ABDOMINAL PAIN CASES

Ask about; SIQORAAAA, ROS, PAMHITSFOSS

1.

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32 yo male, c/o ABD pain

HPI:
Right testicular pain, at the top of it
urethral yellow discharge,
burning during urination.
Married but has other 4 SP in the past years, inconsistent with the use of condoms.
PE:
ABD: including CVAT
Dx: Orchiepidiyimitis, Gonoccoccal urethritis, non gonococcal uretritis
WU: Genital examination, UA, US testes, urethral culture
Counseling: STD and condoms, HIV test

2. Abdominal pain. Male 50s yo.

HPI:
- Worsening abdominal pain for the last 2 days.
- Mid epigastric, tearing, raidiating to back.
- Feels sweaty.
- RUQ pain as well.
- FH: father dies of cirrhosis.
- SH: drinks 6-10 beer every night CAGE 3/4 no eye opener.
- Doesnt smoke. Works in an electric company.
PE:
- Abd: pain on palpation.
- Check peripheral pulses
Dx: Acute pancreatitis, Dissecting aortic aneurysm, pancreatic cance
WU: Amylase, lipase, cbc, electrolyte, US abd, CT abd,
3.
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Abdominal pain. Female 45 yo.

Current pain there for 2 days.
Epigastric pain. Burning , 7/10. Started hour after ate food. Constant, does not radiate.
PMH: epigastric pain for 2-3 months on and off. She felt she was in distress. Felt nauseated but no vomiting.
Everything else clear. No NSAID usage.
- Dx: Peptic ulcer disease, Gastritis, Non ulcer Dsypepsia, GERD
- WU: H. Pylory serology and stool Ag, upper GI endoscopy, cbc, rectal exam, occult blood in stool
4.
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Abdominal pain. Female 22 yo.

Lower abdominal pain.
LMP 4 days ago abundant, 2 days ago spotting.
Sexually active, use condoms irregularly ( suspect cheating boyfriend). No discharge.
If you tell her about pregnancy she asks why if I had periods 4 days ago?
PE: abd exam, conjuntivas
Dx: PID, Appendicitis, Ectopic pregnancy.
WU: pelvic exam, rectal exam, cervical cultures, BhCG, CBC/ESR, US pelvic, UA

5. Abdominal pain. Female 46 yo.

- Abrupt onset RLQ abdominal pain.
- Has vaginal discharge.

- LMP 2 month ago/irregular last year/every 2-3 month.

- Sexually active.
- PMH: Previous PID.
- PSH: Appendectomy at 13.
- Dx: Ectopic pregnancy, Ovarian torsion, Ruptured ovarian cyst, PID, vaginitis
WU: pelvic exam, rectal exam, , BhCG, US pelvic, CBC/ESR, US pelvic, UA, cervical cultures,

Diarrhea - adult: DOQPAAAA, ROS (GI, JOINS, constitutional ), PAMHITSFOSS(TRAVEL)

6. Abdominal pain. Female 28 yo.
HPI:
- Abd pain after eating bread, cereal, wheat.
- Also has bloating,
- chronic diarrhea with mucus, no blood.
- Ask for travel hx
PE:
- Abd
- Check LAD
- Check oral mucosa
- Check joints
Dx: Celiac disease, Irritable bowel syndrome, Parasitic infection, Whipple ds, Tropic spours, chronic pancreatitis, lactose
intolerance, C-dificille
WU: anti-tissue transglutaminasa, anti-endomysial, anti-glyandin, cbc, electrolytes, stool examination, small bowell
biopsy.
7. 28 yo male c/o diarrea
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3 weeks watery brown, no mucus, no blood, no relation to food, nothing changes it, tenesmus.
Pain RLQ cramping, for 2 days.
Cramps just before he has to go to the bathroom.
ABD is relieved after defecating
Feels burning when he wipes his anal area after defecating.
Diet filled with fiber, but no changes in diet in past 3 weeks. No stress, no nothing, program director at community
center. Has a daughter, 7 months old. Married to a female, no history of STDs or HIV. All the rest is negative, when
talking about colonoscopy he says something like, thats awful!
PE: abdominal exam, check conjuntiva, Check oral mucosa, Check joints
Dx: Inflammatory Bowel disease (Crohns disease), IBS, Parasitic diarrhea, C Pancreatitis.
WU: rectal exam, occult blood test in stool, stool examination, cbc, electrolytes, colonoscopy
Challenging Question How can I make sure my daughter doesnt get the same thing? well, I understand your concern
but First we have to confirm the dx and after that I will be in a better position to tell you if your child has an increase
risk of it

8.
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Diarrhea. Male 25 yo.

Started 2 weeks ago.
Getting worse
Diarrhea: watery, 4-6 times per day, no mucus, no blood.
Abdominal pain, diffuse, 4/10, cramp, no allev/aggrav, no radiation.
Bloating. Flatulence. Nausea, no vomit.
No rectal pain, fever.
Tried Imodium and Ciprofloxacin that made the diarrhea worse.
Traveled to Kenya 1 mo ago.

