Generic Case Review

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 Allergies NKDA 3 rd year medical students that ask too 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 History Mother- 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, weak Head: headache, nasuea, vomitting Respiratory: SOB, wheeze, cough Cardiac: HTN, murmurs, angina, palpitations GI: appetite, n/v, incont., const/diarrhea GU: frequency, hesitancy, urgency, dysuria hematuria, incont., stones, no dyspareunia, no discharge MSK: muscle weakness, flank pain Neuro: parasthesias, loss of sensation Psychiatric- Pt is not depressed

CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Differential Diagnosis Treatment Physical Exam VS- BP- 140/87 T-98.2 R-16 P-82 General- Pt is well nourished and AxOx3 Heent- EOMI, PERRLA, no vision changes CV- RRR w/o murmurs or rubs, clicks or gallops RESP- Clear to auscultation bilaterally, no wheezes Abdomen- Soft, NT, ND, no masses, BS, no bruits GU- No discharge, bleeding, nodules or masses Positive lloyd’s test MSK- 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 g/dl Chemistry Pregnancy Test Negative

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?