PE & C a s e s

1.
2.
3.
4.
5.

1- 37 y/o F, c/o abdominal-LLQ pain for 3 days.

VS: BP: 110/50, HR: 96
Obese. Her heavy periods were earlier than usual. She has been using 6
pads/day. NO risk factors.
She works as a storage manager.
When was your LMP? How often is your
Ruptured Ectopic
Rectal/ Pelvic exam
menstrual period? How long does it last?
Pregnancy
Cervical cultures

How many pads or tampons do you use in

Ovarian Torsion
analysis
the heavy day? Do you have bleeding
Spontaneous Abortion
CBC w/dif
right now?
Ruptured Ovarian Cyst
Urine hCG
Any cramps? Any vaginal discharge?
PID
US Pelvis /
Any bleeding or spotting between
CT Abdomen/Pelvis
periods?

When was your last PAP smear? Was it

normal?
Do you take contraceptive pills?
Do you use condoms?

BASED ON YOUR ANSWERS & physical exam:

You might have some INFLAMMATION, an infection or a CHEMICAL IMBALANCE in your
body which in MEDICAL TERMS we call

2- * * * * 42 y/o F c/o heavy menses. 6d/5-6 wks, 12 pads/d. Cramps during

menses, hot flashes. Mother menopause at 40 y/o.
1. Premature Ovarian
Failure
2. Uterine Fibroid
3. Dysfunctional Uterine
Bleeding
4. Endometrial Cancer
5. Spontaneous abortion

Genital/ Pelvic
exam
Hysteroscopy
CBC
Urine hCG
Endometrial
curettage
US Pelvis

Any bleeding/ Is this bleeding your

regular menstrual period?
When was your last menstrual period?
How often is you menstrual period? How
long does it last?
Do you have cramps?
How many pads or tampons do you use
per day?
Any bleeding or sporting between
periods?
Any racing heart/ Any unusual sweating
or hot flashes?

Dd

Dd

3- 29 y/o black F c/o chest pain.

The pain is getting better when she lean forward and worst when she lies down.
Racing heart. She is a heavy cofee drinker, 6-8 cups/day to stay awake. She is in
lot of stress because she is a teacher and has 2 children.
1.
2.
3.
4.
5.
6.

Pericarditis
Angina
Panic
GERD
Esophagitis
Hyperthyroidis
m
7. Cofee Abuse
8. hypOglycemia

CBC, glucose electrolytes

CK-MB, troponins, ECG
Upper endoscopy, pH
monitoring
XR Chest, CT Chest
TSH
ECG, Echocardiography

Any difficulty breathing - cough/ mucus (color)/

blood
- difficulty
walking
- how many
pillows
Racing heart do you drink cofee/ how much
- dizziness/weakness/
numbness
Food coming up? (Reflux)
- bad taste in the mouth
- sore throat
- difficulty swallow (Dysphagia)
- any burning in your chest
Any unusual sweating?
Any difficulty to adjust to cold or hot
temperature?/ any unusual hear loss?

b
4- Ms. De Feez (foreign accent), 47 y/o F, c/o knee pain.
PATIENT in real life had RED SWOLLEN KNEE.
RT knee very swollen. Started a week ago, non related w/anything. She was
sleeping and the pain woke her up. History of HTN and take HCTZ 25mg/day.
1.
2.
3.
4.
5.
6.

Gout
Pseudogout
SLE
Septic Arthritis
Rheumatoid
Arthritis
Lyme Disease

CBC
Knee aspiration
and synovial fluid
analysis
ANA, anti-dsDNA, RF
XR - right knee
Blood culture

Do you have painful joints anywhere

else?
Any difficulty moving in you leg?
Any rash or oral ulcers?
Are you sensitive to sunlight?
Have you ever had STD?
Any stifness in the morning?
Have you traveled recently?/ Any tick
bite?/ Any skin rash?

5- Mr. Miller 48 y/o M, c/o strange episodes.

Typical white Jewish lawyer w/attitude. He married 3 months ago. Impending
death sensation
He feels hot flushes and racing heart, sudden onset, non related w/ anything. This
happened even in bed resting, but not sleeping. He overreact when I asked for
other symptoms.
Challenging Q: Dr. do you think this is going to happen to me again?
Why are you asking me such stupid questions??
Mr. Miller, I understand your concern. These are standard questions we ask
everyone one.
6

CHIEF complaint could also be PALPITATIONS: 1.

2.
3.
4.
5.

Panic attack
Adjustment Disorder
HypERthyroidism
Pheochromocytoma
Carcinoid Syndrome

CBC
ECG
TSH
Serum/urine catecholamines
24 h urine 5-HIAA

Describe you episodes?

Any racing heart? Do you drink a
cofee? How much?
Any chest pain?
Any unusual sweating?
Any difficulty adjusting to cold or
hot temperature? Any unusual
hair loss?
Any diarrhea?
Any change in you life recently?

6- * * * * 60 y/o, F, c/o urinary incontinence. Irina had TWICE

Obese, G3 P3 A0, also she refers that the children were big babies. She has been
married for 48 years. She is retired and enjoying life. She wets her pants every
time she coughs or with any efort.
Challenging Q: She will travel in 2 weeks; do you think I can travel, because this is
embarrassing?
BUSON in CLINICAL ENCOUNTER- for questions. Could be UTI
PE is basic and do CVA ..
Closure= now Im telling you what I am thinking.
But to rule out other possibilities it is important to do a pelvic exam.
1.
2.
3.
4.
5.

