History Notes/

CC Physicals Counsel DD Workup

Mnemonics Challenges
1 17 yo M c/o OPD CSF LIQR AA -General *Wrestler, *Pain Meds, - Chostocondritis -CBC w/diff, ESR,
Chest Pain Difficulty of breathing? -Thyroid *ConsentIncluded.* *Rest at least - Muscle Sprain CRP,
-Extrem Breathing and until results - Fracture Rib -CXR, CT chest
Racing heart like a horse?
-Chest, Lifting weights. appear -PFT
Burning pain in your chest? Heart (JVD/ *Physiotherapy is -EKG, Echo
In young patient:
Carotid) #When can I go needed - Troponin, CK-MB
wrestling?
Fear of dying and sense of
terror?

Injury to your chest?

feel tired?

2 18 yo M c/o OPD CSF AA - MMSE Wrestler( foot ball Drug counseling , - HOCM Orthostatic Vitals
LOC Before the episode -General player), Coatch Diet counseling. - Hypoglycemia CBC, Lytes, s.glucose
-Thyroid brought him here , - Drug Induced Urine Toxicology
During the episode -Extremitie light headenesss, -Hypotension EEG, CT Head,MRI
After you regain your Heart(JVD/C had 3 episodes of -Heat exhaustion Brain
consciousness: arotid) racing heart 2 weeks EKG CXR
-Rapid before,Uses Ecstasy Holter monitoring
Thyroid>> Do you feel hot Neuro(CN+ 2 years before and TEE,TTE Echo
intolerance ?
MRSP) the last intake 2 days
ago / uses also angel
dust, skipped a meal
3 70 yo F c/o OPD-CSF-AA + FINISH -General H/O UTI's,Has been Keigls Exercise, - Stress -Genitourinary exam
incontinence PUBC -Thyroid suffering from No water, No Incontinence -CBC w/ diff, ESR,
+Do you feel SAD -Extremities incontinence for 30 alcohol and no - Urge CRP, BUN, Creat,
-Abdomen years, problem caffeine intake Incontinence Micro albumin,
(CVAT) worsened 6 mo ago, before sleep, -overflow s.Glucose, HBA1C
aggrevated by meds, stress incontinence(noct -Urinalysis, Urine
sneezing,6-7 times ) C&S, -Urodynamic
/day drippling. 2 -UTI Testing, IVP,
days before went to - DM induced Cystoerethroscopy, Q
a party, wet her Polyurea tip test
pants. + caffeine ,
+nocturia, Patient
cries, tap shoulder,
affirmation, give a
moment of silence,
offer a tissue. Ask
about impact on life.
DM, Previous UTI
Beware: Long case
4 48 yo F c/o OPD-CSF-AA+CT - MMSE - tremors, irritability -Will need to do - Menopause -Pelvic exam.
not feeling YOUNG/OLD/O&G/ROS -General -Irregular periods3 pelvic exam. In - Perimenopause -CBC w/diff, ESR,
like herself -Thyroid years, Hot Flushes the latter part of -Pregnancy(N, V, Lytes,
lately -Extremitie -?planned baby the day. Breast tenderness) - sTSH, fT3, fT4,
-Abdomen -- -Stress - Generalized sFSH, sLH
-Neuro(CN+ Counseling, Anxiety -US abdomen and
MRSP) -Moderation of - Hypothyroid pelvis, TVS,
Caffeine (if any), - Adjustment -DEXA Scan,
-Menopause Disorder -Repeat pregnancy test
5 70 yo F c/o OPD CSF LIQR AA relation -General Beware: HPI Counsel about -Choledocolithias -Rectal Exam, Vaginal
Abdominal to meal -Thyroid Epigastric while Surgery: Its now - Cholecystitis Exam,
Pain Fever, chills& unusual -Extremities physical gives RUQ, much easier. - PUD - CBC w/diff., Lytes, --
sweeting? (tremor) radiation. Shorter post op - Gastritis Bilirubin, AST, ALT,
-Abdomen Challenge: Afraid of period. Social GGT, ALP, Amylase,
nausea? Vomiting?
(Murphy) Surgery, No worker can Lipase, , H. Pylori
difficulty of swallowing?
Support. provide support. testing
recent changes to your Bowel Counsel about -U/S, CT abdomen&
movements? NSAIDs if any HIDA scan
DO you think I - upper GI Endoscopy
pain related to Menses?
have cancer?
C/P? Do you think my
history of recent travel? family needs
to?

