Chief Complaint " Doc, the drugs aren't working for my chest pain!”
Generic Case Review . Chief Complaint.
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Transcript of Generic Case Review . Chief Complaint.
Generic Case Review
www.drzaid.com
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Chief Complaint
• What questions do we want to ask this patient?
• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Differential• Diagnosis• Treatment
History of Present Illness
• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Differential• Diagnosis• Treatment
Past Medical History
• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Differential• Diagnosis• Treatment
Medications
• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Differential• Diagnosis• Treatment
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
• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Differential• Diagnosis• Treatment
Family Medical HistoryMother- Father-
• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Differential• Diagnosis• Treatment
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
• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Differential• Diagnosis• Treatment
What do we want to order?
• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Differential• Diagnosis• Treatment
Labs
• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Differential• Diagnosis• Treatment
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
• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Differential• Diagnosis• Treatment
Diagnosis
Thank you!
• Questions, comments, concerns?