Pelvic Floor weakness

UTI
Over flow
incontinence
Uterine Prolapse
Cystocele

PELVIC EXAM
UA/Uculture
US Pelvis
Cystoscopy
CBC

Any pain or burning during urination?

Any blood in your urine?
Do you have to push to urinate?
Are you urinating more often? and at night?

Do you feel your bladder empty after

urination?

7- * 67 y/o F, c/o cough. Ask for GREEN MUCUS

Temp: 100.5
Obese. SOB sometimes and wet cough with green mucous, no blood, no pillows to
sleep, no racing heart. History of bronchitis. Heavy smoker. She used marihuana
when she was young.
CHECK LUNGSa
TACTILE FREMITS: 99, 99, 99,
NOW I AM GOING TO TOUCH AND TAP YOUR BACK.

1.
2.

COPD
Bronchiectasis

CBC
PFTs

Any difficulty breathing - cough/

mucus (color)/ blood

3.
4.
5.
6.

Lung abscess
Lung Cancer
Tuberculosis
CHF

CXR
Bronchoscopy
Sputum G stain, PPD
ECG, BNP

difficulty walking

- how
many pillows
Chest pain/Abdominal pain?
Weight loss? Night sweats? When did
you do last PPD?

8- 68 y/o M, c/o fatigue.

SAD
SUICIDAL PLANS- HURTING YOURSELF OR OTHERS? HAVE GUNS IN THE HOUSE?
HAVE A PLAN?
ANY DIFFICULTY CONCENTRATING ON YOUR DAILY ACTI
CHECK HAIR SKIN, HAIR, NAILS FOR PALLOR, CHECK THYROID, PRETIBIAL
Myxadema
Fatigue started when son and grandchild left the house.
PMHx of Eye surgery. Smoker.
1. Adjustment
disorder
2. Depression
3. Hypothyroidism
4. Anemia
5. Malignancy

CBC
UA toxicology
TSH
Peripheral smear
CT Chest/
Abdomen

Do you feel sad? Yes: Suicidal ideas/ plans/

- Do you feel like hurting
yourself? Others?
- Do you have guns?
- Any change in your life
recently
Any difficulty adjusting to cold or hot temperatures?
Any unusual lose hair? (Hypothyroidism)
Any diarrhea/ constipation / loss weight (Malignancy)
Any racing heart? (Anemia)

9- * * * * 32 y/o F, black, c/o chest pain.

BP: 100/50
Radiation to the back. No stress. Father w/ HTN.
MAKE UP YOUR OWN DIAGNOSIS PANCREATITIS,

1.
2.
3.

Aortic dissection
MI
Peptic Ulcer

CBC, amylase, lipase

ECG, CPK-MB, troponin
Upper endoscopy, pH

Any difficulty breathing - cough/ mucus

(color)/ blood
-

Disease
Pancreatitis
Abdominal
Aneurism

4.
5.

101.
2.
3.
4.
5.

monitoring
Aortic angiography
US - Abdomen

difficulty walking
- how
many pillows
Racing heart do you drink cofee/ how
much
- dizziness/weakness/
numbness
Food coming up? (Reflux)
- bad taste in the mouth
- sore throat
- difficulty swallow
(Dysphagia)
- any burning in your chest

45 y/o F, c/o not feeling myself. Irritable, LMP 2 weeks ago.

Menopause
Hyperthyroidism
Pheochromocytoma
Carcinoid Syndrome
Hypoglycemia

CBC
TSH
Serum/urine
catecholamines
24 h urine 5-HIAA
Serum glucose

Any dryness of you skin/ Any

unusual sweating/ Any change
in your moods?
Any racing heart?
Chest pain?

1125 yo M, c/o diarrhea for 6 wks.

Watery diarrhea. Recent trip to Kenya. Large number of people sick in Kenya.
ABDOMINAL EXAM
DO RECTAL, STOOL FOR OVA LEUCOCYTES
1.
2.
3.
4.
5.

Parasitic
Gastroenteritis
Celiac Disease
Crohns Disease
Ulcerative colitis
IBS

Rectal exam, FOBT

Colonoscopy
Stool for ova and leucocytes
CBC
CT - Abdomen

Any change in color of your

stools?
Any blood? Is the blood on top or
mixed in the stools? Is it bright or
dark red?
Any abdominal pain/cramping? Do
you need to push?
Have you traveled recently?
Anyone around you have similar
symptoms? (Sick contacts)

121.
2.
3.
4.
5.

40 y/o F, c/o difficulty swallowing. Hx of GERD, getting worse recently.

Esophageal
Adenocarcinoma
Achalasia
Esophagitis
Systemic Sclerosis
GERD

CBC
Esophageal manometry
Upper endoscopy
Barium swallow
CXR

Food coming up? (Reflux)

- bad taste in the mouth
- sore throat
- difficulty swallow
(Dysphagia)
- any burning in your chest
- cough at night
Fatigue/ night sweat/ weight loss
Any change in your skin/ any rash

10

11

131.
2.
3.
4.
5.

