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Published byBrett Harrell Modified over 9 years ago
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Generic Case Review www.drzaid.com
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Chief Complaint
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What questions do we want to ask this patient?
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CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Differential Diagnosis Treatment History of Present Illness
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CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Differential Diagnosis Treatment Past Medical History
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CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Differential Diagnosis Treatment Medications
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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
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CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Differential Diagnosis Treatment Social History
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CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Differential Diagnosis Treatment Family Medical History Mother- Father-
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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
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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
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CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Differential Diagnosis Treatment Differential
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CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Differential Diagnosis Treatment What do we want to order?
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CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Differential Diagnosis Treatment Labs
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CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Differential Diagnosis Treatment CBC 10 14 g/dl 40 300 Chemistry 140 4.2 100 24 8.0 1.1 100 Pregnancy Test Negative
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CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Differential Diagnosis Treatment
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CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Differential Diagnosis Treatment Differential
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CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Differential Diagnosis Treatment Diagnosis
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Thank you! Questions, comments, concerns?
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