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University of Puerto Rico

Medical Sciences Campus


School of Medicine
Department of Medicine

CASE PRESENTATION
Student's Name:

vv

Student Number:

Patient's Initials:
Date of Encounter:

_________________________________________________________________________________

Chief Complaint:
History of Present Illness:
vddd

Case Presentation - Page 2


Allergies:
Childhood illnesses:
Adult medical history:
Medications (include doses):

Surgical history:
Family history:

Social history:

Review of systems:
Yes

No

SYSTEM

General:
Recent weight loss
Recent weight gain
Weakness
Fatigue
Fever
Chills

Skin:
Rashes
Lumps
Sores
Itching
Dryness

Yes

No

SYSTEM
Changes in skin color
Changes in hair
Changes in nails
Changes in size or color of moles

Head, Eyes, Ears, Nose & Throat


Headache
Dizziness
Lightheadedness
Loss of vision
Wears glasses or contact lenses
Eye pain
Redness of the eyes
Excessive tearing

Case Presentation - Page 3


Yes

No

SYSTEM

Yes

No

SYSTEM

Head, Eyes, Ears, Nose & Throat

Cardiovascular

Blurred vision

Paroxysmal nocturnal dyspnea

Double vision

Edema

Spots, flecks, flashing lights

Gastrointestinal

Loss of hearing

Trouble swallowing

Tinnitus

Heartburn

Vertigo

Loss of appetite

Earache

Nausea and/or vomiting

Ear discharge

Change in bowel habits

Frequent ear infections

Change in stool color

Frequent colds

Change in stool consistency

Nasal stuffiness

Pain with defecation

Nasal discharge

Rectal bleeding

Nosebleeds

Tarry black stools

Sinus pain

Hemorrhoids

Neck

Constipation

Swollen glands or lumps

Diarrhea

Goiter

Abdominal pain

Pain

Excessive belching

Stiffness

Excessive flatulence

Breasts

Jaundice

Lumps

Peripheral Vacular

Pain

Intermittent claudication

Discomfort

Leg cramps

Nipple discharge

Varicose veins

Respiratory

Ulcers

Cough

Past clots in veins

Sputum

Swelling of calves, legs or feet

Hemoptysis

Color change in fingertips or toes when cold

Dyspnea

Urinary

Wheezing

Increased frequency

Pleurisy

Nocturia

Cardiovascular

Urgency

History of heart murmurs

Burning or pain during urination

Chest pain or discomfort

Frequent urinary infections

Palpitations

Flank pain

Dyspnea on exertion

History of kidney stones

Orthopnea

Hematuria

Case Presentation - Page 4


Yes

No

SYSTEM

Yes

No

SYSTEM

Urinary (Male)

Neurologic

Reduced caliber or force of urinary stream

Changes in speech

Hesitancy

Changes in orientation

Dribbling

Frequent headaches

Genital (Male)

Dizziness

Hernias

Fainting or blackouts

Discharge from penis

Weakness

Sores or ulcers

Paralysis

Testicular pain

Numbness or loss of sensation

Testicular masses

Tingling sensation

Scrotal swelling

Tremors

History of sexually transmitted disease

Involuntary movements

Genital (Female)

Seizures

Irregular menses

Hematologic

Prolonged menses

History of anemia

Excessive bleeding

Easy bruising

Bleeding between periods

Excessive bleeding

Dysmenorrhea

Past transfusions

Menopause

Endocrine

Menopausal symptoms ("hot flushes")

Heat or cold intolerance

Postmenopausal bleeding

Excessive sweating

Vaginal discharge

Excessive sweat or hunger

Vaginal itching

Polyuria

Sores, ulcers or lumps

Changes in shoe or glove size

History of sexually transmitted diseases

Musculoskeletal
Muscle pain
Joint pain
Backache
Swelling of the joints
Stiffness of the joints
Muscular weakness
Limitation of motion
History of fractures or trauma

Psychiatric
Nervousness
Anxiety
Depressed mood

Health Maintenance:
Vaccinations
Hepatitis B
Influenza
Measles-Mumps-Rubella
Pneumococcal
Tetanus toxoid
Varicella

Last Dose

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Health Maintenance:
Screening

Last Performed

Screening

Bone densitometry

Lipid profile

Colonoscopy

Mammography

Diabetes screening

Pap smear

Last Performed

Physical Exam:
Vital signs:

Temperature
Weight

Normal

Abnormal

Heart rate

Respirations

Height

BMI

SYSTEM
General: Alert, awake, and oriented. Appropriate grooming
and hygiene. No acute distress.
Skin: Moist skin. No ulcers, rashes, or lumps. Normal hair
and nails. No jaundice.
HEENT: Normocephalic. Sclearea white. Normal visual
acuity. Pupils equally reactive to light. Normal eye fundi.
Normal ear canal. Weber midlince. Rinne AC>BC.
Normal nasal mucosa. No sinus tenderness. Moist oral
muscosa. Good dentition. No erythema or exudates.
Neck: No palpable masses or lumps. No goiter. Neck supple.
No palpable lymph nodes. No jugular venous distention. No
carotid bruits.
Thorax and Lungs: No tenderness to palpation of spinal
processes. Normal lung expansion. Normal tactile fremitus
No egophony or whispered pectoriloquy. Lungs clear to
auscultation with no ronchi, crackles or wheezing.
Breasts and Axillae: No lumps or masses. No discharge.
Heart: Non-displaced apex. Regular rhythm. Normal S1
and S2. No S3 or S4. No audible murmurs. No clicks, rubs
or other sounds.
Abdomen: Normal bowel sounds. No abdominal bruits
No tenderness to palpation. No masses. Normal liver span.
No splenomegaly. No ascites.
Extremities: No ulcers or discoloration. No edema.
Peripheral pulses +2 throughout. No deformities of the
joints. Normal range of motion. Normal muscle bulk and
tone.

Blood pressure

ABNORMAL FINDINGS

Case Presentation - Page 6


Normal

Abnormal

SYSTEM

ABNORMAL FINDINGS

Neurologic:
Mental status: Alert, awake, and oriented. Appropriate
speech. Normal mentation, insight, judgement, and memory.
Cranial nerves: Normal sense of smell. Normal visual
acuity, visual fields, and ocular fundi. Normal pupillary
reaction. Normal extraocular movements. Normal corneal
reflex, facial sensation, and jaw movements. Normal facial
movements. Normal hearing. Weber midline. Rinne AC>
BC. Normal swallowing and rise of the palate. Intact gag
reflex. Normal voice and speech. Normal shoulder and
neck movements. Normal tongue symmetry and position
Motor system: Normal muscle tone and bulk. Strength 5/5 in
all muscle groups. Point-to-point movements and rapid
alternating movements intact. Normal gait.
Sensory system: Normal sensation to pain, temperature,
light touch, vibration,and point discrimination.
Reflexes: Normal biceps, triceps, brachioradialis, patellar,
and Achilles deep tendon reflexes.

Laboratory Findings:

Segmented neutrophils

Aspartate dehydrogenase (AST)

Lymphocytes

Alanine dehydrogenase (ALT)

Eosinophils

Alkaline phosphatase

Monocytes

Bilirubin, total

Mean corpuscular volume

Bilirubin, direct

Mean corpuscular hemoglobin

Magnesium

Other relevant laboratories:

Imaging studies:

Electrocardiogram:

Case Presentation - Page 7


Assessment:

Plan:

References:

STUDENT SIGNATURE:

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