50 y/o M, c/o lower back pain, radiates to the RT hip.

Disk herniation
Muscle strain
Lumbar Vertebral
Fracture
Metastatic prostate
cancer
Multiple myeloma

CBC, calcium
XR L spine
CT L spine
Serum/urine
protein
Electrophoresis
PSA??

Any weakness or numbness in your legs or

arms?
Any difficulty moving in your legs?
B
U
S
O
N
Do you feel empty your bladder after
urination?
Do you have urinary or fecal incontinence?
Fatigue/ night sweat/ weight loss

BACK PAIN AND EXAM

14* * * * 17 y/o M, c/o chest pain, constant, sharp pain, do sports w/ parents
permission.
From NEWLIST CHEST PAIN with DEEP INSPIRATION:
*** SPORTS- KARATE RIB FRACTURECostochondritis
Muscle sprain
Pneumotorax
Pericarditis
Fib fracture
Pneumonia

12

1.
2.
3.
4.
5.
6.
7.

Costochondritis
Pericarditis
Spontaneous
Pneumothorax
GERD
Pneumonia
Angina Pectoris
Aortic Dissection

CBC
ECG, CPK-MB, tropinin
XR-Chest
Upper endoscopy, pH
monitoring
XR T spine

Any pain when you move your

arms? Do you exercise?
Any difficulty breathing - cough/
mucus (color)/ blood
- difficulty walking
- how many pillows
Racing heart do you drink
cofee/ how much
- dizziness/weakness/ numbness
Food coming up? (Reflux)
bad taste in the mouth
sore throat
difficulty swallow
(Dysphagia)
any burning in your chest

15** * * 33 y/o F, c/o weakness and numbness of L arm.

Hx: Migraine. Mother w/ migraine. Muscle strength normal.
Challenging Q: Do you think that I have paralysis in my arm?

1.
2.
3.
4.
5.

Complicated Migraine
Cluster Headache
Tensional Headache
Temporal arteritis
Meningitis

CBC
CT Head
ESR
MRI brain
LP CSF analysis

Any blurry vision, dizziness?

Any pain or tenderness in your
face?
Any runny nose or watery
eyes?
Any injury of your head
recently?
Does anyone around you have
similar symptoms?

16* * * * 42 y/o F c/o heavy menses. 6d/5-6 wks, 12 pads/d. Cramps during
menses, hot flashes. Mother menopause at 40 y/o.
6. Premature Ovarian
Failure
7. Uterine Fibroid
8. Dysfunctional Uterine
Bleeding
9. Endometrial Cancer
10.
Spontaneous
abortion

Genital/ Pelvic exam

Hysteroscopy

CBC

Urine hCG
Endometrial

curettage

US Pelvis

17-

Any bleeding/ Is this bleeding your

regular menstrual period?
When was your last menstrual period?
How often is you menstrual period? How
long does it last?
Do you have cramps?
How many pads or tampons do you use
per day?
Any bleeding or sporting between
periods?
Any racing heart/ Any unusual sweating
or hot flashes?

Telephone, grandma calls for grandson w/ fever (Dylan)

13

1.
2.
3.
4.
5.
6.

Acute Otitis
UTI
URI
Meningitis
Scarlet fever
Rubella

Physical exam
CBC w/dif
Blood cultures
UA urine culture
CXR
LP-CSF
Throat cultures

Did you check Dylans temperature?

Any vomiting/ diarrhea?
Any runny nose?
Any ear discharge?
Is Dylan touching his face or pulling
his ear?
Any difficulty breathing?
Any cough?
Is Dylan crying more than usual?
Is Dylan sleeping more than usual?

1833 y/o, F c/o abdominal pain.

Lying down and in severe pain. She just seats for physical exam. LMP 6 weeks ago.
No OCP.
1.
2.
3.
4.
5.

Ectopic Pregnancy
Ovarian Cyst Rupture
Ovarian Torsion
PID
Appendicitis

CBC w/ dif
Urine hCG
Rectal/ Pelvic exam
US Pelvis
CT Abdomen/Pelvis
Cervical cultures
analysis

When was your last menstrual period?

How often is you menstrual period?
How long does it last?
Any cramps?
How many pads or tampons do you
use per day?
Any bleeding or sporting between
periods?
Any diarrhea/ constipation?
Any change in color of your stool?
Any pain or burning during urination?

1962 y/o, F, c/o chest pain.

SOB on exertion, swollen feet and dry cough sometimes
1.
2.
3.

CHF
COPD
Angina
Pectoris
4.
Myocardial
infarction
5.
Pericarditis

CBC, BNP
Pulmonary function
test
ECG, CPK-MB,
troponin
CXR, CT-Chest
Echocardiography

Any difficulty breathing - cough/ mucus

(color)/ blood
- difficulty
walking
- how many
pillows
Racing heart do you drink cofee/ how much
- dizziness/weakness/
numbness
Food coming up? (Reflux)
- bad taste in the mouth
- sore throat
difficulty swallow (Dysphagia)
- any burning in your chest

14

2036 y/o M c/o chest pain

Positive for heartburn.
1.
2.

GERD
Acholasi
a

3.

Peptic
Ulcer

4.
5.

