Mini-CPX 6

Part 2: Approaching the Physical Exam

Further history obtained from the patient:

Past medical history:
Medical illnesses: Seasonal allergies, for which the patient takes
Zyrtec (she has been on this medication for over 5 years); shes had
seasonal allergies since childhood. No other major ongoing chronic
medical problems. No history of hospitalizations or surgeries.
Health maintenance: she regularly sees her primary care doctor for
routine health visits, including annual pap smears. She is up to date
on her vaccines, including her influenza vaccine this year. She has not
had her cholesterol checked recently (in the past year), but the times it
has been checked in the past, it has been normal.
Diet: reports eating a typical American diet, without any dietary
restrictions.
Family history:
Mother: type 1 DM requiring injectable insulin since her early 20s.
Father: HTN and hypercholesterolemia since his mid-50s, and is on
medications for both.
Maternal aunt has rheumatoid arthritis.
No other chronic illnesses in the family, as far as the patient is aware.
Medications:
Zyrtec 10 mg once daily
Ortho Tri-Cyclen, once daily
Allergies: NKDA

Social history:
Occupation: librarian at the local public library
Living situation: married, lives with husband and 2 children (5 year-old
girl and 7 year-old boy), both healthy.
Sexual history: sexually active with husband, who has been her only
partner since they were married (>10 years ago); has always used
condoms with all past partners, including her husband; no history of
sexually transmitted diseases in the patient or her husband.
Substance use: Does not smoke (never has). Alcohol use: consumes
1-3 drinks (beer or wine) at the most, per weekusually only on
weekends (not daily). Denies recreational drug use now or in the past.
Travel: no recent travel to foreign countries.
Sick contacts: no one around her has been sick lately (other than
minor colds), including no known tuberculosis (TB) exposures. No
exposure to hospitals, nursing homes, homeless shelters, or
incarceration facilities.
Denies major life stressors, other than this illness.
Review of symptoms:
General: reports weight gainapproximately 20 pounds over the past
6 months; denies changes in diet over that period of time.
Distribution of weight gain seems equal throughout her body.
Also reports feeling cold all the time, compared to her
husband, who often complains about how warm she keeps the
temperature in the house (this symptom started several
months ago and has progressively worsened). Denies fevers,
night sweats, problems sleeping, excessive thirst, or appetite
changesappetite has been normal.
HEENT: Mild chronic rhinorrhea, nasal congestion, clear nasal
discharge, and occasional sneezing (no worse than usual),
attributed to her seasonal allergies; denies headaches, sore
throat, eye pain or discharge, ear pain or discharge, or unusual
gum bleeding.
Respiratory: shortness of breath with exercise/exertion, mild to
moderate in intensityenough to discourage her from finishing

a task; noted this symptom primarily over the past 2 to 3

weeks, and it has progressively worsened over that period of
time. Denies cough or difficulty breathing when lying down or
when sleeping at night.
CV: reports dizziness upon standing sometimes, but not always
(doesnt notice it as much if shes well hydrated)noted this
symptoms more frequently over the past several weeks;
denies chest pain, chest pressure, heart palpitations, syncope,
or lower extremity swelling.
GI: reports constipation, which she describes as difficulty passing stool
more than in the past, and it sometimes hurts when a stool is
very large in size; she has bowel movements about once every
2 to 3 days, but sometimes she goes close to a week before
passing a BM. Stools are non-bloody and are brown in color
(no black or tarry appearance). Denies abdominal pain
other than times when shes very constipated; denies nausea,
vomiting, diarrhea, or heartburn.
Skin: reports dry skin recently (over the past few months), attributed
to being indoors in the dry heat during the winter; shes tried
applying moisturizing lotion for this, but it doesnt seem to
help much. Denies rashes or unusual skin lesions, yellowing of
the skin, itching, easy bleeding with scratches, easy bruising,
or swelling.
GU: reports her menstrual periods have become heavier than in the
past, requiring her to use at least 4 to 5 large pads a day, for
the duration of her period; but her period still lasts the same
number of days it has in the past (~5 to 7, every 28 days).
Denies vaginal bleeding between menses, vaginal discharge,
lesions or rashes in her genital area, pain with sexual
intercourse, dysuria, urinary frequency or urgency, or loss of
interest in sexual activity.
MSK: Denies joint pain or swelling; denies muscle aches or pain.
Psych: reports doing her hobbies less than prior to when her
symptoms began (e.g., running, gardening). Denies depressed
or anxious mood, irritability, loss of interest in social activities
or things that normally bring her pleasure, loss of interest in
sex, loss of self esteem, feelings of hopelessness, feelings of
guilt, difficulty concentrating, or thoughts of suicide.

Instructions:
Based on the information given in this patients HPI and chart, use the
template below (starting on page 5) to create a list of PE
maneuvers you would perform on this patient.
For each PE maneuver on your list, indicate the specific reason you
would perform this maneuver in the right column, in terms of
how it is relevant to your revised differential diagnosis for this patient.
You must include this information for every PE maneuver, to receive
credit.
Note:

It is important that you avoid including unnecessary PE

maneuvers that are no longer needed based on what you know
so far, focusing your exam content using your revised differential
diagnosis after reading the full history. QUALITY is much more
important than QUANTITY, in this regard. That said, do not short
cut areas of the exam, if more exploration is needed.

The number of rows included in this template in no way indicates

the number of PE maneuvers expected to be included in any part
of this assignmentthey are simply here to provide a structure
for creating your planned PE, however long or short you make it.

Physical Exam Maneuvers

Organize this list according to organ system.

Add additional rows, if needed.

Reason(s) why this PE

maneuver is relevant to the
exam for this patient