rinne AC>BC (which is normal) - then = sensori on the other side [nothing can get thru the cond-nerve-brain circuit] .if rinne BC>AC - then = cond on that side [things can still get thru the circuit bc nerve intact - its louder on the bad side bc no interference from air conduction] oe - HEENT (hearing finger rubbing, Rinne/Weber, inspection ear canal wax/external deformity redness swelling, palpate pinna, LYMPH NODES (no adenopathy), TMJ (NL ROM) and pharynx (clear) ddx - (loud noises, age, wax/cerumen, infection, tumor, gentamicin/drugs, referred) AOM (recent loss after cold, achy pain in ear, no pain movement pinna, conductive hearing loss, NO MASTOID TENDERNESS (mastoiditis), NO WAX in ear, red/bulging tympanic membrane), unilateral (not ototoxicity), recent onset (tumor unlikely) ix - no tests indicated, audiogram challenging - move to be clsoe to patient qs .do i need a hearing aid (I suspect u will not need a hearing aid. However id like to clear up this ear infection first and then see again to recheck your hearing

elderly woman - fall - hip injury ddx -# left hip -dislocation left hip -# acetabulum hx - SOCRATES, mechanism, assoc sx bf/aft, hx OP, sh - who does she live with oe - HEENT, neck, Chest/lungs/cardiac, Abd, pelvis, neuro - lwr extremity motor/sesation, pulses ddx - hip pain (arthritis, septic arthritis, bursitis, tendonitis, AVN, referred[herniated disk,spinal stenosis, meralgia paresthetica, fracture pelvis/femur, SCFE) - # hip, # acetabulum, dislocation hip (slip and fall, pain in hip, incr pain with movement, decr ROM hip, shortened externally rotated leg, hip tender to palpation, [NB no previous surgery/hip replacement makes an isolated dislocation less likely] ix - XR hip/pelvis, CXR, CBC/type and screen/PT/PTT, EUC, glucose, Cr, BUN,

ECG

challenging - verbalise that u see the pt in great pain - place urself where the pt does not have to turn to make eye contact - offer comfort with the drape - unable to turn to look at you t/f place in their line of sight - i can see u r in a lot of pain. please let me gently cover ur legs for warmth - i have a pet at home - who will feed them ? if u have the number of a neighbor I can call for you qs . collapsed outside your clinic - acute ill - seizure hx - SOCRATES, fhx, med, allergy, shx, D+A+CAGE, pmhx (admissions, surgx, trauma), prev diagnosis seizure *************PLUS - why they came to see you in the first place ************* oe - HEENT (tongue, palpate head + neck), chest (inspect injuryies, auscultate), Neuro (minimental, pupils/cranial, motor extremities, cerebellar finger/nose/gait) ddx - seizure, CNS lesion (seizure, chronic HA, memory, no motor weakness, mental status, post-ictal ix - CT-B, EUC, BUN, Cr, glucose, calcium, ECG, EEG challenging qs .(bf your history asks) - what happened ? - respond ï'd like ot finish talking/examie, then I will answer" .i'm going to have the nurse take a blood sample. In addition, we need to do a CT scan of your brain. .I'm wetResponse = yes, i will have some clean scrubs right away chest pain - shingles hx - SOCRATES, assoc (SOB, sweat, N/V), prev, meds, immuniz, pmh (immunocompro, chicken pox), risk of transferring/exposure the sick/immunocompro oe - HEENT, neck/mening, chest, abd, skin ddx - herpes zoster (itchy skin, dermatomal rash, blisters with red base, does not cross midline) ix - no studies indicated challenging - immunocompro contacts ? when blisters stopped appearing and dried, see in a week qs: ever had chicken pox? immunized for shigles blisters can cause infection - do you go near babies, or anyone with bad immune system HA ddx: -tension, migraine, temporal arteritis, sinusitis, glaucoma, subdural hematoma, cluster, SAH CP ddx: ACS, PE, pneumonia, Pthx, dissection, pericarditis, costochondritis, herpes zoster, esophageal reflux SOB ddx: HF, COPD, asthma, anemia, obstruction, MI, anaphylaxis RUQ pain ddx: biliary colic, cholecystitis, PUD, pancreatitis, hepatitis





Aortic dissection ripping chest pain or back pain blood pressure difference between arms sudden onset heart murmur (if aortic insufficiency) pain radiates to neck or back pulse differences between sides Pericarditis pain better sitting up and leaning forward pleuritic fever started after viral URI

cardiac rub

Costochondritis sharp pain point tenderness causing the pain hurts with movement and twisting Herpes zoster unilateral unilateral blistering rash on a dermatome paresthesia of skin unilateral dermatome fever GORD heartburn no fever sour taste coming up to mouth no pleuritic pain pregnant no abdominal pain better with antacids pain worse if lies down after eating SHORTNESS OF BREATH Heart failure dyspnea on exertion rales in lungs pedal edema gallop heart rhythm (S3, S4) orthopnea distended neck vein (JVD) hx of HTN, smoking, coronary disease distended liver Chronic obstructive pulmonary disease dyspnea tachypnea cough increased chest AP diameter weight loss clubbing of fingers pursed lip breathing decreased air entry chronic condition, smoking hx prolonged expiratory phase Asthma recurrent attacks of dyspnea wheezing cough wheezing hx of allergies family history of asthma/allergies Anemia fatigue pallor (conjunctiva, nail beds) generalized weakness Airway obstruction