6 40 yo F c/o OPD CSF AA -General COPD 10 years ago, -Physiotherapy is - Asthma -CBC w/diff,ESR /
SOB -Thyroid Pneumonia 6 months needed - Bronchitis sputum for cytology ,
Difficulty of breathing?yes, -Extrem -Have you taken (COPD C/S
Do you have Racing heart like -Chest, Challenging case: the Flu shots? excacerbation) -CXR, CT chest
a horse ? Heart (JVD/ Patient has a long Pneumococcal - Cardiac (MI, -EKG, Echo,
Carotid) typed page of co- vaccine? Ang, CHF) -ABGs Pulse
If
Do you have chest pain?
morbidities and -Have you ever - Pleural Effusion Oxymetry,
yes, OPD CSF LIQR polypharmacy (copy been tested for effusion -Pulmonary Function
AAA it): HIV infection? - Pneumonia Tests,
Robitussin, - Pulmonary -Bronchoscopy
Lisinopril, Embolism
Ipratropium, - Panic Attack
Metoprolol - Pneumothorax
7 70 yoM c/o OPD CSF LIQR AA+ -General Pain in the mid foot , -Foot Care, Htn, - Foreign Body -CBC w/diff, ESR,
Heel Pain WET SURF-D - HCIS -Full Joint No ankle pain, pain DM? - Plantar Faciitis CRP,
Exam is only in the heel -Letter to the -Calcaneal Stress -X-Ray, MRI ankle
(IPROMMR ,Hx of OA in both employer Fracture joint, DEXA Scan
SP), Other knees Hx of Walking explaining your - Calcaneal spur
joint on glass but nothing situation and -Foot Sprain
Palpation entered the heel, Can findings -
you see anything in
my leg? Pt has Htn.
Variation of the
Case: Ankle Pain,
h/o ankle twisting
8 50 yo M c/o OPD CSF AA -General Pt has tenderness Smoking - Chronic -CBC w/Diff,ESR,
Congestion -Thyroid over R Maxillary Sinusitis CRP
Fever, chills& unusual -Extremities Sinus. +ve Sick - COPD -XR CT Paranasal
sweeting? Runny nose? -HEENT contacts. Pt gets - URI Sinuses
Pain? Cough? dry or -Chest angry when you - ABGs, CXR
with mucus? Difficulty counsel about
of breathing?chest smoking( use it is
pain? any pain in your my
stomach area?Recent recommendationk
change in your voice? eep calm..smile)
Rash?Feel fatigue?
Swollen glands
elsewhere all over your
body? Any joint
pains/muscle
aches/vaginal
discharge
9 32 yo F c/o OPD CSF AA -General Pt has amenorrhea Counsel on - Hypothyroidism - Breast Exam, Genital
Fatigue F >>heart failure -Thyroid for 13 months Contraception and - Sheehans Exam
A>> anemia -Extremities (Pregnancy + 4 alcohol Syndrome -CBC w/diff, Lytes,
(blur,palp,diz) -Heart Months Post - Pregnancy -TSH, fT3, fT4, B
T>>thyroid, TB, Tumor Partum), thinning in - Anemia HCG,
I >>infection with HIV her hair, no breast Variation of the - Brain MRI
GI>> malabsorption milk, ETOH +ve, Case:
U>> uremia Rhythm - Postpartum
E>> endocrine: DM Contraception Depression
D>> depression - Caregivers
S>> sleep disorders Fatigue
S>> stress and caffeine - Hypothyroidism
SIGME CAPT
+MMSE
+Relationship with
Baby?
Prenatal, natal,
Postpartum?
10 44 yoF c/o OPD-CSF-AA+CT -General Irregular Patient will ask - Hypothyroidism -Pelvic exam.
Irregular YOUNG/OLD/O&G/ROS -Thyroid periods3years. about Premature - Perimenopause -CBC w/diff, ESR
menses Crampy abdominal -Extremities LMP 2 months ago, Ovarian - Anemia ,Lytes
pain>> OPD CSF LIQR -Heart pregnancy test Failure(iam -Endometroisis - sFSH, sLH, TSH,
AAA negative, Hot flushes young yet I have -Fibroid fT3, fT4, , Fe Studies
4months/y. menupause at -TVS
Crampy pain while such young -Diagnostic
menstruation, heavy age)and laparoscopy
bleeding relieved by *Pelvic exam
Tylenol *Counsel for
HRT?
11 35 /45 yoF OPD CSF AA+ TT- -General Irritable F, Hot -Stress -Panic Attack -Pelvic exam.
c/o CDSM-FAWR -Thyroid flushes, Palpitations, Counseling -Anxiety -CBC w/diff,ESR
Nervousness +MMSE+ -Extremies Excessive sweeting, - -TSH, fT3, fT4
(Snapping) Amenorrhea Old -Heart ask for mood Pheochromocyto -EKG, Echo, Holter
patient(>48 y)HAVOC -Neuro(CN+ m -EEG
MRSP) -Menupause
-Arrhythmia
-MVP
-Caffeine/ Stress
-Hyperthyroidism
-Hypoglycemia
12 Phone OPD-CSF-AA + N/A Consent -Bring the Child - Rota Virus -Physical Exam,
encounter, 3.5 week kid c/o -Can I give him - Bacterial -CBC / diff Lytes,
Grandfather FGEAV DTI+ diahrrea, no fever cow's milk? Diarrhea -Rota Virus EIA
of a baby PMAHUG EASFS BP -baby given Allergy aggrevate -Malabsorption -Stool culture ova and
w/diarrhea N D expressed breast his condition, - Gastroenteritis parasitology, stool pH,
milk ORS (Pedialyte or - Food Poisoning -stool for reducing
+ Dehydration Mother met with an Home-made 1L substance
accident that make of water<5 cups>
her ill?? +1/2 tsp. salt+6
tsp. sugar) can be
used until you get
him to thehospital
-If bluish
discoloration or
distress>> call
911
Notransportation?
13 62 yo M c/o OPD CSF LIQR AA relation -General *Pt works as a NSAIDs and - GERD -CBC w/diff, Lytes
Abdominal to meal -Thyroid coach, Nice man. MEDEM - Gastroparesis -Manometric Studies,
pain Fever, chills& unusual -Extremities *History of Monitor - Gastritis pH monitoring
sweeting? -Abdomen DM/hypercholestero Education - PUD -Gastroscopy, H. Pylori
lemia Diet - MI (DM masks tests,
nausea? Vomiting?
*Intake of NSAIDs? Exercise Chest Pain, comes -s Glucose, HBA1C,
difficulty of swallowing?
Ibuprofen for Joint Medication w/atypical pain) , LFTs
Any recent changes to your Pain, *Epigastric
Bowel movements? pain related to meals
C/P?
history of recent travel?
14 16 yo F c/o OPD CSF AA -General 16 yo high school F -Stress counseling - Caregiver - Breast Exam, Genital
fatigue F >>heart failure -Thyroid takes care of 2 -Talk to mom fatigue Exam
A>> anemia -Extremities sisters, not -Talk to loved one -Hypothyroidism -CBC w/diff, Lytes,
(blur,palp,diz) -Heart interested, tired, Hx -Involvement in - Atypical -TSH, fT3, fT4, B
T>>thyroid, TB, Tumor of wt gain, insomnia pleasurable Depression HCG,
I >>infection with HIV constipation, low activities - Anemia - Brain MRI (exclude
GI>> malabsorption mood, decrease both - Pregnancy pregnancy first)
U>> uremia energy and interest,
E>> endocrine: DM no suicidal ideation,
D>> depression appetite and
S>> sleep disorders concentration are
S>> stress and caffeine good.Menst.Hx is
SIGME CAPT important
+MMSE
15 35 yo F Introduction+What's N/A Pt calls with C/O Bring the Patient, - Paralytic ileus -Complete Physical
constipation the patient name? constipation Post Meds - Drug induced Exam,
Phone what's his age? What's cholecystectomy Paralytic ileus - Rectal Exam,
Encounter his relation with you? POD 5th.passed stool - Diverticulosis -Stool for Occult
where is he right now? once in the hospital, - Low fiber diet Blood, CBC w/diff,
hasn't passed since - Gallstone Lytes, s Glucose,
OPD CF AA that induced Ileus -Barium Enema, CT
+abdominal pain and Abdomen,
Was this constipation fever - Colonoscopy
associated with special Prescription:
event?Fever, chills& Vicodin, Robitussin
unusual sweeting? (1 tab codeine/6
nausea? Vomiting? any hour, 2 tabs
bouts of Diarrhea in codeine/6 hours)
between? any blood ?
any change in the stool
consistency? Caliber?
How many motions /day
or /week?on special
diet?any pain when you
move your bowel?
desire to evacuate your
bowel but you can
not?Any pain in your
stomach area?Thyroid?
Medications?ROS
16 70 yo M c/o Introduction+What's N/A Post R hip Get him to the - Drug induced IC -Physical Exam and
Confusion. your father's name? replacement for OA Hospital ASAP. Bleeding MSE,
Phone what's his age? What's 4 weeks ago, NPO? - Delirium due to - CBC w/diff, PT, PTT,
Encounter, his relation with you? clotting, Blood Discontinue (Metabolic INR, Lytes (Complete
Daughter where is he right now? Thinners, Rehab. for Drugs? encephalopathy BMP), s Glucose,
calls the hip, Home for 3 /Electrolyte -CT Head, MRI Brain
OPD CF AA days, since then Imbalance)
Confused. - Hypoglycemia
associated with special Not eating well/fluid
event? intake
Fever, chills& unusual
sweeting?
FORGETS HIM +
DEATH SHAFT +
MMSE