- Had diarrhea 1 mo ago in Kenya (not known how long, lets say for 2 days).
- Had vaccination before trip against yellow fever, Hep A, Hep B and for malaria prophylaxis.
PE: abdominal exam, check conjuntiva, Check oral mucosa
Dx: Parasitic diarrhea (giardiasis, amebiasis) Psudomembranous colitis, tropic sprue
WU: rectal exam, occult blood test in stool, stool examination, cbc, electrolytes,colonoscopy
Challenging Question - I have 7 yo daughter at home and scare to infect her too, what can I do to prevent that. (Ask it
if Dr. said that it may be an infection): wash hands after toilet and before preparing food

FOLLOW UP: 1D 2M 5C, PAMHITSFOSS

9. HTN medication refill. Male 49 yo.
- BP: 190/110 mm Hg
- His medication does not come in the mail for past two weeks.
- He was on HCTZ, ACE (Lisinopril).
- C/o fatigue, decreased energy for past 3-4 months.
- SOB on exertion for 3-4 months (gets tired when walks with girlfriend short distance).
- No chest pain, no erectile dysfunction. Was diagnosed of diabetes, but do not take any treatment.
- Last check up 1 year ago.
- Dating a women 15 years younger.
PE: decreased sensation on feet.
o Heent, funduscopy,
o Neck: tyroid JVD, carotid auscultation
o CV
o Check LE
Dx: CHF, Diabetic polyneuropathy, Anemia
Challenging Question - Is it normal for a man of my age to feel tired? What can I do to keep up with my girlfriend? I
really understand your concern and Im glad you come to visit me because as you suspect your symptoms are not normal
in people with your same age. But the good news is that with the right treatment, we can slow the progression of your
disease and improve your symptoms.
10. Cholesterol meds refill. Male 34 yo.
- Erectile dysfunction.
- Wants blue pill.
- Hypercholesterolemia 3 yrs.
Ask fot symptoms of DM, medication, marital problems, ask if he has erections in the morning, smoking, alcohol, visual
defects, milk production.
Dx: Hypercholesterol induced ED, Smoking induced ED , Psycogenic ED, Hypogonadism, prolactinoma, hypothyroidism
WU: genital exam, cbc, testosterone, prolactine,TSH, cholesterol and lipid panel, Hb A1c, glucose.
MUSCULOSKELETIC CASES: SIQORAAAA, PAMHITSFOSS
11.31 yo female c/o groin pain
- Pain in her groin region.
- Long distance runner, training for marathon.
- While she was training felt down and since that she has had this pain.
- Lesbian, her partner died of breast cancer.
- While she was training felt down and since that she has had this pain.
PE: hip examination, LE exam (neuro, vacular)
Dx: Hip strain, hip sprain, Femoral Neck fracture, stress fracture, Avascular femoral necrosis. Femoral hernia, hip
dislocation
WU. XR of hip, MRI of hip, Inguinal US

Challenging Question I want to keep running?, Can you give me corticosteroids?, Will I be able to run soon again?
I understand your concern but at this moment is more important to make an accurate diagnosis before you return to
your normal daily activities. After we run some test I will be in a better position to discus treatment option and
prognosis.
12.Shoulders stiffness. Black man 72 yo.
- C/o aching and stiff shoulders and hips.
- Worse in the morning.
- BPH treated with Flomax (Tamsulosin).
PH: JOIN EXAMINATION, MOTOR, SENSATION, REFLEXES, PULSES, HANDS EXAM
Dx: Osteoarthritis, Polymyalgia rheumatic, Polymyositis,
WU: CBC, ESR, CPK, ALDOLASE, RF, CXR, HIP AND SHOULDERS XR
13. Back pain. Male
Male in fetal position.
Very heavy male.
Carries heavy boxes.
Radiation to left leg.
Smokes marihuana, makes pain better.
Rest the same as first aid. (CASE 27)
PE: back exam, lower extremities (neuro and vascular)
Dx:, Disk herniation , Lumbar muscle sprain,
14.Neck pain. Black Female 65 yo.
- Pain for 2 weeks, started after went to yoga class.
- Had it for 2 weeks, but got worse yesterday.
- Numbness and tingling in right forearm.
- Right neck pain extending to right shoulder, tingling in right forearm to thumb.
Last night, she was moving stuff in her closet, and since then has gotten really bad.
PE: no tenderness on palpation. Decreased ROM in her neck due to pain. +LHERMITE + SPURLING ON AFFECTED SIDE.
Dx: Herniated cervical disk, Cervical muscles strain, Cervical vertebral fracture
WU: neck XR, neck MRI, nerve conducting studies, CBC, Ca, BUN/Cr
Challenging Question Can I go to the chiropractor, because the insurance give me more if I go there than to the
hospital ?
I understand your concern but first we need to rule out any serious condition that may be aggravating by the
chiropractor
15.Pain in left arm. Female 70 yo.
- Left arm pain after moving some boxes. No lesions. Doesnt hurt with use, but hurts with exercise, like walking 3 miles.
PE. CV exam complete and UExt exam
Dx: Angina, MI, Tendonitis, Osteoartritis
WU: ECG, troponine, myoglobin, CPK MB, stress test, CBC, ESR, XR shoulder,
Challenging Question Is it something serious?, Can I keep walking, I like to walk?
I understand your concern and as you suspect your symptoms can be related to more serious conditions, but first we
have to run some test to learn what is going on with you
16. Knee pain. Female 40 yo.
- Right knee pain.
- She went for two weeks on a trail, after first week she started to have the pain, now she uses a crutch to walk now
(asses for meniscal tear, ligaments and drawer signs) a little bit aggressive.

