Generic Case Review

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Chief Complaint

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• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Differential• Diagnosis• Treatment

History of Present Illness

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Past Medical History

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Medications

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AllergiesNKDA

3rd year medical students that asktoo many questions

• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Differential• Diagnosis• Treatment

Social History

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Family Medical HistoryMother- Father-

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Review of systems

General: weight change, fever, chills, weakHead: headache, nasuea, vomittingRespiratory: SOB, wheeze, coughCardiac: HTN, murmurs, angina, palpitationsGI: appetite, n/v, incont., const/diarrheaGU: frequency, hesitancy, urgency, dysuria

hematuria, incont., stones, no dyspareunia, no discharge

MSK: muscle weakness, flank painNeuro: parasthesias, loss of sensationPsychiatric- Pt is not depressed

• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Differential• Diagnosis• Treatment

Physical ExamVS- BP- 140/87 T-98.2 R-16 P-82General- Pt is well nourished and AxOx3Heent- EOMI, PERRLA, no vision changesCV- RRR w/o murmurs or rubs, clicks or gallopsRESP- Clear to auscultation bilaterally, no wheezesAbdomen- Soft, NT, ND, no masses, BS, no bruitsGU- No discharge, bleeding, nodules or masses

Positive lloyd’s testMSK- No weakness, mild tenderness in R flank

TTA T11-L-1 EXT- No edema, negative moses, pulses b/l

• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Differential• Diagnosis• Treatment

Differential

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What do we want to order?

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Labs

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CBC

1014 g/dl

40

300

Chemistry

140

4.2

100

24

8.0

1.1

100

Pregnancy TestNegative

• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Differential• Diagnosis• Treatment

• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Differential• Diagnosis• Treatment

Differential

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Diagnosis

Thank you!

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