Current Case Review

Transcript Current Case Review

Generic Case Review

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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: Head: Respiratory: Cardiac: GI: GU: MSK: Neuro:

Psychiatric weight change, fever, chills, weak headache, nasuea, vomitting SOB, wheeze, cough HTN, murmurs, angina, palpitations appetite, n/v, incont., const/diarrhea frequency, hesitancy, urgency, dysuria hematuria, incont., stones, no dyspareunia, no discharge muscle weakness , flank pain parasthesias, loss of sensation 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 MSK No discharge, bleeding, nodules or masses Positive lloyd’s test No weakness, mild tenderness in R flank EXT TTA T11-L-1 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 10 14 g/dl 40 Chemistry 140 4.2

100 24 Pregnancy Test Negative 300 8.0

100 1.1