17 40 yo F c/o OPD CSF AA -General Frank blood in stool, - Anal Fissure -Rectal Exam,
Blood in -Thyroid pain while passing, - Angiodysplasia - CBC w/diff
Stools Fever, chills& unusual -Extremities Pt is having anal sex, - Recurrent -Occult Blood in
sweeting?ABCDO -Abdomen asks you is it Haemorrhoids Stools, Leukocytes in
nausea? Vomiting? because my sexual - Diverticulosis/ stools,
practices? You will Diverticulitis -
Bowel movements?
ask her are you by - Colon Cancer Anoscopy,Colonoscopy
Diarrhea,
any chance having - Low Fiber diet , -Flexible
constipation,Heart burn
receptive anal proctosigmoidoscopy
especially related to
intercourse?
food? Yes, for how
Ask about her HIV
long?
status
has a Hx of
when you move your
Haemorrhoids, +/-
bowel? Do you feel that
Constipation, +/-
you have the desire to
LLQ Pain
evacuate your bowel but
you can not

any pain in your

stomach area?

previous history of
chronic bowel
inflammation?/
abnormal tissue growth
inside your bowel?/
radiation exposure?
18 40 yo F c/o OPD CSF AA+ TT- -MMSE Pt recently moved to -Stress - Gen.Anxiety -Pelvic exam.
Nervousness/ OPD CSF OPD CS (How -General Houston 3 months Counseling Disorder -CBC w/diff, ESR
Snapping/Irri this problem bothers you?( do you
have any idea what may have
-Thyroid ago, change the job, -Cut down coffee - Adjustment -TSH, fT3, fT4, FSH,
table caused that?)F AA AA
-Extremities Electrical Engineer Disorder LH
White lady associated with -Heart Husband with son - Stress induced -Polysomnography
sweating? -Neuro(CN+ living elsewhere , Caffeine Intake
MRSP) she is worried about - Social Phobia
drink coffee??drink them -Hyperthyroidism
anything containing 4-5 cups of
caffeine? coffee/day, H/O
insomnia, inc.sleep
How many hours of latency(lies down
sleep are you getting?? @9,sleeps @12)
eel hot intolerance, Do
you feel heart racing
like a horse? have
shaking movements in
your hand?
headache/feel light
headed /blarry vision?
numbness or weakness
in arms or legs?
S Stress, Sad
SIGME CAPT
Amenorrhea Old
patient(>48 y)HAVOC
19 60 yo M c/o Fever, chills& unusual -General Cough induced by -Staying away - CHF -CBC w/diff,ESR, CRP
Cough sweeting? cough dry -Neck Exercise, Wakes from what is - Angina - Allergy Challenge
or with -Extremities patient up from calling your - Exercise Test, PFT,
mucus?ABCDO -Chest Sleep(PND), allergy induced - CXR, CT Paranasal
C/P>>>>> LIQR -Heart Palpitation, no -Carry inhaler Asthma Sinuses,
AAwheezes? Any orthopnea or ankle always -arrythmia -Sputum Analysis
edema -Breathing Remember: (C&S, Acid Fast), TB
difficulty of breathing
excercise PLEURAL CAP PCR, PPD -
? Racing heart like a
Bronchoscopy, , EKG,
horse ?Runny Echo,
nose?any secretions -LDH, CPK, Troponin
behind your
nose?Nasal allergy?
Sore throat?Cough
occur at a specific time
of the day? Specific
season?Recent change
in your voice?Feel
tenderness over your
sinuses?Feel any pain
in your stomach area?
IF YES; does any food
come up? Do you feel
bad taste? Do you have
difficulty of swallowing?
Similar condition?Any
recent travel?PPD
20 60 yo M c/o F >>heart failure -General Maintenance Man, Smoking - Lung Carcinoma -CBC w/diff,
Fatigue A>> anemia -Thyroid Long Smoking - TB -Sputum Analysis, TB
(blur,palp,diz) -Extremities History, Weight - CHF PCR, PPD, Tumor
T>>thyroid, TB, Tumor -Heart Loss - Anemia Markers (CEA),
I >>infection with HIV -Chest - COPD - Spiral CT Chest,
GI>> malabsorption -Bronchoscopy, EKG,
U>> uremia Echo,
E>> endocrine: DM -TSH, fT3, fT4
D>> depression
S>> sleep disorders
S>> stress and caffeine