MI
Costoch
ondritis
6.
Pericardi
tis

CBC, CK MB and troponins

Lower Esophageal
Manometry Upper
endoscopy, pH monitoring
XR Chest
CT Chest
ECG, Echocardiography

Food coming up? (Reflux)

- bad taste in the mouth
- sore throat
- difficulty swallow (Dysphagia)
- any burning in your chest
Any difficulty breathing - cough/ mucus
(color)/ blood
- difficulty
walking
- how many
pillows
Racing heart do you drink cofee/ how
much
- dizziness/weakness/
numbness

21Tommy w/jaundice. 4 days old., irritable

Mother O+ and father AChallenging Q: Does Tommy have to be hospitalized?
1.
2.
3.
4.
5.

Physiologic Icterus
Biliary Atresia
Hemolytic Anemia
Rotor Syndrome
Dubin Johnson Syndrome

1. PHYSICAL
EXAM

Serum bilirubin
CBC, Hb
Blood Type, Coombs
Test
US Abdomen

Any fever/ vomiting/ diarrhea?

How many diapers do you change per
day?
Any change in the color of his urine/
stool?
Is Tommy sleeping a lot?
Is Tommy crying more than usual?
Is Tommy being breast fed or taking
formula?
Any change Tommys appetite? Is
Tommy sucking well?
Do you know your blood type?
Did you have a blood transfusion
recently?

15

22** * 17 y/o M (Chinese), c/o Passed out when playing soccer.

Passed out for a few seconds. Racing heart. No drugs, no smoking, no sleep
deprivation.
Challenging Q: Do you think I can play next week?
1.
2.
3.
4.
5.

Hypertrophic
Cardiomyopathy
Cardiac arrhythmia
Hypoglycemia
Vasovagal syncope
Dehydration

CBC, electrolytes
ECG,
Echocardiography
Glucose
CT- Head
MRI- Brain

When did it happen?

Was anyone with you? Yes: Did they say
for how long you pass out? Did they say if
you had shaking movements? Did you
bite your tongue?
Any racing heart?
L lightheadedness
D dizziness
H headache
V blurry vision
C consciences LOC
W weakness/ numbness
I Any injury to your head recently?
U Did you loss bladder control? (pee
yourself)
G gait / loss of balance

2321 y/o, F, c/o shoulder pain.

No headaches. Fever. Multiple partners for the last 6 months.
1.
2.
3.
4.
5.

1.
2.

Septic Arthritis
Reactive Arthritis
Bursitis
Rotator Cuf Tears
Shoulder Dislocation

CBC
Join aspiration for culture,
Gram stein and Crystal
HLA B27
XR Shoulder
MRI - Shoulder

Do you have painful joints

anywhere else?
Any difficulty moving in your
arms?
Any redness or swelling of your
joints?
Any trauma recently?
Have you traveled recently?

2448 y/o, F, c/o heavy periods. LMP 6 weeks ago.

Challenging Q: Do you think is menopause?
When was your LMP? How often is your
Menopause
Genital/ Pelvic
menstrual period? How long does it last?
Pregnancy
exam
16

3.
4.
5.
6.

Endometrial Cancer
Thyroid Disease
Pituitary Tumor
Uterine Fibroid

Urine hCG
Hysteroscopy
TSH
CT - Head
US Pelvis

How many pads or tampons do you use in the

heavy day? Do you have bleeding right now?
Any cramps? Abdominal pain? Any vaginal
discharge?
Any bleeding or sporting between your
period?
When was your last PAP smear? Was it
normal?
Any racing heart? Do you feel hot or cold
when other dont? Any change in your skin or
hair?
Any nipple discharge?

2538 yo, M, c/o personal problems BP: 142/92

No HTN, no DM. No erections AM and PM. He started a new relation 3 months
ago.
1. ED caused vascular
diseases
2. ED due to DM
3. ED due to HTN
4. Psychogenic Erectile
dysfunction
5. Hypogonadism
6. Peyronies disease
7. Depression

Genital exam
CBC
Serum glucose
Testosterone
Prolactin, TSH
Doppler US - penis

Do you get erection at night? / morning?

On the scale from 1 to 6 how would you
rate your erection?
Do you still want to have sex? (Desire)
Are you thirsty more than usual?/ Do you
urinate more often than usual?
Any change in your medications recently?
Any change in your life recently?

2678 y/o M, c/o Difficulty to concentrate.

Sad and concern about his memory loss. Difficulty to remember daily activities like
apartment No...
Rx: Medication list = Albuterol x COPD Smoker. Hx: Cardiac Stent. MMS= normal
1.
2.
3.
4.
5.

Alzheimers disease
Vascular Dementia
Picks disease
Pseudodementia
Subdural hematoma

6.

Hyp

othyroidism

CBC
Electrolytes, glucose
CT Head
MRI Brain
EEG
TSH

What things are you forgetting?

Is it getting worse?
Any difficulty dressing and
bathing yourself?
Who pays your bills? Who does
your grocery shopping?
Do you feel sad?/ hurting or
other/ gun/ suicidal plan/ any
change in your life recently?
L lightheadedness
D dizziness
H headache
V blurry vision
C consciences LOC
W weakness/ numbness
I Any injury to your head
recently?
U Did you loss bladder control?
(pee yourself)
G gait / loss of balance

17

27** * 55 y/o F c/o palpitations

PMH: Hypothyroidism
Rx: Synthroid and weight loss pills. Associated w/ + lightheadedness. + Stress.
Works in costumer services but in her job are reducing personnel.
1.
2.
3.
4.
5.

