Mini-CPX 6

Part 3: Developing a differential diagnosis and

diagnostic and management plan

Physical exam findings:

Vitals: Temp 97.1
HR 50
RR 12
Orthostats: Supine BP: 144/80; sitting BP: 136/76; standing
BP: 111/69
Gen: alert; pale complexion; appears comfortable, nontoxic; flat affect.
HEENT: no facial swelling; no acne. Normal distribution of scalp hair.
No abnormal facial hair. Palpebral conjunctivae pale. Sclerae nonicteric and mildly injected bilaterally. Oral mucous membranes
moist; buccal and gingival mucosae pale. No abnormal oral
mucosal lesions. No gum bleeding. Mild injection and
cobblestoning of the posterior pharynx; no posterior pharyngeal or
tonsillar erythema or exudate. Mild periorbital edema. Nasal
mucosa pale; turbinates boggy in bilateral nares; small amount of
clear nasal discharge present bilaterally.
Neck: neck tissues are symmetric without visible masses; no palpable
cervical LNs; thyroid is mildly, diffusely enlarged, nontender, and
diffusely firm; no thyroid nodules palpated.
Chest wall: no abnormal breast masses; no palpable supraclavicular,
infraclavicular, or axillary LNs.
CV: bradycardic rate. Regular rhythm. Normal S1 and S2. No S3 or
S4. No murmurs or other extra heart sounds. PMI located in the
left mid-clavicular line. JVP 2 cm above the sternal angle. Pulses
2+ centrally and peripherally. Cap refill 2 seconds.
Pulm: lungs clear to auscultation bilaterally. Normal respiratory rate
and effort.
Abd: soft, nondistended; normal active bowel sounds; nontender
throughout to both light and deep palpation. Liver span 8 cm;
normal liver edge contour. Spleen non-palpable. No other masses.
Extr: hands and feet cool; no clubbing, cyanosis, or pitting edema.
Nail beds pale and brittle; no splinter hemorrhages.

Skin: diffusely dry, rough, and pale; no jaundice; no rashes or other

lesions, including no petechiae, purpura, ecchymoses, striae, or
areas of hypo- or hyperpigmentation.
GU: no palpable inguinal LNs; no visible skin or mucosal lesions; no
active vaginal bleeding; no abnormal discharge; cervix normal in
appearance; normal bimanual exam. Normal rectal exam, without
visible blood or perianal lesions.
Neuro: Oriented x 4. CNs II XII intact, including normal visual fields.
Strength 5/5 in all muscle groups in bilateral upper and lower
extremities. Decreased sensation to light touch and pin prick on
the plantar and dorsal surfaces of feet bilaterally. Upper and lower
extremity DTRs 1+ throughout upper and lower extremities.
Normal attention and short-term memory. Cerebellar function
intact. Normal gait.

Instructions:
Based on the information given in this patients history and PE,
complete your write-up to include the following, which will essentially
simulate how youve completed your H&Ps for prior mini-CPX
cases:

Your assessment, including:

o Summary statement, including all major abnormalities noted in
the history and PE
o Your revised differential diagnosis for the patient, explicitly
noting your leading diagnosis

Your plan, including:

o Your diagnostic plan for the patient
o Your management (treatment) plan for the patient
o Your anticipatory guidance for the patient
o Your disposition for the patient

For each diagnostic study on your list, you must indicate the
specific reason you would obtain that study, in terms of how it is
relevant to your revised differential diagnosis for this patient. You
must include this information for every study, to receive credit.

Similarly, you must justify your management and your

disposition for the patient, citing the reason from your differential
diagnosis and assessment of the patients current clinical stability. You
must include this information to receive credit.