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 <3wk:

URTI, cold, sinustis
LRTI (pneumonia, bronchitis, COPD, irritant/smoke/fumes)

ddx - chronic cough:

COPD, asthma, GORD, rhinitis/postnsal, bronchiectasis, ACEI, lung carcinoma,
cardiac failure, psychogenic

Major sx respiratory - must ask about:

cough, sputum, hemoptysis, SOB, wheeze, chest pain, fever, hoarseness, night
sweats, weight loss

Major sx gastro - must ask about:

abd pain, appetite, weight gain/loss, early satiation, post-prandial, N/V, GORD,
dysphagia, defecation (diarrhoea, constipation, incontinence), bloating, bleeding
(melena, hematemsesis, rectal), jaundice, dark urine, pale stools, pruritis,
lethargy, fever

ddx proteinuria:
1. RENAL DISEASE
2. NO RENAL DISEASE (FUNCTIONAL)
Exercise
Fever
Hypertension (severe)
Congestive cardiac failure
Burns
Blood transfusion
Postoperative
Acute alcohol abuse
Orthostatic proteinuria

Causes of positive dipstick test for blood in the urine :

 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 19.2)
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 400 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?
10. What other medications do you take?
11. Have you had heart or blood vessel problems?
12. Have you had overactive parathyroid glands or parathyroid surgery?

ddx dysphagia:
esophageal - esophagitis (GORD), stricture, carcinoma, webs, pouch/diverticuli,
schatzki ring, foreginbody
other - goire retrosternal exetnesion, mediastinal tumor
motility/neuromuscular (solids and liquids equal) - achalasia, diffuse spasm,
scleroderma
pharyngeal - zenker diverticulum
neurological - bulbar, pseudobulbar palsy, MG, polymyositis, myotonic dystrophy

ddx GIT bleeding:

Upper GIT - PUD*, mallory weiss (gastro-esoph jtn), varice, esophagitis,
carcinoma/polyp, dieulafoy ulcer, fistula, AVM, crest, amyloidosis, diathesis
lower GIT - Angiodysplasia** diverticular dz** colonic carcinoma/polyp**
hemorrhoids** anal fissure**, IBD, ischemic colitis, meckels

H-megaly:
massive - mets, ETOH fatty liver, myeloproliferative, RHF, HCC
mod - hemochrom, CLL, NAFLD (DM, obesity), amyloid
mild - hepatits, biliary obstruction, hyatid dz, HIV

pulsatile liver ddx:

TR, HCCC, vascular

ddx = weight gain: depression, eating disorder, hypoTHY, cushing, edema (liver
failure, cardiac, nephrotic)
ddx = weight loss: depression, eating disorder, hyperTHY, amphetamine, chronic dz
ddx incr sleep: depression, hypoTHY, sleep apn, drugs
ddx decr sleep: deprssion, hyperTHY, mania, drugs

smoking history: when started, packs/d, years smoked, previous attempts to quit -
how, associated sx - SOB, wt wloss, hemoptysis, hoarseness
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 -
- i can see you are upset. I was also upset when I got the
results
- 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

ddx
MUSCLE STRAIN BACK
RENAL COLIC
# SPINE

-fracture
-infection
-tumor
-disc
-muscle
-referred (pancreatitis, AAA, posterior penentrating ulcer, kidney stones)

continuous - neoplasia, infection

on waking - depression
activity and relieved w rst - mechanical
worse at rest - inflamm/arthritis
worse stand/walk and relieved sit - spondyloisthesis
worse w sitting + better w standing - disk

throbbing - inflamm/sacroilitis
deep/diffuse - referred
superficial diffuse - muscular
boring - bone dz
stabbing/sharp - sciatica

Probability ddx - IVD, spondylosis/OA, strain/sprain

Serioud ddx - cardiac AAA/hemorr, tumor, infections, OP#, cauda equina

Other ddx - spondyloarthropathy, SIJ, spondyloisthesis, claudicaiton

ix -
- rectal exam - tone
- UA
- thoracic XR
- Lumbar XR

Screening chronic pain

- plain XR
- UA
- ESR/CRP
- ser ALP
- PSA (male > 50 yo)

Specific
- CT-angio
- HLA-B27
- multiple myeloma - EPG

challenging
- Mr Jones I have finished my physical exam and would like to discuss what might be
the cause of your back pain.
- 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, ix, challenging

ddx
- certical strain
- cervical #
- ICH

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, ix, challenging

ddx
-
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 - ddx, ix, challenging

hx
- OG
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.

10. 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.

11. 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)

12. 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
-

13. 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.

