A -Year-Old with A -Year-Old with Medical Student Presentation Name of Student Date and time

Chief Complaint and History of Present Illness Concise statement of chief complaint Concise statement of chief complaint Quality/Location/radiation/severity Quality/Location/radiation/severity Chronology – onset, timing, duration, frequency, changes over time Chronology – onset, timing, duration, frequency, changes over time Aggravating/alleviating factors Aggravating/alleviating factors Associated symptoms Associated symptoms Pertinent risk factors Pertinent risk factors Attributions (what does patient think is causing the problem?) Attributions (what does patient think is causing the problem?) 2

Past History Past Medical History: Past Medical History: –diagnoses –complications/sequelae/progression –current management and status Surgical History Surgical History –Reason if appropriate 3

Medications and Allergies Current Medications Current Medications –Dosages, OTC meds., alternative therapies –Immunizations –Hormone replacement, aspirin, calcium –Devices –Nutritional supplements Allergies: Note specific reactions Allergies: Note specific reactions 4

Social History Tobacco, alcohol, drug, and caffeine Tobacco, alcohol, drug, and caffeine Exercise/diet Exercise/diet Travel /exposures Travel /exposures HIV risk factors HIV risk factors Occupation and current living situation Occupation and current living situation –Seat belts use, smoke alarms, helmet use, and gun safety Social cultural/ethnic background Social cultural/ethnic background Screening examinations Screening examinations 5

Family History Cancer Cancer Hypertension Hypertension Heart disease Heart disease Diabetes Diabetes Other relevant diseases Other relevant diseases Illness similar to present illness Illness similar to present illness 6

Reproductive/Sexual History Sexually active Sexually active Contraception; STD prevention and STD Contraception; STD prevention and STD Menarche (age) Menarche (age) Menses Menses Menopause (age) Menopause (age) Pregnancies; abortions: spontaneous; full- term, premature, living (Para Gravida format) Pregnancies; abortions: spontaneous; full- term, premature, living (Para Gravida format) 7

Review of Systems General: Fever; sweats; weight change; energy level General: Fever; sweats; weight change; energy level Skin: Rashes; pruritus; lumps or lesions Skin: Rashes; pruritus; lumps or lesions HEENT: HEENT: –Headache; trauma, vision; glasses; diplopia; inflammation; pain; hearing; tinnitus; vertigo; pain, epistaxis; obstruction; drainage; dental care; dentures; sores; sore throat Breasts: Lumps; discharge; pain; swelling Breasts: Lumps; discharge; pain; swelling Respiratory: Dyspnea; pleuritic pain; cough; sputum; wheezing; asthma; hemoptysis; cyanosis; snoring; apnea; TB exposure; PPD Respiratory: Dyspnea; pleuritic pain; cough; sputum; wheezing; asthma; hemoptysis; cyanosis; snoring; apnea; TB exposure; PPD 8

Review of Systems Cardiovascular: Chest pain; dyspnea-various types, orthopnea; edema; palpitations; claudication Cardiovascular: Chest pain; dyspnea-various types, orthopnea; edema; palpitations; claudication Gastrointestinal: Appetite; dysphagia/odynophagia; heartburn; nausea/vomiting/diarrhea; constipation; change in bowel habits; hemorrhoids; jaundice; hematemesis/melena/hematochezia Gastrointestinal: Appetite; dysphagia/odynophagia; heartburn; nausea/vomiting/diarrhea; constipation; change in bowel habits; hemorrhoids; jaundice; hematemesis/melena/hematochezia Genitourinary: Dysuria; nocturia; hematuria; frequency; urgency; hesitancy; incontinence; discharge Genitourinary: Dysuria; nocturia; hematuria; frequency; urgency; hesitancy; incontinence; discharge Musculoskeletal: Joint/back pain; swelling; stiffness; deformity; muscle aches Musculoskeletal: Joint/back pain; swelling; stiffness; deformity; muscle aches 9

Review of Systems Neurological: Dizziness; syncope; loss of coordination; weakness; memory changes; seizures; paresthesias Neurological: Dizziness; syncope; loss of coordination; weakness; memory changes; seizures; paresthesias Psychiatric: Depression; sleep disturbance; anorexia; anhedonia; suicidal/homicidal ideation; anxiety; eating disorders; hallucination; delusions; behavioral changes Psychiatric: Depression; sleep disturbance; anorexia; anhedonia; suicidal/homicidal ideation; anxiety; eating disorders; hallucination; delusions; behavioral changes Hematologic: Anemia; easy bruising; heavy bleeding Hematologic: Anemia; easy bruising; heavy bleeding Endocrine: Polyuria; polydipsia; heat/cold intolerance Endocrine: Polyuria; polydipsia; heat/cold intolerance Functional Status (optional): Activities of Daily Living: bathing; ambulating; toileting; transfer; eating; dressing Functional Status (optional): Activities of Daily Living: bathing; ambulating; toileting; transfer; eating; dressing 10

Physical Examination Vital signs and General Appearance Blood pressure (standing/lying if indicated) Blood pressure (standing/lying if indicated) Temperature Temperature Pulse Pulse Respiratory Rate Respiratory Rate Oximetry on _____ Oximetry on _____ Height and weight (if appropriate) Height and weight (if appropriate) 11

Physical Examination Head / Face /Ears / Nose / Mouth /Neck Head / Face /Ears / Nose / Mouth /Neck 12

Physical Examination Chest Chest 13

Physical Examination Abdomen Abdomen 14

Physical Examination Neuromuscular Neuromuscular 15

Physical Examination Rectal and Genitalia Rectal and Genitalia 16

Physical Examination Osteopathic structural examination Osteopathic structural examination 17

Differential Diagnosis What is the differential diagnosis of this patient’s problem based on symptoms and signs? What is the differential diagnosis of this patient’s problem based on symptoms and signs? 18

Differential Diagnosis 19

What Testing is Indicated? 20

Test Results

Discussion of Disease Process 22

Discussion of Management 23

References 24

Questions 25