Drug induced
Palpitations
Cardiac arrhythmia
Stress induced
arrhythmia
Pheochromocytom
a
Carcinoid tumor

CBC
UA toxicology
ECG
Serum/ Urine
cateholamines
24 h urine 5-HIAA

Any chest pain?

Any racing heart? Do you drink a
cofee/ How much? Any w/ n/ d
Any chest pain?
Any unusual sweating?/ headache/
weight loss
Any hot flashes / diarrhea

18

2890 y/o F, c/o Frequent urination

Burning sensation. Push and rush to urinate. Thirsty all the time.
Hx: UTI (3 times last year, untreated)
1.
2.
3.

Cystitis
Pyelonephritis
Diabetes
mellitus
4.
Pelvic Floor
Weakness
5.
Diabetes
Insipidus

B
Dysuria: Any pain or burning during
urination? Hematuria: Any blood in your
urine?
U
Urgency: Do you have to rush or
rush to urinate?
S
Stream: Any weakness in your
urinary stream? Any dribbling/leakage of
urine?
O
Frequency: Are you urinating more
often?
N
Nocturia: do you have urinate at
night?

CBC
UA cultures
Glucose
Genital/ Pelvis exam, US
Bladder
Fluid Deprivation test

Do you feel your bladder empty after

urination?

Are you thirsty more than usual?

Any change in your medications

recently?

293035 y/o, F, c/o cough

Dry, no mucous x 3 weeks. Smoker x 20 years. Work in nursing home
administration. PPD. No fever, no sweating. Hx: Flu, no risk contacts.
1.
2.
3.
4.
5.

Atypical Pneumonia
Lung Cancer
Pulmonary Fibrosis
Pulmonary
Tuberculosis
Sarcoidosis

CBC, electrolytes
PFTs
Sputum cultures, G
stain
PPD
CXR

Any difficulty breathing - mucus (color)/

blood
- difficulty
walking
- how many
pillows

Chest pain?

Any unusual sweating/ any weight

loss?

Do you have night sweat? / Have you

been exposed to anyone who has TB? /
When did you do last PPD?

Does anyone around you have similar

symptoms? / Any travel recently?

19

31* * * * Grandfather calling. Rachel is 3 y/o c/o diarrhea

Rachel had jaundice at birth, everything else is normal. Grandpa had to change the
diaper 3 times this morning.
1. Infectious diarrhea (viral,
bacterial, parasite)
2. Gastroenteritis
3. Colitis
4. Food Poisoning
5. Malabsorption

2. PHYSICAL
EXAM
CBC w/dif, Electrolytes
Blood cultures
Barium enema
US/ MRI/ CT Abdomen
Upper endoscopy

Is Rachels diarrhea related with

some food?
Any change in Rachels stool?
Any blood in the stool/ Is it on the
top or mixed? Is it bright red or
dark?/ Any mucus?
Any pain in Rachels stomach
area?
Does Rachel have pain when she
moves her bowel?
Any travel outside of the US
recently? / Does anyone around
Rachel have similar symptoms?
Is Rachel sleeping more than
usual?
Is Rachel crying more than
usual?
Is Rachel playful?
Do you give to Rachel plenty
fluids?

3260 y/o F, c/o dizziness for 3 weeks

+ Diarrhea, non bloody. HTN treated w/ Furosemide
1. Dehydration
2. Arrhythmia
3. Drug induced Orthostatic
Hypotension
4. Vasovagal Syncope
5. Cardiac Arrhythmia
6. Anemia

CBC,
Electrolytes
Peripheral
smear
ECG
Holter
monitoring
Echocardiograp
hy

Did you pass out?

Does anything happen
before the dizziness?

Any sudden movements

make you dizzy?

When you feel dizzy, do you

fall? Any difficulty walking?

Any haring loss?

Any racing heart?

L lightheadedness
D dizziness
H headache
V blurry vision
C consciences LOC
W weakness/ numbness
I Any injury to your head recently?
U Did you loss bladder control? (pee yourself)

20

G gait / loss of balance

3355 y/o F, c/o dizziness for 2-3 months.
+ hearing loss in R ear, w/ fullness sensation in R ear for 3 weeks, after a flight.
Hx: HTN treated w/ HCTZ. Rinne +
1.
2.
3.
4.
5.

Middle Ear Barotrauma

Meniere Disease
Acoustic Neuroma
Labyrinthitis
Benign Paroxysmal
Positional Vertigo

Audiometry
Tympanography
CT Head
MRI Brain
Dix Hallpike test

Did you pass out?

Does anything happen
before the dizziness? Any blurry vision?
Any sounds?

Any sudden
movements make you dizzy?

When you feel dizzy, do

you fall? Any difficulty walking?

Any haring loss? Is it

one ear or both? One: Which one? Have
you ever been exposed to loud noises?
Any pain or discharge from your ears?
Any ringing in your ears?
L lightheadedness
D dizziness
H headache
V blurry vision
C consciences LOC
W weakness/ numbness
I Any injury to your head recently?
U Did you loss bladder control? (pee
yourself)
G gait / loss of balance

3430 y/o, M, c/o cough for 1 week ago

Green mucous, he feels warm, chest pain, sharp when take a deep breathe. SOB
when talk and walk. Father died in a car accident and mother has breast cancer.
1.
2.
3.
4.
5.