14. TELEPHONE - ACE-I Medications refill - ddx, ix, challenging

ddx
-hypertension
-ACE-I cough
-heart failure

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 911
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 911 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

15. 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

16. fever + wt loss + cheesy rash in mouth - no safe sex - ddx, ix, challenging
ddx
-HIV
-pneumocystiis pneumonia
-esophageal candidiasis
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

17. Broken nose + LOC - ddx, ix, challenging

ddx
- broken nose / blunt head trauma with LOC
- substance use disorder - alcohol
- seizure
- cardiogenic / 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

18. TELEPHONE - Adolescent weight loss - ddx, ix, challenging

ddx
-depression
-eating disorder - anorexia
-hyperthyroid
-drug use
-diabetes
-neoplastic
-sport

hx
-

oe
-

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

19. TELEPHONE - Adolesecent depression - ddx, ix, challenging

ddx
-depression MSIGECAPS
-hypothyroid
-drug effects
-primary sleep disorder
-pregnancy

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

20. 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
-
21. 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

22. 50F Cancer checkup - ddx, ix, challenging

ddx
-

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.

23. 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.

24. 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.

25. 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

26. 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.

27. abdominal pain, fatigue, malaise (Domestic violence) - ddx, ix, challenging
ddx

-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.

28. INTERLOCUTOR - Child 18 mo F - vomiting/ diarrhoea - ddx, ix, challenging

ddx
-dehydration
-gastroenteritis
-diarrhoea from amoxicillin

-antibiotic - clostridium difficile

-food poisoning
-food intolerance
-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

29. Life insurance exam - ddx, ix, challenging

ddx
-obesity
-diabetes
-peripheral neuropathy

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

30. INTERLOCUTOR - 15 F - Obesity - ddx, ix, challenging

ddx
- 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.

31. 70M Parkinsons disease + fever + htn + tachypnoea - ddx, ix, challenging
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

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.

32. 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 -
- i can see you are upset. I was also upset when I got the
results
- 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

33. 48 M, wants to quit Smoking, tachypnoea - ddx, ix, challenging

ddx
-emphysema
-chronic bronchitis
-lung cancer

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.

34. Schizophrenia - ddx, ix, challenging

ddx
-schiz
-bipolar 1

oe
-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 ?

35. 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

36. 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.

37. 36M - Back pain - ddx, ix, challenging

ddx
-renal colic
-biliary colic
-testicular torsion

-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

38. 55 M - chronic Diarrhoea + current fever + tachypnoea - ddx, ix, challenging

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
-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.

39. 30 F, Chest pain - GERD - ddx, ix, challenging

ddx
-gord
-pud
-pancreatitis

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

40. 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

41. 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 -
.

42. 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 '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 wet...Response = yes, i will have some clean scrubs right away
43. 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
Chronic cough ddx:
asthma, allergic rhinitis, GORD, COPD, pneumonia, ACE-I, TB, pulmnary malignancy

Acute pelvic pain ddx:

appendicitis, diverticulitis, PID, ectopic, ovarian torsion

Blood in stool:
hemorrhoid, fissure, diverticulosis, infectiuous diarrhoea, IBD

Syncope ddx:
vasovagal, arrhythmia, orthostatic hypo (etoh, alpha blockers, antihypertensives,
dehydration/hemorrhage), aortic stensosi, HCOM

Unilateral swollen leg ddx:

baker cyst rupture, cellulitis, lymphatic obstruction, DVT

Bilateral swollen legs ddx:

HF, nephrotic syndrome, liver failure, obesity, venous insufficiency

vomiting: medications/chemo, GA/opioids, GIT (rotavirus, norovirus, food poisoning,

campylobacter), vestibular, CNS (migraine, mass lesion, AVM, seizure, trauma,,
pseudotumor cerebri, visceral (appendicitis, cholecycstitis, hepatitis, PUD, bowel
obstruction, torsion of gonads), Endocrine, toxins (etoh, DKA), MI, PE, dissection

Tension HA
History Physical
bandlike headachebilateral normal vital signs
last for hours normal neuro exam
recurrent
constant, not throbbing
better with massage

Classic migraine HA
History Physical
unilateral or bilateral throbbing no fever
photophobia, phonophobia normal neuro exam
nausea
aura/prodrome
recurrent

Temporal arteritis
History Physical
age over 50 tender over temporal artery
throbbing one-sided headache
low-grade fever or afebrile
jaw pain
visual changes

Sinusitis
History Physical
recent upper respiratory infection tenderness to palpation of maxillary or frontal
sinus
pain in cheek below eye or toothache inflamed, swollen nasal mucosa
dull, constant ache, worse leaning over
colored nasal discharge and stuffiness

Glaucoma (closed angle)

History Physical
pain centered over eye red eye
first episode decreased visual acuity
dilated pupil

Subdural hematoma
History Physical
history of trauma mental status changes
on warfarin ataxia
headache focal weakness
visual changes

Cluster headache
unilateral lacrimation
sudden and intense blushing of face
pain behind the eye
lasts a couple of hours and gone
recurrent same time of day