sudden onset stridor change in voice cyanosis choked on food or denture Myocardial infarction with CHF substernal chest pain lasting more than 15 min diaphoresis dyspnea (list any abnormal vital signs) nausea hx of smoking, HTN Anaphylaxis acute shortness of breath wheezing hypotension hx of exposure to allergen tachycardia

hives tachypnea

RIGHT UPPER ABDOMINAL PAIN RUQ pain - Biliary colic RUQ pain—intermittent no fever can last several hours tender right upper quadrant occurs after fatty meal risk factors: female, overweight, pregnant RUQ pain - Cholecystitis RUQ pain fever radiates to R scapula + Murphy’s sign tender right upper quadrant RUQ pain - Peptic ulcer disease epigastric RUQ pain epigastric and RUQ tenderness taking aspirin or NSAIDs blood in stool pain may radiate to back RUQ pain - Pancreatitis epigastric and RUQ pain epigastric and RUQ tenderness pain after eating nausea/vomiting hx of alcoholism hx of gallstone RUQ pain - Acute hepatitis B fever jaundice jaundice tender enlarged liver RUQ pain − Murphy’s sign hx of unprotected sex, IV drug use fever CHRONIC COUGH CHRONIC COUGH - Asthma

recurrent attacks of dyspnea wheezing cough wheezing hx of allergies family hx of asthma/allergies CHRONIC COUGH - Allergic rhinitis runny nose rhinorrhea itchy watery eyes watery eyes recurrent with season allergic shiners intermittent hoarse voice/phlegm in throat

cobblestoning in posterior pharynx

CHRONIC COUGH - Gastroesophageal reflux heartburn no fever sour taste coming up to mouth no pleuritic pain pregnant no abdominal pain better with antacids CHRONIC COUGH - Chronic obstructive pulmonary disease dyspnea tachypnea cough increased chest AP diameter weight loss clubbing of fingers pursed lip breathing decreased air entry chronic condition, smoking hx prolonged expiratory phase CHRONIC COUGH - Pneumonia pleuritic chest pain fever cough dullness to percussion sputum production abnormal breath sounds increased tactile fremitus CHRONIC COUGH - ACE inhibitor taking ACE inhibitor no fever dry, nonproductive cough normal lung exam CHRONIC COUGH - Tuberculosis chronic cough fever hemoptysis lung findings weight loss low weight exposure to TB night sweats CHRONIC COUGH - Pulmonary malignancy hx of smoking weight loss cough wheezing chest pain shortness of breath hemoptysis ACUTE PELVIC PAIN ACUTE PELVIC PAIN - Appendicitis



positive family history SYNCOPE SYNCOPE - Vasovagal emotional, stressful situation quick recovery in minutes no seizure activity occurred in bathroom

normal vital signs (when recovered)

SYNCOPE - Arrhythmia palpitations abnormal heart rate chest discomfort irregular heartbeat shortness of breath medication history SYNCOPE - Orthostatic hypotension symptoms upon standing, esp.

lower leg warm

BILATERAL SWOLLEN LEGS BILATERAL SWOLLEN LEGS - Heart failure dyspnea on exertion rales in lungs pedal edema gallop heart rhythm orthopnea distended neck vein hx of HTN, smoking, coronary disease

distended liver

BILATERAL SWOLLEN LEGS - Nephrotic syndrome foamy urine edema bilaterally weight gain edema also around face fatigue BILATERAL SWOLLEN LEGS - Liver failure jaundice jaundice (skin, hard palate, sclera) fatigue ascites right upper quadrant pain right upper quadrant tenderness mental status changes edema bilaterally asterixis BILATERAL SWOLLEN LEGS - Obesity/venous insufficiency pain, swelling in legs red legs and ankles with darkened skin changes elevated body mass index bilateral edema VOMITING Note: Be as specific as possible in selecting the diagnosis. For a symptom as general as vomiting it is helpful to think of possible causes based on organ system or other groupings as shown below. For the actual exam, be specific. For example, in the first section below, write “Vomiting from chemotherapy,” not “Vomiting from medication.” VOMITING - Medications (chemotherapy, general anesthesia, opioids) temporal history of medications followed by vomiting no fever no blood in emesis abdomen soft, nontender vomiting VOMITING - Gastroenteritis (rotavirus, norovirus, food poisoning, Campylobacter) sick contacts or those sharing food also sick possible fever abdominal cramps and pain soft abdomen diarrhea possible diffuse abdominal tenderness vomiting VOMITING - Benign paroxysmal positional vertigo (BPPV) triggered by movement of head possible nystagmus vertigo vomiting VOMITING - Cerebellar (posterior basilar artery) stroke severe vertigo (may be unable to open eyes) vertical nystagmus falling ataxia vomiting dysmetria + Romberg sign VOMITING - Endocrine and toxins (alcohol, diabetic ketoacidosis)

weakness, fatigue dry mucous membranes dehydration darkening of skin vomiting