Ask TB Questions

21 50 yo black F OPD CSF LIQR AA+ -General Resturant -Heavy Weight - Lumbar Disc -CBC w/diff, ESR,
c/o lower WET SURF-D - HCIS -Back joints manager>>moving Lifting Herniation CRP,
Back Pain -SLRT tables, lower back -Physical Therapy - Lumber Muscle -MRI Lumbar Stage,
*Pain worsened on -Neuro(CN+ pain radiating to the - Bend at knees Sprain CT Back and R Lower
bending>>Prolapse MRSP+gait) leg, worsened on not at back - Lumbar Extremity,
*Pain better on Help her sit bending, used to Sponylosis/ -EMG, NCV
bending>>LS stenosis down resolve earlier with Ankylosing -
Tylenol, attained Spondylitis
menupause - Tumor in
Vertebral Canal/
lumbar Canal
Stenosis
- Vertebral
Compression/oste
oprotic Fracture
22 30 yo M c/o OPD CSF LIQR AA+ -General Contractor/ Heavy Weight - Lumbar Disc -CBC w/diff, ESR,
R Back Pain WET SURF-D - HCIS -Back Joint Construction Lifting Herniation CRP,
-SLRT Worker, Pain Physical Therapy - Back Muscle -MRI Lumbar Stage,
*Pain worsened on - Radiating to - Bend at knees Sprain CT Back and R Lower
bending>>Prolapse Neuro(MRS Buttocks and R foot, not at back - Lumbar Extremity,
*Pain better on P+gait) Smoker Steroids? Sponylosis/
bending>>LS stenosis Ankylosing
Spondylitis
- Tumor in
Vertebral Canal/
lumbar Canal
Stenosis
- Vertebral
Compression
Fracture
- Steroid induced
Osteoporosis
23 40 yo F c/o OPD-CSF- LIQR AA + General Pain radiates to Drink Water and - Pyelonephritis -CBC w/diff, ESR,
Back FINISH PUBC Abdomen groin, Pt has Hx of Cranberry Juice - Nephrolithiasis CRP,
Pain(Renal CVAT Stones, Mild Fever - UTI -Urinalysis, Urine
pain) Bleeding from other Back joints - Renal Cell C&S, BUN, Creat,
orifices? Carcinoma Micro albumin
, -U/S Kidneys B/L, CT
Abdomen
-Cystourethroscopy,
IVP
24 50 yo M c/o OPD CSF AA -General Smoking for 30 year, *Physiotherapy is - Pneumonia -CBC w/diff,ESR /
SOB -Thyroid Yellow Sputum, Hx needed - Exacerbation of sputum for cytology ,
( if ER case Difficulty of breathing? Yes, -Extremeties of COPD, Htn, *Have you taken COPD C/S
not in Racing heart like a horse -Chest Orthopnea,PND the Flu shots? - CHF -CXR, CT chest
distress>.do ?Yes, -Heart Wheezes, O2 Pneumococcal -Ca lung -EKG, Echo,
not shake Therapy, ankle vaccine? -ABGs Pulse
hands) Chest pain? If yes, LIQR swelling, * Have you ever Oxymetry,
AAA Increase.cholesterol, been tested for -Pulmonary Function
Increase BP HIV infection? Tests,
Lungs>Physiother -Bronchoscopy
apy and breathing
exercise
Heart> restrict
salt and fluids
25 60 yo M c/o OPD CSF AA -General Family Hx of Colon Smoking - Colon -Rectal Exam,
Fatigue F >>heart failure -Thyroid Cancer, Weight Dont forget to carcinoma -Stool for Occult
A>> anemia -Extremeties Loss, Smoker ask about - Lung Carcinoma Blood,
(blur,palp,diz) -Chest Colonoscopies - Anemia -Colonoscopy,
T>>thyroid, TB, Tumor -Heart Abdomen - TB -Spiral CT Chest,
I >>infection with HIV -Abdomen Questions? -ABGs,
GI>> malabsorption Diet -CBC w/diff, Iron
U>> uremia Studies, vit B12,
E>> endocrine: DM -Sputum Analysis if
D>> depression applicable
S>> sleep disorders
S>> stress and caffeine
SIGME CAPT
26 16 yo F c/o OPD CSF AA -MMSE Constipation, Stress Counseling - Hypothyroidism -CBC w/diff, , Iron
Fatigue F >>heart failure -General Weight gain, - Adjustment Studies, vit B12,
A>> anemia -Thyroid Problems at Home Disorder -TSH, fT3, fT4, B
(blur,palp,diz) -Extremities - Depression HCG,
T>>thyroid, TB, Tumor -Heart - Anemia -Neck US for thyroid
I >>infection with HIV gland
GI>> malabsorption - Brain MRI (exclude
U>> uremia pregnancy first)
E>> endocrine: DM
D>> depression
S>> sleep disorders
S>> stress and caffeine
SIGME CAPT
+MMSE

27 25 yo M c/o OPD CSF LIQR AA -General Rock Climber, sharp Marijuana - -CBC w/diff, ESR,
Chest Pain Difficulty of breathing? Yes, -Thyroid knife pain H/o Costonchondritis CRP,
-Extremities Asthma, Use of - Muscle Sprain -CXR, CT chest,
Racing heart like a horse ?Yes,
-Chest Marijuana, Shoulder - Rib Fracture shoulder joint
Feel burning pain in your -Heart pain (Diff between - Pericarditis -PFT
chest? -Joint radiation and - URI -EKG, Echo
In young patient: concurrent pain), - Exercise - Troponin, CK-MB
Fever induced Asthma
+what's your hobbies?

Fear of dying and sense of

terror?

Injury to your chest? Do you

feel fatigue?
28 32 yo F c/o OPD CSF AA -MMSE Pt Planning Stress Counseling PAPA MCH -CBC w/diff,
Heart Racing -General wedding, PhD - cut down on - Panic Attack - Urinary VMA,
Sweating? Drink -Thyroid student coffee and high - Anxiety (GAD) -EKG, Cardiac Echo,
coffee? Drink anything -Extremities Variation of the energy drinks - -TSH, fT3, fT4, s.
containing caffeine? -Heart same case: Pheochromocyto Glucose
Hours of sleep?Stress -Neuro(CN+ *2-3 Weeks ago she ma -MSE (written if not
due to coming MRSP) went to the ER for - Arrhythmia done)
event?Headache/any Dont forget numbness of both - MVP
dizziness/blurring of to test for hands, and is now - Caffeine/Stress
vision? numbness or tremors coming for follow- induced
weakness in arms or up, h/o carpal tunnel - Hyperthyroid/
legs?Difficulty walking Syndrome in College Hypoglycemia
* Sometimes
especially
*2-3 cups of coffee Hyperthyroidism
upstairs?Need many
with 2-3 high energy w/ Carpal Tunnel
pillows to sleep? drinks /week, stress
Swollen ankles?travel at school work
recently? Have you had initially 1-2 min.
a prolonged now 3-5 min.
immobilization?chest
pain? LIQR A?Do you *c/o hypothyroid on
have any difficulty of synthyroid>>
breathing? doubling the dose,
HTN, Family history
cough? Is the cough dry of sudden
or with mucus?feel hot death,anxious
when others not ?
shaking movements in
your hands?
29 25 yo M c/o OPD CSF AA -MMSE Pt. smokes Smoking and - Anemia -CBC, Lytes,
Fatigue F >>heart failure -General marijuana, takes marijuana - Drug related -s glucose, Fe studies,
A>> anemia Thyroid herbal medicine Fatigue Vit B12,
(blur,palp,diz) Extremities - Chronic fatigue -TSH, fT3, fT4,
T>>thyroid, TB, Tumor -Heart syndrome -polysomnography
I >>infection with HIV -Neuro(CN+ - Obstructive
GI>> malabsorption MRSP) sleep apnea
U>> uremia - Depression
E>> endocrine: DM -
D>> depression Hypothyroidism?
S>> sleep disorders
S>> stress and caffeine
SIGME CAPT +MMSE
*Sleep analysis
*Diet analysis
30 35 yo F c/o OPD CSF LIQR AA -General Usually Female Pt Stress MM IT -CBC w/diff, Lytes,
Headache -Thyroid Different scenarios: counseling,Yoga ACHES ESR, -CT Head, MRI
Any fever, chills? -Extremities #Headache+ floating Caffeine Intake - Meningitis Brain,
Neck stiffness? Any -Complete white spots+ pain - Migraine -LP, CSF Analysis
rashes? Any dizzziness HEENT with behind the - Inc. Intracranial (C&S, Cl, Gluc),
lose consciousness? fundoscopy eye+Blurring of P -U/S Carotid, Temporal
suffer from seizure?Any vision - Tension a. Biopsy,
weakness or numbness -Neuro with Headache, - Paranasal Sinuses
in your body? Any CN+ #Headache +bright -Temporal Imaging
visual disturbances +- MRSP light problem+neck Arteritis
before the attack? pain +meningeal stiffness+sore - AV
with looking to the signs throat+Runny nose Malformation
- Hypertension
lights?Any watery eye?
#Young F+ - Eye
Any runny nose?Any
photophobia+vomiti Problems(ref.erro
tenderness on your ng+Babiniski r)
face?Pain in your jaw? sign+the mother has - Subarachnoid
Any pain in your migraine Hge, Systemic,
neck?Speech Sinusitis
difficulties? attack wake
you up from sleep?Any
nausea? Have you
vomited?
ABCDO?Drink
coffee?anything
containing caffeine?
menstruation? Do you
use OCP?Stress/sad
31 65 yo M c/o OPD CSF LIQR AA - MMSE Pt is a known Hypertension - Arrhythmia -CBC w/diff, Lytes,
LOC -General Hypertensive, +/- - TIA ESR, -CT Head, MRI
OPD CSF AA
-Thyroid Lightheadedness, h/o - Drug Induced Brain,EEG
Before the episode -Extremitie MI 5 years ago, Hypotensioin -LP, CSF Analysis
Heart(JVD/C Checking his mail/ - Stroke (C&S, Cl, Gluc),
During the episode
arotid) Grocery Store - Complex Tonic -U/S Carotid, Temporal
After you regain your -Rapid +ve tearing Clonic Seizures a. Biopsy,
consciousness: Neuro(CN+ - Hypoglycemia -EKG,Echo
Thyroid>> Do you feel hot MRSP) - Intracranial - s Glucose, Lipid
intolerance N.B. Make Tumor Profile, Urine
Sure to test - Severe Aortic Toxicology
stress in your life? Gait, Stenosis -ABG, V/Q scan
Cerebellum, - Vasovagal
Romberg, attack
Babinski