Pneumonia
Lung Abscess
Tuberculosis
Bronchiectasis
Lung Cancer

CBC, electrolytes
PFTs
Sputum cultures, G
stain
PPD
CXR

Any difficulty breathing - mucus (color)/ blood

- difficulty walking
- how many pillows
Chest pain?
Any fatigue?/ Any unusual sweating/ any
weight loss?
Do you have night sweat? / Have you been
exposed to anyone who has TB? / When did you
do last PPD?
Does anyone around you have similar
symptoms? / Any travel recently?

21

3525 y/o F, c/o Abdominal pain (RLQ) for 6 months

LMP 2 wks ago, normal. No vaginal discharge or bleeding. Sexually active w/
boyfriend, use condoms. Episode of non-bloody diarrhea 3 days ago. No fever, no
vomit. + stress because study and work.
1. Crohns Disease
2.
Ulcerative colitis
3.
Pelvic
Inflammatory Disease
4.

5.

Celiac Disease

Irritable Bowel
Syndrome
6.
Parasitic Diarrhea
Celiac Disease

CBC, electrolytes, glucose

Rectal exam, FOBT
Pelvic Exam, Cervical
CULTURE, Cervical motion
Tenderness?
Colonoscopy
XR-Abdomen
CT Abdomen
Stool for ova and leucocytes

Does your pain

related with some food?
Any diarrhea/
constipation? How often?
Any change in
color of your stools?
Any blood? Is
the blood on top or mixed? Is it
bright or dark red?
Any cramping?
Do you need to push?
Have you
traveled outside of US recently?
Yes: Where?
Anyone around
you have similar symptoms?
(Sick contacts)

3665 y/o M, c/o fatigue

Sad because his wife was diagnosed w/ dementia 2 wks ago. Weakness, sleep
more than usual. Episode of dizziness yesterday while reading, bruises on the
arms. Father died from liver cancer. Mechanic.
Challenging Q: Do you think that I have a serious condition?
Mr. Brown, I understand your concern but first I need to do a rectal
exam, check for bleeding, run some blood tests, and take some xrays of
chest and abdomen. Once I have the results, I will be in a better position
to tell you about the diagnosis, I will be able to answer all of your
questions and we can talk about the treatment options.
Let me assure you, this hospital specializes in your condition and we
will do everything to make sure you are well taken care of. Your health
and safety is our number one concern.
1.

Malignancy

(Liver

CBC, glucose,

Do you feel sad? Yes: Suicidal ideas/ plans/ Do you feel

22

cancer)

2. Adjustment
Disorder
3. Depression
4. HypOthyroidism
5. Anemia
6. Vitamin D def.
7. HypERcalcemia

electrolytes,
Calcium
RECTAL, FOBT
UA toxicology???
TSH, Free T4, T3
Peripheral
smear ??
CT Chest/
Abdomen
Vitamin D

guilty about anything? / Do you feel like hurting

yourself? Others? /Do you have guns? / Do you loss of
concentration and interests in you daily activities? /Any
change in you energy level?/ Any change in your life
recently?
Any difficulty adjusting to cold or hot temperatures?
Any unusual lose hair?/ Any change in your skin?
(Hypothyroidism)
Any night sweat? / loss weight (Malignancy)
Any racing heart? (Anemia)

37* * * * * 50 y/o F, c/o hearing loss

Exposed to loud noises. Work in a factory and play in a country music band.
1.

Cochlear nerve
Damage
Otosclerosis
Acoustic Neuroma
Meniere disease
Presbycusis
MIDDLE EAR TUMOR
OTOTOXICITY
(Vancomycin)

2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

CBC w/ dif
Audiometry
Tympanography
CT Head
MRI Brain

Any haring loss?

Is it one ear or
both? One: Which one?

Have you ever

been exposed to loud noises?

Any pain or
discharge from your ears?

Any ringing in
your ears?
L lightheadedness
D dizziness
H headache
V blurry vision
C consciences LOC
W weakness/ numbness
I Any injury to your head
recently?
U Did you loss bladder control?
(pee yourself)
G gait / loss of balance

Sensory presbycusis
Neural presbycusis.
Metabolic (ie, strial) presbycusis
Mechanical (ie, cochlear
conductive) presbycusis.

12.

Any racing heart?

3845 y/o F c/o palpitations

Rx: HCTZ, Diltiazem, OTC pills to lose weight. Stress related to work.
1.
2.
3.
4.
5.
6.
7.

Drug induced arrhythmia

Stress related arrhythmia
HypERthyroidism
Pheochromocytoma
Orthostatic Hypotension
Carcinoid
Cocaine Abuse

CBC
ECG
TSH, Free T4, T3
Serum/ urine
Catecholamines
Urine 5-HIAA
Urine TOX SCREEN

Racing heart cofee/ how much do you

drink?
- dizziness/weakness/
numbness
Any chest pain?
Any unusual sweating?/ any headache?
Any difficulty adjusting to cold or hot
temperature?/
Any weight loss? Are you trying to loss
weight?
Decrease in urine output?
Is your urine darker (dehydrated)

23

DIARRHEA CHA CHA CHA/

Any stress?

