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1. 32 yo male, c/o ABD pain
x HPI:
o Right testicular pain, at the top of it
o urethral yellow discharge,
o burning during urination.
o Married but has other 4 SP in the past years, inconsistent with the use of condoms.
x PE:
o ABD: including CVAT
x Dx: Orchiepidiyimitis, Gonoccoccal urethritis, non gonococcal uretritis
x WU: Genital examination, UA, US testes, urethral culture
x 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.
-‐‑ ŽĞƐŶ͛ƚƐŵŽŬĞ͘tŽƌŬƐŝŶĂŶĞůĞĐƚƌŝĐĐŽŵƉĂŶLJ͘
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. 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. 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.
-‐‑ /ĨLJŽƵƚĞůůŚĞƌĂďŽƵƚƉƌĞŐŶĂŶĐLJƐŚĞĂƐŬƐ͞ǁŚLJŝĨ/ŚĂĚƉĞƌŝŽĚƐϰĚĂLJƐĂŐŽ͍͟
-‐‑ PE: abd exam, conjuntivas
-‐‑ Dx: PID, Appendicitis, Ectopic pregnancy.
-‐‑ WU: pelvic exam, rectal exam, cervical cultures, BhCG, CBC/ESR, US pelvic, UA
Diarrhea -‐ adult: DOQPAAAA, ROS (GI, JOINS, constitutional ), PAMHITSFOSS(TRAVEL)
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 ʹ ͞ĂŶ/ŐŽƚŽƚŚĞĐŚŝƌŽƉƌĂĐƚŽƌ͕ďĞĐĂƵƐĞƚŚĞŝŶƐƵƌĂŶĐĞ give me more if I go there than to the
ŚŽƐƉŝƚĂů͍͟
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.
-‐‑ >ĞĨƚĂƌŵƉĂŝŶĂĨƚĞƌŵŽǀŝŶŐƐŽŵĞďŽdžĞƐ͘EŽůĞƐŝŽŶƐ͘ŽĞƐŶ͛ƚŚƵƌƚǁŝƚŚƵƐĞ͕ďƵƚŚƵƌƚƐǁŝƚŚ 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 ʹ ͞/ƐŝƚƐŽŵĞƚŚŝŶŐƐĞƌŝŽƵƐ͍͕͟͞ĂŶ/ŬĞĞƉǁĂůŬŝŶŐ͕/ůŝŬĞƚŽǁĂůŬ͍͟
͚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
Neuro-‐psychiatric
32.62 Y F, c/o hearing loss
-‐‑ zĞƐƚĞƌĚĂLJƐŚĞĚŝĚŶ͛ƚŚĞĂƌƚŚĞĨŝƌĞĂůĂƌŵĨƌŽŵŚĞƌďƵŝůĚŝŶŐ͕
-‐‑ Problems hearing with both ears
-‐‑ She takes osteoporosis meds she tells you the commercial names
-‐‑ ^ŚĞƵƐĞĚŚĞĂƌŝŶŐĂŝĚƐŝŶƚŚĞƉĂƐƚďƵƚϲŵŽŶƚŚƐĂŐŽŝƚĚŝĚŶ͛ƚŚĞůƉĂŶLJŵŽƌĞ so she stopped using them
-‐‑ She lives alone (ask her about support)
-‐‑ zŽƵŚĂǀĞƚŽƐƉĞĂŬůŽƵĚĞƌ>>ƚŚĞƚŝŵĞ͕ĂƐŬŚĞƌŝĨƚŚĞƌĞ͛ƐĂŶLJĞĂƌƚŚĂƚƐŚĞŚĞĂƌƐďĞƚƚĞƌƚŽƚĂůŬƚŽƐŚĞǁŝůůƚĞůůLJŽƵƚŚĂƚ
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
ŶĞƵƌŝƚŝƐ͕Ws͕ǀĞƌƚĞďƌŽďĂƐŝůĂƌŝŶƐƵĨĨŝĐŝĞŶĐLJ͕ďƌĂŝŶƐƚĞŵŽƌĐĞƌĞďĞůůĂƌƚƵŵŽƌ͕DĞŶŝĞƌĞ͛ƐĚŝƐĞĂƐĞͿ
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
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
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 Q͗͞/ƐƚŚŝƐŐŽŝŶŐƚŽŚĂƉƉĞŶĂŐĂŝŶƌ͍͟
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.
-‐‑ ĂƵŐŚƚĞƌŚĂƐŶ͛ƚŵĞƚŚŝŵŝŶƉĂƐƚϴŵŽŶƚhs.
-‐‑ 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
ŚĞ͛ƐŚĂǀŝŶŐŝŶƐŽŵŶŝĂ͘
-‐‑ 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,
-‐‑ ŚĞ͛ƐŐĂLJƐĂĨĞƐĞdžƉƌĂĐƚŝĐĞƐ͕
-‐‑ 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.
-‐‑ tĂƐŶ͛ƚĚŽŝŶŐĂŶLJƚŚŝŶŐŝŶƉĂƌƚŝĐƵůĂƌǁŚĞŶŝƚƐƚĂƌƚĞĚ͘
-‐‑ 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 ʹ ͞ƐŬƐĂůůƚŚĞƚŝŵĞĂďŽƵƚǁŚĂƚŝƐŐŽŝŶŐǁŝƚŚŚŝŵĂŶĚŝĨLJŽƵĐĂŶŐŝǀĞŚŝŵŵĞĚŝĐĂƚŝŽŶĨŽƌŚŝƐƉĂŝŶ͘͟
57. Chest pain. Female 40 yo.
-‐‑ RR ʹ 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