32 Pediatric Introduction..+Why are N/A 8 yo Child c/o pain * Bring Child to - Somatoform -Physical Exam, Rectal
Phone Call you here today? If after breakfast, not Hospital, support Disorder Exam,
8 yo M c/o telephone call>>Why going to school. new her Psych - Adjustment - CBC w/diff, Lytes
Abdominal are you calling today? family member with * Is my child Disorder -Stool Analysis for
Pain Down S, too much faking?> common - Low Fiber Diet ova,cysts and parasites,
What is your child homework, New in his age group, - Malingering? , Stool Culture
name?How old is School Teacher with him -Blood( pb) level
he/she?Where is *can get well -WISC-R
name's right now? Appointment 3 -CT Abdomen
days later so
OPD-CSF-AA + should I bring
FGEAV DTI+ him now?
PMAHUG EASFS BP
N D+SIGMECAPT
33 Pediatric Introduction..+Why are N/A *18 months, ill *Bring Child to - Febrile Seizures -Physical Exam,
Encounter you here today? If contact @ day care. Hospital ASAP - Meningitis -CBC w/diff, Lytes,
with mother telephone call>>Why Ask mother to sit - Encephalitis ESR,
of 3 yo M c/o are you calling today? down *Make the pt lie - Tonic Clonic -EEG, LP, CSF
Seizures *Fever 2 days on flat surface Seizures Analysis, -CT Head,
What is your child before,armpit and *put on belly if -Sepsis MRI Brain
name?How old is thigh she vomits -Blood culture
he/she?Where is * Runny nose in the *Sponging to -Urine analysis, culture
name's right now? morning, rolling of control fever
the eye *mother Q: can I
OCDCFAA *Seizures for 2-3 go to ICU?/Does
FEVER CUB D TI min. only/episode it affect his brain?
PMAHUG EASFS BP * Bp=90/60& breast
N D+ feeding>>give breast
feeding
34 45 yo F c/o OPD CSF AA+Feel -General Hispanic, Physical Therapy - Cervical disc -CBC w/diff, , ESR,
Numbness fever CNS M VAN -Thyroid Hairdresser, Pain herniation - EMG Nerve,
and JMM+MSE -Extremities just got better on the - Ulnar nerve Conduction Studies,
Weakness of Neuro(CN+ day of the exam, +ve compression -X Ray Shoulder,
Left Hair loss? Cold MRSP) previous episodes - Cervical canal Elbow, Wrist and
arm=(Weakn intolerance? TB and -Joint stenosis Hand, CT,
ess+Neck Respiration in cases of - Thoracic outlet - s. Calcium, Vit. D,
pain) Neck Pain. Dont syndrome -DEXA Scan
Forget: - Cervical rib
Phalen or - Muscle sprain
Tinnel - Cervical
Vertebral
Dislocation
35 60 yo F c/o OPD-CSF-AA + -General Pt is talkative, Smoking HITTERS -Genitourinary Exam,
Bloody Urine FINISH PUBC -Thyroid Painless Haematuria, Say Genitourinary - Haematologic -CBC w/diff, ESR,
-Extremities Smoker, Multiple Exam in the later - Infection - s Creat, BUN,
-Abdomen UTI, CVA -ve part of the day - Tumor - Renal U/S,
(CVA) ? taking NSAIDS for - Exercise -Pelviabdominal,CT
artheritis,Hx of sore - Renal Disoder -IVP
throat, No Hx of wt - Stones -Cystourethroscopy,
loss In this case: -Microalbumin, s
- Bladder Cancer Ferritin, -Urinalysis,
- UTI/ Cystitis Urine C&S,
- -PT, PTT,
Glomerulonephrit -Urine Cytology, Red
is Cell Casts
36 70 yo M c/o OPD CSF LIQR AA+ General Wake up with neck Physical Therapy/ - Cervial Disc -X Ray Cervical Spine
Neck Pain WET SURF-D - HCIS Neck pain, Weakness and neck collar Herniation P/A and Lateral Views,
Joint Numbness of Left - Cervical -MRI C spine,
Neuro Arm, FHx of Vertebral Fracture -DEXA Scan,
Osteoporosis - Osteoarthritis -s. vit D, s. Calcium,
Variation: 30 yo m - Cervical -CBC w/diff, Lytes,
felt before from Spondylosis ESR, Rh Factor.
horse 3 months ago, - Neck Muscle
pain started Sprain
suddenly, neck - Rheumatoid
stiffness, radiating to Arthritis
the RUL (Sublaxation of
Atlanto Axial
Joints)
37 Pediatric Introduction+Why N/A Fever and Rash Bring Child to - Fifth Disease -Physical examination.
Case c/o are you here today? Hospital - Varicella - Pneumatic Otoscopy,
Fever - Scarlet Fever Tympanometry
Mother What is your child - Otitis Media - Parvo Virus B19 IgM,
sitting and name?How old is -Varicella Ab Titre,
tells he/she?Where is -Skin Lesion Scrapings
name's right now? with C&S
OPD-CSF-AA +CUB
FEVERS +PMAHUG
EASFS BP N D+
Fever Analysis?
Distribution of Rash?
38 60 yo F c/o OPD CSF AA - MMSE HTN,feeling TV (Blue Light - Brief Psychotic - CBC w/diff, MRI
Sleeping -General difficulty falling a interferes with Episode Brain, -CT Head, EEG,
Problems 4D-N-4S-T -Thyroid sleep 4:5 weeks Circadian - Generalized Polysomnography,
SIGME CAPT -Extremities Challenge: Pt Rhythm), Anxiety or PTSD - Sleep Pulse
Neuro(CN+ doesnt want to let Depression, (in variation) Oxymetry,
MRSP) Look go of her bag, +/- stress, Naps, - Depression with -TSH, fT3, fT4,
For tremors, visual Caffeine, Psychotic -Urine toxicology
DTRs(thyroi hallucination,Delusi Relationship? Features
d) on that People in the *Doc, am i going - Schizophrenia
bank want to rob her. mad? - Drug Induced
Variation of case: Psychosis
Patient was robbed -Hyperthyroidism
before - Obstructive
Sleep Apnea
39 45 yo M c/o OPD CSF LIQR AA General *Pt is having and Safe Sex, Tell * Epidydimitis -Complete Urogenital
Testicular -Thyroid affair but does not Wife, Consent for *Gonococcal/chyl Exam,
 Pain( back pain? -Extremities tell at first HIVtesting amedial orchitis -CBC w/diff, U/S
abdominal Abdomen *pain relieved by *prostatitis -Pelviabdominal, CT,
pain in door any groin swelling? (CVAT) lifting legs *Testicular Urinalysis,
way your testis hang down * Ask: Are you Torsion -Analysis of discharge
information) than normal? being monogamous? -*Hernia if any (Gram Stain,
*Yellow C&S),
a history of any injury to discharge/Itching -VDRL, RPR,
your testis? Chlamydia and
Gonorrhea PCR, HIV
noticed Any redness?/ testing
Hotness?/ Swelling? In
your tesis?
any discharge from
your penis?ABCDO
Any problem with
erection?/ Or the desire
to have Sex?/Is the
ejaculation
painful?/Does it contain
blood?
Any Joint pain? Any
Rashes
+ FINISH PUBC?