39* * * * 68 y/o M c/o Neck pain. Ex-Truck Driver* ** ** *

Doesnt speak clearly. ETOH-CAGE: . History of neck Surgery.
1.
2.
3.

Cervical Stenosis
Muscle Strain
Cervical
Osteoarthrosis
4.
Cervical Herniated
Disk
5.
Torticollis
6.
Cervical Vertebral
Fracture

CBC
XR C-spine
MRI C-spine
Serum calcium

Any
Any
Any
Any
Any
Any

weakness in your arms or legs?

numbness in your arms of legs?
difficulty moving arms?
trauma recently?
fatigue?
headache? Any lightheadedness?

4060 y/o F c/o BLOOD IN STOOLS.

Tarry stools. History of Peptic Ulcer Disease. FH of multiple 1st degree w/diferent
types of cancer.
1.
2.

3.
4.
5.
6.
7.

Bleeding Gastric
Ulcer, peptic ulcer
Zollinger Ellison
Syndrome
(Gastrinoma part of
MEN 1?FMHx of
MEN1????)
Angiodysplasia
Gastric Cancer
Hemorrhoids?? NO!
Colorectal cancer
Diverticulosis

Rectal exam, FOBT

CBC, electrolytes
Secretin stimulation test (for
ZE Syndrome)

Upper endoscopy

, pH monitoring
Colonoscopy
Barium enema
AXR, CT Abdomen

Any diarrhea/ constipation?

How often?
Is the blood on top or mix
stools? Is it bright or dark red?
Any pain/cramping? Do you
need to push?
Any fatigue? / Night sweat?/
Weight loss?
Do you fee anything unusual
coming from your rectum?/ Any
pain during defecation?
Any travel recently?

41*elena cases*30 yo M c/o Abdominal pain

History of mononucleosis some wks ago. (ELENA HAD SORE THROAT some weeks
ago)
2.
3.
4.
5.
6.

1. Acute HIV
A little Splenic
Rupture
RIB FRACTURE
Kidney Stones
Rib Fracture
Splenic Infarct

CBC,
AXR
CXR

Sputum Gram stain analysis

Laparoscopy
Upper endoscopy

Do you exercise? Any

trauma recently? Any unusual
foods?
Is your abdominal pain
relieved by defecation? Is
defecation painful?
Does eating make pain
worse?

24

7.
8.

Pneumonia
Peptic Ulcer Disease

42-

Does eating make pain

better?
Any sore throat recently? /
Runny nose, fever?/ Swollen
glands and lymph nodes?/
Yellow skin/ weight loss?
Any cough? Any sputum?
Any mucus or blood?
Any SOB?
STRONG HAND SHAKE

TELL HIM DONT DO

CONTACT SPORTS

Ellen with constipation, over the phone. She eats macaroni and cheese.
25

1.
2.
3.
4.
5.
6.
7.

Functional
Constipation
Low fiber Diet
Encoparesis
Hirschsprungs
Disease
Hypercalcemia

Hypothyroidism
Anal Stenosis

1. PHYSICAL
EXAM
CBC, electrolytes, Ca, Mg
XRAY ABDOMEN, PELVIS
FOBT
Rectal BIOPSY
TSH, T3, T4
Rectal manometry
XR Abdomen

Any fever/ vomiting?

Any pain in Ellens
stomach area?

Does Ellen have pain when

she moves her bowel?

Any blood in the stool? Is it

on the top or mixed? Is it bright
red or dark?
Does Ellen eat fruits and veggies?
(Do recommendation!)
Does Ellen feel cold when other
dont?/ Any change in her skin?/ Is
Ellen playful?

26

1.
2.
3.
4.
5.

5061 yo grumpy M c/o fatigue.

He also has abdominal pain, in epigastrium. Loss of weight. FH: father died of
pancreatic cancer, heavy drinker.
Any pain?
Gastric cancer
1. Rectal exam, FOBT

Any diarrhea/
Chronic Pancreatitis
2. CBC
constipation?
/
lost
weight/ unusual
Pancreatic Cancer
3. Lipase, Amylase
sweating?
Alcoholic Hepatitis
4. AST/ ALT, Bilirubin

Any change in color of

Acute Gastritis
US Abdomen, ACT
your stools?
Rectal exam, FOBT

Change in the CALIBER

51-

of your stool?
ALTERNATING
DIARREAH CONSTIPATION?
Any blood? Is the blood
on top or mixed? Is it bright or dark
red?
Do you need to push?

Josh, M, 2 yo. Mother comes to the clinic = SOB

1. URI
2. Pneumonia
3. Epiglotitis
4. Ashthma
5. Allergic RXN
6. Croup
7. GERD
8. Meningitis
9.. Scarlet
fever
10. Otitis
media

CBC,
Blood culture, rapid strep
test
Sputum culture, G stain
LP-CSF analysis
Throat culture
CXR

Any runny nose /watery eyes?

Is josh Pulling at his ears?
or touching his face?
Any fever/ vomiting/ diarrhea?
Any difficulty breathing?
Any cough? Any sputum/ mucus/ blood?
Is Josh touching his face or pulling his ear?
Any rash/ yellow skin?
Any pain? Any shaking?
Is Josh crying more than usual?
Is Josh sleeping more than usual?
Any traveled?/ Does anyone around Josh
has similar symptoms?