- ( Traveled to Austria (hiking trip).

- No other symptoms, no rashes, or tick bites, no trauma, no autoimmune, ask STD. Detective
PE: skin examination, L Ext exam
Dx: meninscal or ligament tear, lyme ds, pseudogout, gout, septic arthritis, reactive arthritis
WU: CBC,Knee XR/MRI, blood and urethral cultures, uric acid, arthocentesis with synvial fluid analysis
17.Pain in right foot. Male 50 yo.
- One week ago he stepped on a glass in his kitchen and think he has a piece of glass in the foot.
PE: no inflammation sighs, L Ext exam (neuro/vascular).
Dx: Foreign body , fasciitis, foot strain , DM
WU: foot XR, cbc, ESR, glucose, HbA1c
18.Ankle pain. Female.
- Sprained it by running and twisting it on curb. She is wearing a wrap. Make sure to take it off examine and put it back
PE: L Ext exam (neuro/vascular).
Dx: ankle sprain, ankle dislocation, ankle fracture
WU: ankle XR
19. Back pain. Female 75 yo.
- After tripping on the sidewalk.
- No radiating pain down the leg.
- DEXA scan?
- PMH: Breast cancer.
PE: Back examination, L ext examination
Dx: vertebral Fracture. Metastatic breast cancer, Osteoporosis, lumbar muscle strain
WU: spine XR/MRI
20.Hip pain. Male 35 yo.
- Left hip pain for past 45 days.
- Married with 1 child.
- Sleeping on the hip causes pain, pain to palpation.
- Pain on exertion, little bit of gait.
Dx: Trochanteric Bursitis , Hip sprain
WU: hip XR/MRI
21. Shoulder pain. Male 28 yo.
- Right shoulder pain after playing tennis
- PE: U Ext (neuro/vascular)
- DX: tendonitis, shoulder dislocation, Rotator cuff injury
- WU: shoulder XR/MRI, cbc
URO-GYNECO CASES: DOQPAAAA, ROS, PAMHITSFOSS
22.Blood in urine. Male.
- 3 weeks ago URI.
- Urine more brown than red.
- Asks if it is blood?

- PE: ABDOMINAL WITH CVA, check throat

- Dx: PSGN, Nephrolithiasis, UTI, TUMOR
- WU: UA and microscopic examination of urine, ASO, anti-DNAse ab, BUN/Cr , CBC, US renal, CT abd/pelv , urine
cytology,
23.Pain during urination. Female 17 yo.
- Dysuria.
- Had repeated UTI in past.
- Sexually active, condoms inconsistent, various sexual partners, no history of STD.
- PE: abd w CVA
- Dx: Urethritis, Cystitis
- WU: urogenital exam, UA, urine culture, urethral discharge gram stain and culture, Chlamidia and gonorrhea PCR, US
renal, BUN/cr
- Challenging Question. - How many sexual contacts should I have to get STD from my partner? , I had HPV vaccine,
does it protect me from against all the SDTs?, Does my mom need to know about this?
24. Vaginal bleeding. Female 67 yo.
- Vaginal spotting for 2 weeks.
- Difficult patient.
- HRT for 12 yrs.
- Bad attitude.
- PE: conjunctivas and abdominal
- Dx: Endometrial hyperplasia, Endometrial cancer, Cervical cancer
- WU: pelvic exam, pelvic US, endometrial biopsy, pap smear,cbc
25. Heavy menses. Female 40s
- Woman with heavy menses with same days and frequency.
- Double the tampons, same duration.
- No extra hair growth, no fatigue, no weight gain.
- Smokes 1-2 cigarettes once a month, tell her to stop smoking anyway she will ask you.
- Ask painful periods, spotting, clots during menstruation.
- PE: conjunctivas and abdominal
- Dx: Uterine fibroids, endometrial polyps , Endometrial hyperplasia, coagulopathy
- WU: genitopelvic exam, pelvic US, CBC, PT/PTT, bleeding time
- Challenging Wants OCP which she has used 2 year in the past to make her menses normal Tell that OCP are
contraindicated in smokers above 35

26.Vaginal discharge. Female old.

- Burning pain in genital area, pruritus.
- Vaginal discharge, malodorous, yellowish.
- 2 month ago started to have sex with her boyfriend, since then she has the pain, worse during sex, also c/o vaginal
dryness.
- PMH: HTN, DM. Med: HCTZ, metformin.
- Dx: tricomonal vaginitis, candida vaginitis, cervicitis Atrophic vaginitis, vaginosis
- WU: genitopelvic exam, vaginal discharge analysis ( ph, KOH prep, wet mount) cervical discharge gram stain and
culture, Chlamydia and gonorrhea PCR,
- Challenging Is it ok to have sex at my age? Are you going to be gentle during genital exam? yes it is normal, use
condom for STD
PEDIATRIC CASES: DOQPPAAAA, RUDDS FEVEER, PAM IF BIG DEALS
27.Pediatric cough. Father of 4 yo Male.
- Son has dry cough for the last 2 weeks, worse with exercise.

Had cold 3 weeks ago.