40 25 yo M c/o Do you have Fever, -General +ve Tenesmus (Do - IBD -Rectal Exam,
Diarrhea chills& unusual -Thyoid you have a sense of - Malabsorption -CBC w/diff, Lytes,
 sweeting? -Extremities incomplete - Infection ESR
-Abdomen evacuation after -Stool C&S,
ABCDO defecation), No Leukocytes in Stools,
associated with travel History Stool for ova,cysts
vomiting? Any pain in Occult blood in Stools,
your stomach -Colonoscopy,
area?LIQORAA -CT Abdomen
-,
diarrhea related to
food? eat recently eat
uncooked? unusual
food? Dairy products ?
Sea food? Junk food?
regular bowel
movements before? Any
Excess laxative use?
use antibiotic recently?
similar condition?
recent travel?
Wt loss,shaking,hot
intolerance?
Joint pain? feel dizzy
when you stand up?

41 30 yo F c/o Fever, chills& unusual -General *Dry Cough, Drug Counseling - Exercise -CBC w/diff,
Cough sweeting? cough dry -Thyroid *Pt is on Captopril Induced Asthma - -CXR, Chest CT,
or with -Extremities *Post nasal drip - Allergic Asthma PFT,
mucus?ABCDO -HEENT *nocturnal cough - Drug induced -Allergy Challenge
C/P>>>>> LIQR (sinuses) ?seasonal - Post Nasal Drip Test, PPD,
AAwheezes? Any -Chest allergies/variation Remember: -Bronchoscopy
-Heart PLEURAL CAP
difficulty of breathing
? Racing heart like a
horse ?Runny
nose?any secretions
behind your
nose?Nasal allergy?
Sore throat?Cough
occur at a specific time
of the day? Specific
season?Recent change
in your voice?Feel
tenderness over your
sinuses?Feel any pain
in your stomach area?
IF YES; does any food
come up? Do you feel
bad taste? Do you have
difficulty of
swallowing? Similar
condition?Any recent
travel?PPD
42 65 yo F c/o OPD CSF LIQR AA -General Pain ppt by heavy - MI -CBC w/diff, Lytes,
Heartburn relation to meal /Radiation? If Yes -Thyroid meals and radiates to - GERD -CXR, Cardiac Echo,
Heart Questions?
Fever, chills& unusual -Extremities left neck for 2-3 - Angina -CPK, LDH, Troponin,
sweeting?nausea? -Heart minutes -EKG,
-Abdomen - Ph Monitoring,
Vomiting?ABCDO
Manometry,
Does any food come - Upper endoscopy
up? Do you feel bad
taste? Do you have
difficulty of
swallowing?
pain in your stomach
area? OPD CSF LIQR
AA,Any recent changes
to your Bowel
movements? Diarrhea,
constipation / Bloody
stool?
Any change in your skin
color? Any itching? Any
joint pain?Any
rashes?recent travel?
cough? mucus?ABCDO
Stress:Does this
problem increase in
times of Stress?DM?
43 25 yo F c/o OPD CSF LIQR AA+ -MMSE Patient is victim of Verbalize the - Domestic - CBC,
Jaw Pain WET SURF-D - HCIS -General abuse , Jaw pain, presence of Violence -CXR, XR Wrist,
-Thyroid wrist bandage lesions, - Depression -X Ray Skull and
+ -Extremities Recognize -Hypothyroidism paranasal Sinuses
If you find Bruises or -HEENT Severity, - sTSH
suspect a case of abuse Joints(Jaw, Emphasize Trust
Wrist) and
SAFEGARDS Confidentiality,
Ensure Safety,
Measures for
Children,
Presence of
Shelters and
Social Workers,
Need to document
abuse
photographically

44 50 yo M c/o OPD CSF LIQR AA+ General Pt says he wants an SPORTS -CBC w/diff, ESR,
Knee Pain WET SURF-D - HCIS Joint orthopedic doctor Septic Arthritis CRP,
instead of you Pseudogout, -Knee Aspiration
Psoriatic arthritis, w/C&S, ANA, Rh
Patello-Femoral Factor, Synovial Fluid
Pain Syndrome Analysis,
Osteoarthris - Blood Culture, X
Rheumatoid Ray, MRI
Arthritis, Reiters
Tophi of Gout,
Trauma
Sac (Bursitis)
45 70 yo M c/o OPD CSF AA -MMSE -I would like to - Vascular -CBC w/diff,
Memory Do you have any idea what -General ask ur permission Dementia Lytes,ESR,CRP
Loss might caused that? -Thyroid to speak with ur - Alzheimers - CT head, MRI Brain,
-Extremities family - Depression -Doppler on Carotids,
What things do you usually -Neuro - Normal Pressure - s B12, VDRL,
forget? Who is concerned
(CN+MRSP) 2-i would like Hydrocephalus - s TSH
with your matter is it you or
u&ur family to - B12 Deficiency
your family?>>
meet a social - Hypothyroidism
DEATH SHAFT+ worker to assess - Neurosyphilis
FORGETS HIM +
home safety (if Promiscuous)
&supervision - TIA
- CJD