5249 yo M c/o abdominal pain and diarrhea

No pain at night. He had a similar episode in Vietnam (veteran)
1.
2.
3.
4.
5.

Irritable Bowel Syndrome

Crohns Disease
Ulcerative colitis
Celiac Disease
Parasitic Diarrhea

53 23 y/o M c/o

CBC
Rectal exam, FOBT

Colonoscopy
XR-Abdomen
CT Abdomen

Stool for ova and leucocytes

hearing voices

Any change in
color of your stools?
Any blood? Is
the blood on top or mixed? Is it
bright or dark red?
Any weight
loss?/ fatigue?/

Is your pain
related with food?
Have you traveled recently?/
Anyone around you have similar
symptoms? (Sick contacts)

sleep deprivation

27

Challenging Q: Can I leave now?

1.
2.
3.

Substance abuse
Schizophrenia
Acute Psychotic
Disorder
4.
CNS Lesion
5.
Meningitis
6.
7.
Sleep deprivation
8.
Schizophrenic form
disorder

CT Head
SPINAL TAP
CBC
UA
toxicology
TSH
ECG
Blood alcohol
level
Syphilis, if
appropriate
ANA antibody
to detect lupus

erythematosus

54.

Command auditory hallucinations?

Do the voices tell you to do anything?
Do you ever feel like following the voices?
Do the voices order you to harm yourself or
other?
Do you have any problems falling asleep/
staying asleep/ waking up?
Do you feel sad? Yes: Suicidal ideas/ plans/ Do
you feel guilty about anything? /Do you feel like
hurting
Mini Mental Status EXAM
Is the voice in your head or outside?
Any changes in your hearing?
Do you hear voice right now?
What is the voce talking about?
yourself? Others? /Do you have guns? / Do you
loss of concentration and interests in you daily
activities? /Any change in you energy level?/
Any change in your life recently?
Neck Stifness? PHOTOPHOBIA? Neck stiffness
may suggest meningitis or subarachnoid hemorrhage
Neurological examination to look for focal neurological
signs and papilledema

Hoarseness of voice, 50 yo men, suddenly, singer in the church, smoker

for 40 years, 2.5 packs per day (2.5PPD)
1.
2.
3.
4.
5.

Larynx cancer
Laryngitis
Chorditis
GERD
Thyroid
disease
6. Mitral stenosis

CBC w/dif
Laryngoscopy
Upper endoscopy, pH
monitoring
TSH, free T4
Echocardiography
XR, CT - Chest

Any change in you voice?

Any cough/ difficulty swallowing?
Sore throat?/ any swollen lymph
nodes?
Any night sweat?/ weight loss/ fatigue?
Do you feel food coming up?/ bad taste
in you mouth?/

28

Tests that may be done include:

Laryngoscopy

Throat culture

Throat examination with a

small mirror

X-rays of the neck or CT

scan

Do feel cold when other dont?/ Any

change in her hair or skin/ Any change
in your mood?

Blood tests such as a complete

blood count ( CBC) or blood
differential may be done.

55. Female, fatigue, 76 years old lady black, fatigue for 7 days, same, drink 1glass of
wine per day, 6 times per week for 30 years, has bruise on her shoulder, feel dumb, eyes
look really yellow.
1.
2.
3.
4.
5.
6.

Alcohol hepatitis
Pancreatitis
Cirrhosis
Cancer of pancreas
Liver cancer
Subdural hematoma

CBC, w/dif
Amylase, lipase
AST, ALT, serum
bilirubin
US abdomen
CT abdomen
CT head, MRI brain

Do you feel sad? Yes: Suicidal ideas/

plans/ Do you feel guilty about
anything? / Do you feel like hurting
yourself? Others? /Do you have
guns? / Do you loss of concentration
and interests in you daily
activities? /Any change in you
energy level?/ Any change in your
life recently?
Any abdominal pain? Any diarrhea or
constipation?
Any change in you stool? Any blood?
Any night sweat? Weight loss?
Any change in your skin?/ rash/ yellow skin?
Any racing heart

Recent EF
123456-

18 y/o SOB give antibiotic basketball player

60 y/o Fatigue, depression, lost his job. Father suicidal.
50-60 y/o. almost pass out. I need a letter for my job.
25 y/o M Fatigue. Stomach Discomfort, cramps
30 y/o F c/c cough. Nurse, flu weeks ago, smokes, TB?
Pediatric. Diarrhea. Icterus at Birth
29

7- 40 y/o M, personal problems. Erectile Dysfunction

8- 60 y/o black. Pain in both knees. Stifness in the morning x 30 minutes. Plays golf
9- F low back pain. Trauma in her back with mail box. PMHx UTI, breast Ca surgery 7
years ago.
1055 y/o F dizziness. When change position. Also has Diarrhea.
1160 y/o F c/o Difficulty walking. SOB
Others:
1- 45 y/o hearing loss.
2- 62 y/o F blood in the stools
3- 48 y/o M, Chest pain
4- 30 y/o F nausea and Vomiting
5- Dylan with fever
6- 25 y/o m, Chest Pain
7- 70 y/o M cough.

30

31