He has his sons vaccination sheet with him.
He says that missed his last DTP vaccines b/c of wifes fault, inquire about parent relationship.
SH: The father smokes 1 PPD around the kid. The mother has hay fever.
DX: Asthma, whooping cough (B. Pertussis infection), bronchitis,
WU: CXR, CBC, peak flow measurement,# methacholine, pertussis serology/PCR

28.Pediatric diarrhea. Phone case. Grandfather of 3.5 weeks old Female.

- Grandfather was watching his granddaughter who was 3.5 weeks old.
- Baby had diarrhea, brown, no blood in stool.
- No fever, no nothing.
- Had no car.
- Mother is in hospital due to accident.
- He is running out of milk and there is no formula in the house.
- Does not know what to do?
- Dx: osmotic diarrhea, milk allergy, gastroenteritis
- WU: CBC, electrolytes, stool examination, stool leukocytes, occult blood
- Challenging Question WHAT ARE THE SIGNS OF DEHYDRATION IN THE CHILD? Dry eyes, dry month, decrease
frequency of urination, cry without tears
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29. Pediatric fever. Grandmother of 2 yo Male.

- Ear pulling. Had otitis media.
- He was premature and stayed 1 week in the hospital after birth.
- His brother had flu symptoms one week ago, he took antibiotics.
- Dx: Otitis media, otitis externa, URI,
- WU: physical exam, pneumatic othoscopy, cbc,
- Challenging Question My daughter is out of town, is it necessary to take him to the hospital? I have a lot of
medication here can I give it to him? I understand but in this case is necessary to bring him to the office to do a
physical examination and run some studies and treat him according to them.
30.Mother of a 12 c/o weight loss
- 4 pounds lost in the past 4 days.
- her daughter is eating more, going more frequently to the bathroom to pee.
- Dx: T1DM, Diabetes Insipidus, Hyperthyroidism
- WU: serum glucose, HbA1c, CBC, electrolytes, ESR, TSH, FT4, serum and urine osmolarity.
- When you talk about the possibility of type 1 DM she gets even more concern and asks Will I have to take care of her
all the time? Is our family life going to change a lot now? Counseling of DM
31.Adolescent weight loss. Mother of 15 yo Female
- BMI 15. Weight loss. Thirsty. Polyuria ?. Eat a lot.
- Going to bathroom frequently. Every question negative. No stress.
- Challenging Question- Should I control my daughter more seriously? (But said it in slang and unclear).
- Dx: Anorexia , Diabetes mellitus, hyperthyroidism
- WU: cbc, electrolytes, serum glucose, HBA1c, tsh, FT4,

Neuro-psychiatric
32.62 Y F, c/o hearing loss
- Yesterday she didnt hear the fire alarm from her building,
- Problems hearing with both ears
- She takes osteoporosis meds she tells you the commercial names
- She used hearing aids in the past but 6 months ago it didnt help anymore so she stopped using them
- She lives alone (ask her about support)
- You have to speak louder ALL the time, ask her if theres any ear that she hears better to talk to she will tell you that
she has.
- She asks if she will ever get better and also tells you that she thinks that this problem is due to her age,
Hx: Ask DO QPP AAAA, PAM HITS FOGSS
PE: Do HEENT and screen for Neurological exam (Do especially Rinne and Weber)
DDx: Presbycusis, Labyrinthitis, Cochlear nerve damage [due to load noise] (others; Ototoxicity due to drugs, acoustic
neuroma, Meniere disease)
WU: Audiometry, tympanography, brain stem audiotry evoked potentials, CT head, CBC, MRI brain, VDRL/RRR,
33.Dizziness. Female 65 yo.
- Complaining of dizziness for 5 days has been having reoccurring of dizziness.
- Has had 3 episodes, one occurring while she stood up, one occurring while she picked something up off ground, and
one occurred while she was just knitting.
- She feels really lightheaded when this happens.
- First and last time her vision started decreasing while she was having that dizziness.
- Lower limb edema.
- PMH: HTN, taking HCTZ, diarrhea.
Hx: Hospital AAA, PAM HITS FOGSS
PE: Do CNS exam and CVS
DDx Orthostatic hypotension, Arrhythmia, Vestibular neuritis (other: BPV, vertebrobasilar insufficiency, brain stem or
cerebellar tumor)
WU: orthostatic vital signs, CBC, electrolytes, MRI/MRA brain, FOB, Audiogram, Dix-Hallpike test
34.Dizziness. Female 30 yo.
- Dizziness and lightheadedness.
- Happened 2 times last two days.
- Just opened a wine bar at restaurant, under a lot of stress at work, stressed out about everything.
- Palpitations.
- No hearing loss, no infections, no room spinning just lightheadedness, no passing out.
- SH: quit smoking, drinking every day 3 cocktails. She is sexually active with boyfriend, without contraceptives. LMP 4
weeks ago, heavy menstrual periods.
- Barely drinks 2 glasses of water a day.
Hx: Hospital AAA, PAM HITS FOGSS
PE: Do CNS exam and CVS
DDx: Anemia, Orthostatic hypotension (dehydration) [other diagnosis; alcoholic intoxications, arrhythmia, Vestibular
neuritis, BPV, vertebrobasilar insufficiency, brain stem or cerebellar tumor, Menieres disease)
WU: orthostatic vital signs, CBC, peripheral blood smear, Reticulolcyte count, electrolytes, MRI/MRA brain, FOB,
Audiogram, Dix-Hallpike test
Counsel: her about Alcohol habits, condoms usage

35.Headache. Female 65 yo. BP 160/100

- Bilateral temporal headache.