Subarachnoid bleed
headache mental status changes
syncope stiff neck
very severe intensity
first episode
vomiting

CHEST PAIN

Acute coronary syndrome

heavy substernal pressure feeling diaphoretic

shortness of breath abnormal vital signs
nausea no high fever
diaphoresis Levine sign (clenched fist held over chest)
lasts minutes to starting couple hours ago
risk factors male over age 40 or postmenopausal woman, smoking, family history,
diabetes, hypertension, high cholesterol

Pulmonary embolism

pleuritic chest pain tachycardia

shortness of breath tachypnea
unilateral swollen lower leg no pain to palpation of chest wall
hx of DVT in past unilateral swollen leg
not on warfarin

Pneumonia

pleuritic chest pain fever

cough dullness to percussion
sputum production abnormal breath sounds
increased tactile fremitus

Pneumothorax

pleuritic unilateral chest pain tachycardia

sudden onset tachypnea
shortness of breath decreased unilateral breath sounds
decreased tactile fremitus
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 cardiac rub

pleuritic fever
started after viral URI

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 hives
wheezing hypotension
hx of exposure to allergen tachypnea
tachycardia

RIGHT UPPER ABDOMINAL PAIN

RUQ pain - Biliary colic

RUQ painintermittent 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 + Murphys 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 Murphys 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

midabdominal pain migrating to RLQ RLQ tenderness
anorexia + obturator sign
nausea/vomiting + psoas sign
feverish fever
acute onset

ACUTE PELVIC PAIN - Diverticulitis

LLQ pain fever
fever LLQ tenderness
diarrhea often
vomiting

ACUTE PELVIC PAIN - Pelvic inflammatory disease

fever fever
lower abdominal pain lower abdominal tenderness
vaginal discharge + pain with cervical motion tenderness
hx of unprotected sex, new sexual partner shuffling gait

ACUTE PELVIC PAIN - Ectopic pregnancy

lower abdominal pain lower abdominal tenderness
may radiate to top of shoulder unilateral adnexal fullness
late period or known pregnant possible hypotension (if ruptured)

ACUTE PELVIC PAIN - Ovarian torsion

sudden onset lower abdominal tenderness

unilateral, severe pelvic pain
nausea and vomiting
can start with exercise

BLOOD IN STOOL

BLOOD IN STOOL - Hemorrhoid

bright red blood no abdominal tenderness
streaks usually on stool or toilet paper no fever
hx of patient able to palpate hemorrhoid

BLOOD IN STOOL - Anal fissure

pain with defecation no fever
bright red blood with straining at stool no abdominal tenderness

BLOOD IN STOOL - Diverticulosis

abdominal cramps age > 40
blood mixed with stool pallor
may be recurrent

BLOOD IN STOOL - Infectious diarrhea

diarrhea prominent fever
bloody stool diffuse abdominal tenderness
vomiting no rebound
others with same illness
acute onset

BLOOD IN STOOL - Inflammatory bowel disease

fever fever
diarrhea diffuse abdominal tenderness
chronic onset
weight loss
positive family history

SYNCOPE

SYNCOPE - Vasovagal
emotional, stressful situation normal vital signs (when recovered)
quick recovery in minutes
no seizure activity
occurred in bathroom

SYNCOPE - Arrhythmia
palpitations abnormal heart rate
chest discomfort irregular heartbeat
shortness of breath
medication history

SYNCOPE - Orthostatic hypotension

symptoms upon standing, esp. after lying down for a long period of time
tachycardia
hypotension when standing
medication as cause
advanced age
dehydration

SYNCOPE - Aortic stenosis

shortness of breath age 60 and up
anginal chest discomfort narrow pulse pressure
family history of same displaced PMI
systolic ejection murmur

SYNCOPE - Hypertrophic cardiomyopathy

palpitations crescendo-decrescendo midsystolic heart murmur
dizziness
shortness of breath
younger athlete
family history
occurs with exercise

UNILATERAL SWOLLEN LEG

UNILATERAL SWOLLEN LEG - Baker cyst rupture

previous or current arthritis of knee swelling and fullness behind knee or
upper calf
red, swollen, tender calf

UNILATERAL SWOLLEN LEG - Cellulitis

red, swollen, tender calf fever
distal break in skin of leg inguinal adenopathy

UNILATERAL SWOLLEN LEG - Lymphatic obstruction

chronic leg swelling no fever
chronic skin changes inguinal adenopathy
not red or tender lower abdominal mass

UNILATERAL SWOLLEN LEG - Deep vein thrombosis

pain and swelling recently in leg lower leg red
risk factor for hypercoagulable state (OCPs, ERT, malignancy) lower leg warm
lower leg swollen
recent airplane or long bus ride lower leg tender
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