46 Old lady c/o OPD CSF AA -MMSE Old lady divorced *Stress -OSA - CBC w/diff, Lytes
Fatigue -General recently, feeling low, counseling -Hypothyroidism -MRI Brain, -CT Head,
FATIGUED SS -Thyroid snoring at night, +wt *Sleep on side -Adjustment -EEG,
SIGME CAPT + -Extremities gain, met with car *Try losing disorder -Polysomnography,
-Heart accident 5 weeks weight -Acute stress - Sleep PulseOxymetry,
*Sleep analysis -Neuro ago, ask for disorder(accident) -TSH, fT3, fT4,
flashbacks or night -BMP
*Diet analysis mares -Urine toxicology




47 F c/o fatigue OPD CSF AA -MMSE F with 2 children Support>> -postpartum - CBC w/diff, Lytes
-General first 1 year old, *discuss with depression - TSH, fT3, fT4,
FATIGUED SS -Thyroid second 1 month old your loved ones -Caregiver fatigue -BMP
SIGME CAPT +MMSE -Extremities from 3rd trimester of about this -Anemia -iron studies
Heart(anemi 2nd child she is not problem -Hypothyroidism
*Sleep analysis a) feeling well>>Hair *Do not pick up
- thining, wt loss after the baby by
*Diet analysis Neuro(CN+ pregnancy,family yourself alone,
MRSP) H/O SLE, scared have one around
that she might drop *ask if she want
the baby, brown to harm baby>>
stool 10 days You will be kept
under observation
48 30 yo M c/o OPD CSF LIQR AA -General +ve Tearing Stress, Caffeine -Cluster -CBC w/diff, Lytes,
Headache -Thyroid Headache ESR, -CT Head, MRI
Any fever, chills? -Extremities - Migraine Brain,
Neck stiffness? Any -Complete -Tension -LP, CSF Analysis
rashes? Any dizzziness HEENT with headache (C&S, Cl, Gluc),
lose consciousness? fundoscopy -Temporal -U/S Carotid, Temporal
suffer from seizure?Any arteritis a. Biopsy,
weakness or numbness -Neuro with - Paranasal Sinuses
in your body? Any CN+ Imaging
visual disturbances +- MRSP
before the attack? pain +meningeal
with looking to the signs
lights?Any watery eye?
Any runny nose?Any
tenderness on your
face?Pain in your jaw?
Any pain in your
neck?Speech
difficulties? attack wake
you up from sleep?Any
nausea? Have you
vomited?
ABCDO?Drink
coffee?anything
containing caffeine?
menstruation? Do you
use OCP?Stress/sad?
48 68 yo m c/o OPD CSF AA -General 68 yo f BP= 160/90, *Alone, drive -- Orthostatic -CBC w/diff, Lytes,
LOC Before the episode -Thyroid 2 min. LOC while he *Skip meals hypotension ESR, -CT Head, MRI
-Extremities is shopping, noticed - TIA Brain,EEG
During the episode -Heart by wife .HTN 10 y - Arrhythmia -LP, CSF Analysis
After you regain your (carotid ago, on diuretics, - Drug Induced (C&S, Cl, Gluc),
consciousness: /JVP) skipped meal, , her Hypotensioin -U/S Carotid, Temporal
Neuro sister has H/O Breast - Stroke a. Biopsy,
Thyroid>> Do you feel hot (CN+MRSP) cancer, father died - Complex Tonic -EKG,Echo
intolerance suddenly due to MI Clonic Seizures - s Glucose, Lipid
R/O vasovagal attack - Hypoglycemia Profile,
- Intracranial -ABG, V/Q scan
Tumor