Difficulty in concentration.
Nausea.
Previous episode of tension headache.
Mother had migraine.

Hx: SIQOR AAA, PAM HITS FOGSS

PE: Do HEENT and CNS
DDx: Tension headache, Hypertension, Migraine headache, temporal arteritis (others; depression, caffeine or analgesic
withdrawal, cluster headache, pseudotumor cerebria, Intracranial mass)
WU: CBC, Electrolytes, ESR, CT head, LP
36. 65 yo female, c/o headache
- BP 180/85
- HTN uses HCTZ and something else and ASA,
- Had tension headaches in the past but this is the worse ever, pain located in both temples, no vision problems or other
neurological symptom.
Hx: SIQOR AAA, PAM HITS FOGSS
PE: Do HEENT, CNS, CVS
DDx: Hypertensive crisis, Subarachnoid Haemorrhage, Tension headache (others; Migraine headache, temporal arteritis,
depression, caffeine or analgesic withdrawal, cluster headache, pseudotumor cerebria, Intracranial mass, intracranial
venous thrombosis)
WU: CBC, Electrolytes, ESR, Non-contrast CT head, LP, PT/PTT/INR
37.Headache. Male 32 yo.
- ER
- Lying with covering eyes and does not answering questions.
- Ask if he wants lights off, then he will be more cooperative.
- Started 4-5 hours.
- Took cocaine 10 min before he started having sex with girlfriend, in the intercourse started having occipital headache
right when he started doing it.
- 10/10 in intensity.
- FH: father has kidney problem.
Hx: SIQOR AAA, PAM HITS FOGSS
PE: Do HEENT, CNS, CVS
DDx: Hypertensive crisis (due to cocaine), meningitis (bacterial), meningitis (viral), Subarachnoid Haemorrhage, (others:
encephalitis, Tension headache, Migraine headache, cluster headache, pseudotumor cerebria, Intracranial mass,
intracranial venous thrombosis)
WU: CBC, Electrolytes, Urine toxicology, Non-contrast CT head, LP, PT/PTT/INR
Counsel: Drug abuse

38.LOC. Male young.

- Young man playing basketball, has LOC for a few mins, no symptoms after and before that.
Hx: Bad USMLE, PAM HITS FOGSS
PE: CVS and CNS
DDx: Hypertrophic cardiomyopathy, Cardiac arrhythmia, Seizures (others: Complex tonic clonic seizure, substance abuse
or overdose, hypoglycaemia, syncope [vasovagal, convulsive])
WU: ECG, echocardiography, cardiac catheterization, Holter monitoring, EEG, MRI/CT brain, CBC, electrolytes
Challenging Q: Is it necessary all the lab exam?

39.LOC. Male.
- Man comes after falls at bus stop.
- Doesnt remember anything, people said he was shaking after pissed himself.
- Several episodes (3).
- Bad attitude.
- Alcoholic and smoker.
- Unemployed.
Hx: Bad USMLE, PAM HITS FOGSS
PE: CNS and CVS
DDx: Seizures [Complex tonic clonic seizure], syncope [vasovagal, convulsive], hypoglycaemia (others: substance abuse
or overdose, Hypertrophic cardiomyopathy, Cardiac arrhythmia)
WU: ECG, echocardiography, Holter monitoring, EEG, MRI/CT brain, CBC, electrolytes ECG, Glucose
Challenging Q: Wants to leave!!
40.LOC male
- HTN (on vital signs).
- Was at grocery with wife.
- Wife saw episode.
- He had no auras.
- No shaking, tongue biting or loss of bladder control.
- PMH: MI 1 yr ago
Hx: Bad USMLE, PAM HITS FOGSS
PE: CVS and CNS
DDx: Cardiac arrhythmia, TIA (transient ischemic attack), Seizures (others: Complex tonic clonic seizure, substance abuse
or overdose, hypoglycaemia, syncope [vasovagal, convulsive])
WU: ECG, MRI-brain, CT-head, Carotid US with Doppler, EEG, echocardiography, Glucose, Holter monitoring, CBC,
electrolytes
Challenging Q: Is this a stroke? Do you think Im going to die? Asks about Transient ischemic attack because he googled
it.

41. LOC male

- Fainting one hour ago, while going for the mail.
- He had no auras, his neighbor saw him.
- No shaking, tongue biting or loss of bladder control.
- No postictal state, mildly confused of what happened but no real confusion.
- He is homosexual, 30 years same sexual partner, no history of STDs, no use of condoms.
- PMHx: coronary artery disease, MI one year ago, hypercholesterolemia, managed with amlodipine, ASA, etc.
Hx: Bad USMLE, PAM HITS FOGSS
PE: CVS and CNS
DDx: TIA (transient ischemic attack), Cardiac arrhythmia, syncope [vasovagal, convulsive] (others; Seizures Complex tonic
clonic seizure, substance abuse or overdose, hypoglycaemia,])
WU: ECG, MRI-brain, CT-head, Carotid US with Doppler, EEG, echocardiography, Glucose, Holter monitoring, CBC,
electrolytes
Challenging Q: Is this going to happen again Dr?
42. 35 yo female, c/o fatigue
- she feels tired.
- She had her baby 4 mo ago, when asked about delivery complications or bleeding denies anything

- She will tell you that she had bleeding some days after the delivery.
- does not produce milk, also, thin hair, and tells you that she is trying very hard to lose weight but there are 10 pounds
that she cant lose,
- she ask about what can she do for this?
- She has a tattoo on her back, maybe ask about that just in case.
- closes eyes during encounter, kind of bad attitude
Hx: Give a fatigue patients IPADS TO SLEEP, PAM HITS FOGSS
PE: CNS, Thyroid exam, Psychiatric
DDx: Sheehan syndrome (panhypopituitarism), Hypothyroidism, Anaemia (others; depression, DM)
WU: Hormone assays, TSH/FT3/FT4, prolactin level, CBC, MRI-brain/ CT-head
43. Fatigue. Female 32 yo.
- Fatigue for 8 month, low energy.
- Fall asleep in cinema.
- Positive symptoms: dry skin, hair is thinner, cold intolerance, 35 lb in the past pregnancy (hasnt been able to lose).
- Snores at night.
- No depression symptoms.
- Ob/Gyn: G2P2. Hemorrhage post-partum (last pregnancy), lots of bleeding. No lactation. Gave formula. Were regular
before pregnancy, amenorrhea for last 5 month. No contraception use.
- FH: mother SLE. Med: Ta1king ginseng.
- Dx: Sheehan syndrome Hypothyroidism Pregnancy
- Challenging Question. - Can you give me some thing to have more energy?

Hx: Give a fatigue patients IPADS TO SLEEP, PAM HITS FOGSS

PE: CNS, Thyroid exam, Psychiatric
DDx: Sheehan syndrome (panhypopituitarism), Hypothyroidism, Obstrective Sleep Apnea (others; Anaemia, depression,
DM)
WU: Hormone assays, TSH/FT3/FT4, prolactin level, CBC, MRI-brain/ CT-head, nocturnal pulse oximetry,
polysomnography, fasting glucose, HbA1c

44.Fatigue. Young man.

- Weight loss
- Appetite changes
- Night sweats
- File (folder) in his hand,
- Stress from work.
- Works at a hospital but works in IT department no contact with patients. Works a lot.
- Yawns during interview.
- URI 6 weeks ago
Hx: Give a fatigue patients IPADS TO SLEEP, PAM HITS FOGSS
PE: Thyroid exam, Psychiatric, CNS
DDx: Hypothyrodism, TB infection, Lymphoma/leukemia, depression, (others; anaemia, DM, OSA)
WU: Hormone assays, TSH/FT3/FT4, CBC, iron level, MRI-brain, PPD, Chest X-ray, sputum G-stain and AFS and culture,
HbA1c,
Challenging Q: Can I have chronic fatigue syndrome?
45. Fatigue. Female 16 yo. HR 50.
- Tiredness and sleepiness for past 3 months,
- slightly getting worse.
- wakes up once in middle of night, and has difficulty falling asleep.

- Hypothyroid symptoms neg.

- Drinks adequate water.
- Ob/Gyn: uses 3-4 tampons a day during period but last period was lighter than usual.
- Doesnt take vitamin supplements.
- Sexually active with bf, use condom. Had weight gain. Said she feels down. Has been doing poorly in school. Stress in
life bc she has to take care of her siblings.
- Yawns during interview, mom sent her there
Hx: Give a fatigue patients IPADS TO SLEEP, PAM HITS FOGSS
PE: Psychiatric, HEENT (thyroid, conjunctiva )
DDx: Anemia, depression, hypothyroidism
WU: TSH/FT3/FT4, CBC, iron level, PBS

46.Fatigue. Male black 30 yo.

- Weight loss and fatigue.
- Tired all the time.
- No other symptoms.
- Homosexual young male.
- Had a lot of sexual partners
Hx: Give a fatigue patients IPADS TO SLEEP, PAM HITS FOGSS
PE: HEENT (thyroid, conjunctiva), Lymph nodes,
DDx: Acute HIV infection, STDs, Infectious mononucleosis, depression, hypothyroidism
WU: HIV antibodies, TSH/FT3/FT4, CBC

47. Memory loss. Male 75 yo.

- Lost his way once when he took a different way back home.
- DM, missed one insulin dose.
- He does not need help in daily living activities.
- Retired policeman.
- His wife sent him to the hospital
Hx: FORGETTS Daily activity
PE: CNS
DDx: Alzheimer Disease, Vascular dementia, depression, (others; lewy body dementia, Normal pressure hydrocephalus,
chronic subdural hematoma, intracranial neoplasm, delirium, B12 deficiency, neurosyphilis),
WU: CBC, VDRL/RPR, serum B12, TSH, MRI-brain, CT-head, LP-CSF analysis
48.Feeling anxious. Female 20 yo.
- Student states that she has had anxiety, problems concentrating and problems falling asleep.
- She drinks a lot of coffee every day, negative for depressive symptoms. She denies drugs.
- No other symptoms, might have weight loss.
- Yoga twice a week.
- Has a boyfriend. Uses condoms.
- Grades are getting worse.
- Heart racing 2 times a week.
- No tremors. Taking Adderall [which is amphetamine] (for what?).
Hx: Psychiatric history, screen for depression (I,m SSAD because my Terrible GMC car)
PE: Psychiatric examination (and CNS exam?)
Dx: Amphetamine induced insomnia, Caffeine induced insomnia, GAD (others; Hyperthyroidism, insomnia related to
major depressive disorder, insomnia with circadian rhythm sleep disorder)