50 58 yo m c/o OPD CSF AA General 58 yo f BP= 160/90, *Alone, drive - Orthostatic -CBC w/diff, Lytes,
LOC Before the episode Thyroid 2-3 min.LOC, *Skip meals hypotension ESR, -CT Head, MRI
Extremities passed out yesterday - TIA Brain,EEG
During the episode Heart after morning walk, -Hypoglycemia -LP, CSF Analysis
After you regain your (carotid felt light headed with -arrythmia (C&S, Cl, Gluc),
consciousness: /JVP) passed out, H/O - Drug Induced -U/S Carotid, Temporal
Neuro similar c/o 6-7 Hypotensioin a. Biopsy,
Thyroid>> Do you feel hot (CN+MRSP) months ago, Paper - Stroke -EKG,Echo
intolerance with TIA. DM( so - Complex Tonic - s Glucose, Lipid
R/O vasovagal attack think of Clonic Seizures Profile,
hypoglycemia not - Intracranial -ABG, V/Q scan
arrhythmia) HTN 10 Tumor
years, on HCT, - Severe Aortic
Amlodipine,Metopro Stenosis-VVA
51 45 yo OPD CSF LIQR AA+ -General Foot ball or?? Rest -RC tear -XR shoulder
shoulder pain WET SURF-D - HCIS -Thyroid Player, crackling Physiotherapy - sub acromial -MRI shoulder joint
-Extremities sound or pooping after the pain bursitis -Arthroscopy of
DO NOT SHAKE -Joint>> sound, pain allover, subside -ligament injuries shoulder joint
HANDS IPROMMRS numbness, ask if -Shoulder -CBC, ESR,CRP
P pillows needed to dislocation -BMP
:Dugas rest
tes/Neer
test/Drop Variation:black f,
arm test wake up, previous Give me
Drop injury while steroids>>
arm>>RC swimming uses hot When can I go
Neer's T>> compress, similar back to work
supraspinatu episodes before
s tend.,
subacromial Black m with UL Rest -Carpal tunnel -XR wrist
burs. wrist pain increase Physiotherapy syndrome -MRI wrist
52 48 yo m with OPD CSF LIQR AA+ General @ night , radiating after the pain -OA wrist (first -NCV,EMG
Wrist pain WET SURF-D - HCIS -Thyroid to arm subside MCP) -CBC,ESR,CRP
-Extremities Tinel + -Forearm median -Ca++ profile
DO NOT SHAKE Joint>> Phalen +(10 s nerve -BMP
HANDS IPROMMRS spasms) compression
P Numbness+ -Hypothyroidism
H/O trauma to the -#
wrist was a
mechanic now works
on son's car
ROM including
thumb to little finger
53 M with Knee OPD CSF LIQR AA+ General H/O trauma with Rest -Ligament injury XR knee
pain WET SURF-D - HCIS Thyroid Bilat. Hip and knee Physiotherapy -Meniscal tear -MRI knee
Extremities OA, popping sound after the pain -OA -Arthroscopy
Joint>> while playing tennis subside -Patellar -NCV,EMG
IPROMMRS bursitis(young -CBC,ESR,CRP
P Can I use guy exclude H/O -Ca++ profile
steroids? OA) -BMP
54 M with Fever, chills& unusual -General Cough with -Cough -Bronchogenic -CBC w/diff, ESR,
cough and sweeting? cough dry -Thyroid hemoptysis, fever, counseling carcinoma CRP
hemoptysis or with -Extremities COPD for 4 years, -Excerbation of - CXR, CT chest
mucus?ABCDO -HEENT cold for 2 weeks, -Do I have COPD -Sputum Analysis
C/P>>>>> LIQR -Chest pneumonia 6 months cancer?>> -Pneumonia (C&S, Acid Fast), TB
AAwheezes? Any -Heart ago, smoking 40 Information that PCR, PPD
years ago you gave me puts Bronchoscopy with
difficulty of breathing
you@ a higher biopsy,
? Racing heart like a
risk but we can -PFT, ABG
horse ?Runny not be sure until
nose?any secretions we .
behind your
nose?Nasal allergy?
Sore throat?Cough
occur at a specific time
of the day? Specific
season?Recent change
in your voice?Feel
tenderness over your
sinuses?Feel any pain
in your stomach area?
IF YES; does any food
come up? Do you feel
bad taste? Do you have
difficulty of swallowing?
Similar condition?Any
recent travel?PPD
55 M c/o OPD CSF AA General Lost 7 Ibs in 2 GERD counseling GERD with CBC/diff, ESR,CRB
dysphagia Thyroid months, difficulty stricture -Ba.swallow
Where does the food Extremities for solids, Pain on Esophageal -Endoscopy
appear to get stuck? Abdomen swallowing, cancer - 24 h PH monitoring
How sever are your heartburn, epigastric Esophagitis -HIV testing after
tendreness Achalasia consent
symptoms? Are you able
to eat a meal?
Is it more difficult to
swallow solid or liquid
or both?
F.B/Caustic ingestion?
Do you have foul
breath? Do you feel
fatigue?
Any recent changes to
your Bowel movements?
Diarrhea,
constipation,Heart burn
especially related to
food/ any bloody stool?
Yes, for how long?
T Thyroid (Wt loss,
Hotintolerance,Shaking)
56 M c/o OPD CSF AA General Forgetting to do Support, -Alzeimer's -CBC,ESR,CRP
confusion Neck things , wife noticed important to talk disease -sTSH
Do you have any idea
Extremities it first, won't repeat 3 to your wife - Vascular -CT head, MRI brain
what might caused that?
Heart words of MMSE, dementia -Doppler carotid
What things do you Neuro HTN, inc.cholest -Hypothyroidism -BMP
usually forget? Who is father has -Senile dementia
concerned with your hypothyroidism, ask
matter is it you or your for mood
family?>>
DEATH SHAFT+
FORGETS HIM +
57 Abdomoinal OPD CSF LIQR AA General RLQ pain x3 -Appendicular -Rectal exam
pain: relation to meal? Abdominal months, 3 episodes, abscess -Pelvic exam
(Psoas,obtur fever up to 104 F, -IBD - CBC with/ diff, ESR,
Fever, chills& unusual
sweeting?nausea?
ator) sexual activity x9 -Gastroenteritis Lytes
Young F Vomiting?difficulty of months used -IBS -US, CT abdomen
with swallowing?Bowel kaopectate (anti - -colonoscopy
RLQ pain movements?urinary diahrreal) ask pain Pseudomembrano
habits?C/P? during menstruation us colitis if AB
recent travel? for endometriosis, used
? vaginal discharge for
PID
-
M with Pain General Pain in the -Acute -Rectal exam
in the Thyroid epigastrium, pancreatitis - CBC with/ diff, ESR,

epigastrium Extremities hypercholestreolemi -PUD Lytes
Abdominal a, +cocaine abuse -Mesenteric -s. amylase, s.lipase
(Murphy) 6 beers/day ischemia(cocaine -US, CT-angio
induced+hyperch abdomen
olesterolemia) -x ray abdomen erect&

supine
M c/o H/o hyper -Rectal exam, FOBT
epigastric choleserolemia, 1 NPO - PUD -CBC/ diff, ESR, CRP,
pain with General hour after eating -Gastritis Lytes
tarry(black) Thyroid,LN food the pain -Mesenteric - Upper GI endoscopy
stool Extremities subsides 2-3 hours ischemia -AXR, US
Abdominal later, using Ibuprofin -Acute -H.Pylori testing
for artheritis pancreatitis -CT angio
-PT,INR, APTT,s am,li
ER case ,35 General Diffuse pain allover NPO -perforation and -Rectal exam
yo M with Thyroid the abdomen, Hi fiber diet peritonitis -CBC/diff, ESR, CRP,
diffuse Extremities vomiting yesterday, -Appendicitis Lytes
abdominal Abdominal sexually active with -Proctocolitis -AXR erect and supine,
pain boy friend(msm), -acutepancreatitis CXR
pain has no relation -CT abdomen
to food, +cocaine -HIV status
and alcohol, - s. amylase, s. lipase
+guarding,
rigidity,psoas

Blood in stool, Colon cancer Rectal exam

55 yo F General travelled to Hawai Frequent meals -IBD -CBC, ESR
c/o blood in Thyroid constipation, father rich in proteins - Infective colitis -Anoscopy,
stool, LLQ Extremities had polyps, son has colonoscopy
pain Abdominal chrons dis. h/o -US, CT abdomen
hemorrhoids -Stool for C/S,
cytology
58 Peditric Introduction+Why are N/A A boy 12 yo Not Must bring him -DM --Physical exam
encounter, you her today? gaining wt ( 70 lbs), in+ -DI -CBC, ESR, CRP
mother in the inc. hunger, Weaning is Parasitic -BMP with HBA1c
room, not What is your child polyuria, polyphagia, important for infestation -Urine for C/S, U/A,
gaining wt name?How old is polydipsia, child growth microalbumin
he/she?Where is name's Nocturia(wetting -stool for ova, cyst/for
?right now? bed), grand mother reducing substance
had DM -Water deprivation test,
OPD- s. ADH
CSFAA+FGVDEA+
ROS
PMAHUG EASFS BP
ND+
SIGME CAPT
How does this affects
your child?
How does it affects your
life?





59 Pediatric Introduction+Why N/A c/o her 12 m yo baby Bring Child to - Meningitis with - Physical exam
encounter are you here today? has fever 3 days, Hospital sepsis - CBC with/diff,
with fever, wets only =3 -OM ESR,CRP
Mother What is your child diabers, earlier 10-15 -Retropharyngeal - Blood culture
roaming name?How old is diabers,+day case, + abscess - CT, MRI brain
around, black he/she?Where is runny nose, -URTI - LP
young F in name's right now? vaccinated 3 weeks -Immunization - Neck XR,
the ICU before, +pain while bactremia Paranasal
OPD-CSF-AA +CUB swallowing , ear sinuses CT
FEVERS +PMAHUG infection 8 months - -UA,UC
EASFS BP N D+ before - -BMP
Fever Analysis?
Distribution of Rash?