WU: Urine toxicology, CBC, TSH, Mental status exam, polysmnography

Counsel: about the drug abuse
49. Jaw pain. Female black.
- She says she fell down the stairs. Boyfriend is abuser.
Hx: ask SIQOR AAA, SAFE GARDDS
PE: HEENT
Counsel: Domestic abuse
WU: X-ray head, MRI-head
Dx: Domestic abuse, Mandible fracture, TMJ dysfunction
50.57 yo female c/o sleeping problems
- shes sitting on the chair and holds a tissue because she was crying when asked she tells you that her son died 3 weeks
ago and since has problems falling sleep and wakes up at 4:30 and cant go back to sleep, she feels sleepy & tired
during the day but cant take naps, she does not snore.
- Has hallucinations about seeing her son in the kitchen and the other night she heard like a party at her neighbors
house was going on but she is aware that all these things are not real.
- No suicidal thoughts or guilt, she has a very good support system.
- 5 pills of Ambien (Zolpidem). Drinks 3 glasses of wine/day.
- Challenging Question - Can I take the same pills as my friend taking? Is it normal that I see my son?
Hx: Psychiatric history, screen for depression (I,m SSAD because my Terrible GMC car),
PE: Psychiatric examination (and CNS exam? Thyroid?)
Dx: Normal grief, major depression, adjustment disorder with depressed mood, PTSD
WU:CBC, TSH, Mental status exam, polysmnography
51. Insomnia. Female 22 yo.
- Goes to sleep at 11.00 PM,
- no problems to fall asleep.
- Awake at night and difficult to fall back.
- Feels sad but not depressed.
- Father died 1 year ago.
- Live alone, denies any abuse.
- No stress in any places, works on the same work for long period.
- Does not drink coffee.
- No hypothyroidism symptoms.
- Gained 12 lb in last couple month.
- Menorrhagia for 2 month.
- Challenging Question All encounter asking whats going on with her?
Hx: Psychiatric history, screen for depression (I,m SSAD because my Terrible GMC car),
PE: Psychiatric examination (and CNS exam? Thyroid?)
Dx: ?? (may be insomnia with circadian rhythm sleep disorder, insomnia related to major depressive disorder, OSA
WU:CBC, TSH, Mental status exam, polysmnography, urine toxicology

Adult Weight loss cases

52. Weight loss. Male 65 yo.
- Came in because his daughter and wife forced him to.
- Lost 15 lbs in 3 months.
- My clothes are getting bigger.
- Fatigued.
- Polyuria, wakes up twice at night to pee.
- Dyspepsia takes OTC PPI.
- His last colonoscopy was 15 year ago, rectal exam normal one year ago.

- Father DM and MI.

Hx: Ask DO QPP AAAA
PE: ABD
Dx: DM, DI, Malignancy (Gastric? Colon?)
WU:CBC, iron level, TIBC, ferritin, fasting Glucose, HbA1c, TSH, colonoscopy, endoscopy

53.Weight loss. Male 60 yo. e

- Came in because his daughter forced him to.
- Lost 18 pounds in last 8 months.
- Wife died 8 months ago.
- Daughter hasnt met him in past 8 months.
- Not depressed.
- After passage of wife, had no appetite for few months, had trouble cooking. no loss of energy, diet consists of frozen
food.
- Gets tired on exertion.
- Does not want to do all these tests and get charged (mention to him that since he has medicare, he can just get tests
done that are covered).
- Hx of aortic valve replacement.
Hx: Ask DO QPP AAAA, ROS
PE: ABD, CVS, thyroid, psychiatric
Dx: CHF? Hidden malignancy? DM? hypothyroidism? Renal failure? Hypercalcemia?
WU: ECG, Echocardiogram, Cardiac enzymes, CBC, iron level, TIBC, ferritin, fasting Glucose, HbA1c, TSH, rectal exam, FOB,
BUN/Cr, colonoscopy
Cardio-respiratory
54. 16 yo male c/o racing heart
- He is holding an SAT book, ask him about that and he will tell you that he is studying a lot recently
- The episodes happen on evenings, not related to anything apparently, ask about sleeping habits and he tells you that
hes having insomnia.
- Also slight SOB during the episodes
- no LOC,
- episodes lasts like 1 min and resolve by themselves
- .When asked about coffe he tells you that he has nothing so ask about drinks with caffeine, the he will tell you that he
drinks two red bulls per day.
- He plays soccer 3 times a week but has no trouble during practices.
- He is sexually active but uses condoms, smokes weed once a month
Hx: Ask DO QPP AAAA, ROS
PE: CVS
Dx: Cardiac arrhythmias, GAD, Substance abuse (others ; Agoraphobia/specific phobias, hyperthyroidism)
WU: ECG, Echocardiogram, CBC, Electrolytes, TSH, FT4
Counsel him about smoking

55. 24 yo male, c/o chest pain

- had a cold 3 days ago,
- hes gay safe sex practices,
- has been tested for HIV 6 mo ago and was negative.
- Clearly a pleuritic pain, worse when breathing.
- Sputum in the past day, yellowish, small amount no blood, now no sputum but still coughing, coughs during
encounter.
- Had fever during the cold, nothing in lung examination.
- Had pneumonia in the past and was hospitalized.

Hx: SIQOR AAA, PAM HITS FOGSS

PE: Chest
DDx: Pneumonia, PE, costochondritits, pericarditis, pleurisy, muscle strain, MI
WU: ECG, CPK-MB, troponin, CXR, CBC

56.Chest pain. Male 40 yo.

- Emergency case.
- Chest pain on left side of chest.
- Wasnt doing anything in particular when it started.
- Very acute, happened in past 4-5 hours.
- Stabbing pain
- . Aggravates by coughs and inspiration.
- Does not radiate.
- SOB, difficulty breathing. Has dry cough.
- Had URI 1 week ago.
- SH: smokes, homosexual. Nothing else in history significant. Aggressive.
- PE: No pain on palpation.
Hx: SIQOR AAA, PAM HITS FOGSS
PE: Chest
DDx: Pneumonia, PE, costochondritits, pericarditis, pleurisy, pneumothorax, muscle strain, MI
WU: ECG, CPK-MB, troponin, CXR, CBC with diff
Challenging Asks all the time about what is going with him and if you can give him medication for his pain.
57. Chest pain. Female 40 yo.
- RR Tachypnea, HR- Tachycardia
- She is in acute distress.
- Left side chest pain for 1 hour.
- Mid axillary line.
- Radiates to left shoulder, better with leaning forward, worse with lying down and inspiration.
- SH: on OCP (Ortho-novum 7/7/7), smoker, sitting for long time.
- FH: father had MI at 50 (so she is worried about that), mother had breast cancer.
- PE: Does not breath on left side.
Hx: SIQOR AAA, PAM HITS FOGSS
PE: Chest
DDx: Pneumonia, PE, costochondritits, pericarditis, pleurisy, pneumothorax, muscle strain, MI
WU: ECG, CPK-MB, troponin, CXR, CBC with diff

58.Cough. Male 17 yo.

- Mother says you can do physical and everything.
- Dry cough, nonproductive.
- Cant run.
- Drinks 2-3 beers/weekend (underage drinking counseling).
- Ill contacts someone from school. Family history of Asthma.
Hx: DO QPP AAAA, PAM HITS FOGSS
PE: Chest
DDx: Asthma, bronchitis, pneumonitis, foreign body, atypical pneumonia
WU: CBC with diff, CXR, Peak flow measurement, PFTs, Methacholine challenge test
Counsel about drinking

59. Cough. Male 50 yo.

- His boss sent him to check his cough.
- Mildly productive cough for 6 month.
- Sputum whitish-yellowish.
- Smokes 1PPD for 20 years and not interesting in quitting.
- Dx: COPD, TB, Lung cancer
Hx: DO QPP AAAA, PAM HITS FOGSS
PE: Chest
DDx: COPD, bronchiectasis, lung cancer, TB
WU: CBC with diff, CXR, Peak flow measurement, PFTs, CT-chest, PPD, sputum G stain and cluture
Challenging - Ask insistently for a note to his boss that he is fine

60. Cough. Female 45 yo.

- Cough for last couple of months, dry, nagging cough.
- Last week has gotten worse and wakes her up in the night.
- Exacerbated by lying down, not relieved by anything, tried to raise pillows and not eat before sleeping.
- No snoring.
- Negative to everything else.
- PMH: has asthma as a child, history of allergy, episodes of postnasal drip on and off for the past year and stuffy nose
along with it.
- SH: 1 glass of wine a week.
Hx: DO QPP AAAA, PAM HITS FOGSS
PE: Chest
DDx: Postnasal drip?
WU: CBC with diff, CXR?

61. Cough. Female old lady 50-60 yo.

- Lady had cough, in 50s,
- she was a super heavy smoker 38 years,
- had cancer.
- Drank too.
- SOB on exertion.
- She is mad because everybody tell her that is her fault.
- She has try many times to quit smoking.
Hx: DO QPP AAAA, PAM HITS FOGSS
PE: Chest
DDx: COPD, pneumonia, lung cancer
WU: CBC with diff, CXR, PFTs, CT-chest, sputum G stain and cluture
62. SOB. Male 30s yo.
- Real complaint is chest pain.
- SOB for the last 2 weeks.
- Chest pain in the right hemi thorax that worsens with breathing deeply, stabbing pain 8/10 doesnt radiate.
- Also has nonproductive cough.

- No weight loss.
- Sweats at night, has to change shirt.
- 5 year ago had Hodgkin lymphoma treated with chemotherapy, last checkup one year ago, it continued to be in
remission.
- Very scared about recurrence.
Hx: SIQOR AAA, PAM HITS FOGSS
PE: Chest and Lymph nodes
DDx: Recurrent Hodgkins, Pneumonia, TB
WU: CXR, CT chest, CBC with Diff, PBS
34. SOB. Male 60 yo.
- Feels winded down.
- BP 155/90.
- Does not control BP.
- Last check up 20 yrs ago.
- Colonoscopy 20 yrs ago (Nl).
- Sleep on 2 pillow.
- Legs swelling. Smokes 40 years.
Hx: DO QPP AAAA, PAM HITS FOGSS
PE: Chest
DDx: CHF, Colon Cancer, lung cancer
WU: CBC, ECG, Echocardiography, CXR, CT-chest, FOB, Colonoscopy
Challenging Question- Could it be a serious disease?