1.

22 YO male c/o abdominal pain (emergency)

a. vomited once, liquidy, in the morning (yellow/clear)
b. fever, nausea
c. 10/10 RLQ pain
i. pain starts in the epigastric region
d. had traveler diarrhea 1 yr ago (took Imodium)
i. however no he has no diarrhea or constipation currently
e. has had stomach problems for years
f. had loose stools yesterday but not diarrhea exactly
i. he noted that it was related to some food (milk, dairy products)
g. has a kidney shaped container (has no fluid inside of it)
h. patient in lying on the bed in distress (in fetal position)
i. wt. loss and no appetite
j. PE: Rovsing, rebound, CVA tenderness, and Murphy
i. Rovsing was positive
ii. Rebound will only be positive if there is rupture
iii. Positive guarding and rigidity
k. Differentials:
i. Appendicitis
ii. IBD (Crohns)
iii. IBS
iv. Lactose intolerance
v. Gastroenteritis
l. Workup:
i. CBC w/ diff
ii. Electrolytes
iii. Abdominal ultrasound
iv. CT of abdomen
v. Rectal exam w/ FOBT
m. Counseling: Tell patient to not take anything by mouth until the test
results come back (NPO)
2. Middle age female c/o dizziness
a. LMP was 6 weeks ago before that it used to be every 4 weeks
b. Nausea, vomiting?, early morning fatigue
c. Under stress
d. Palpitations
e. No diarrhea
f. Sexually active, no con doms
g. DDx:
i. Pregnancy
ii. Cardiac arrhythmia
iii. Anemia or orthostatic hypotension
 1. (ask about amount of bleeding)
h. Work up:
i. Urine Beta HCG
ii. Pelvic Exam
iii. Pelvic ultrasound
iv. EKG and Holter monitor
v. CBC and electrolytes
vi. Iron studies
vii. If you write orthostatic hypotenstion, then put orthostatic
vitals
3. 17 YO c/o low school performance
a. NO PHYSICAL EXAM
b. Distracted
c. Forgetful (forgot his keys)
d. Worried about future
e. Difficulty concentrating
i. Cant do homework well
f. No problems w/ teachers or parents
i. But having problems in soccer practice
g. Started from early age (usually before 12 years of age to dx ADHD)
h. No mood changes
i. No problem sleeping
j. Wants parents to be proud
k. Father was a high school drop-out
l. Smokes Marijuana (for 2 yrs), snorts cocaine (for 1 yr)
i. Drinking alcohol?
m. Started having sex recently
n. DURING ENCOUNTER:
i. Screen for depression (SIGECAPS)
ii. Screen for conduct disorder (ask about breaking law, getting
into trouble, rule breaking behavior, aggression)
iii. Screen for ADHD questions:
o. DDx:
i. ADHD
ii. Substance abuse disorder
p. Work up:
i. Physical exam
ii. Urine tox
iii. Beck depression inventory
iv. TSH, FT4, FT4
v. Full mental status exam
4. 17 y/o female w/ painful urination (Brittany)
 a. POSSIBLE PHYSICAL EXAM? (abdomen and CVA)
b. Painful urination
i. Burning
c. 2 UTI in the past that resolved (treated)
d. Bump in genital region (only one)
i. Has not seen the bump
ii. Bump is itchy, painful and burning w/ peeing
e. Sexually active w/ multiple partners in past few months
i. 8 in past yr
ii. no condoms
f. clear vaginal discharge (always had the discharge)
g. tried weed but didnt like it
h. DURING ENCOUNTER:
i. Ask about the location of the lump
i. DDX if painful bump:
i. UTI
ii. Vulvovaginitis/Cervicitis
iii. Herpes virus infection
j. Workup:
i. Genitopelvic exam
ii. UA and urine culture
iii. CBC w/ diff
iv. Cervical discharge culture and gram stain
v. NAAT for Chlamydia and gonorrhea
vi. Wet mount, KOH prep
vii. TZANCK smear
k. Challenging questions:
i. Will the HPV vaccine protect me from all the STDs?
ii. My friend told me that you will get a STD after having sex w/
200 partners, how many partners do I need to have sex w/ to
get a STD?
iii. Will you not tell my mom?
l. DDX if painless bump:
i. UTI
ii. Cervicitis/vulvovaginitis
iii. Syphilis (then order VDRL/RPR)

5. 20 y/o F stressed out

a. worried about her grades getting worse (got a C in biology class)
i. has a test and is getting stressed
b. insomnia
 i. sleeping for only 4-5 hrs a night
ii. early morning awakenings
iii. wakes up in the middle of the night v
c. palpatations
d. fatigue
e. drinks lots of coffee (4 cups/day)
f. heat intolerance
g. wt. loss?
h. she does Yoga (once a week )
i. SIGECAPS negative
j. Distracted easily
k. Decreased sex drive
l. PHYSICAL EXAM:
i. Thyroid, DTR, conjunctivae, tremors, CVS, pulses, pretibial
edema, AOx3
m. CQ: Do you think attending a workshop at my school would help me?
n. DDX:
i. Caffeine induced insomnia
ii. Hyperthyroidism
iii. Stress induced insomnia/GAD
o. Workup:
i. TSH, FT3,FT$
ii. Urine toxicology
iii. Beck Depression inventory
iv. Polysomnography
v. Full mental status exam
6. 50 YO F C/o tightness in the throat/chest
a. Coming from the anterior chest
b. No pain in the chestits just tight
c. Happened when mowing the lawn
d. Initially went away w/ tums but no longer relieved
e. No pain during swallowing
i. DDx: Angina, GERD, MI
7. Upper chest pain (Continuation of above case)
a. Travels to neck
b. Pain gets worse w/ exertion alleviated w/ rest
c. Pmh: HTN (HCTZ and Lisinopril)
d. Hx of heart burn
e. This episode was treated w/ OTC meds
f. Spicy meals triggers the episodes
g. Wants to go to Africa in 3 months
h. CQ: want to travel to Africa?
 i. Workup:
i. EKG, Troponin, CPK-MB, upper endoscopy, esophageal pH
monitoring, ECHO, CBC
8. Chubby old lady (42 y/o) c/o sleeping problems
a. Snoring
b. Not refreshed
c. Tired upon waking
d. Does not relate to any particular event
e. Got divorced 4 months ago
f. SIGECAPS are all negative
g. PHYSICAL EXAM:
i. thyroid exam, DTR, pulses, mouth examination, lungs
h. DDx:
i. OSA
ii. Adjustment disorder
iii. Hypothyroidism
i. Workup:
i. Polysomnography
ii. Nocturnal pulse oximetry
iii. Full mental status exam
iv. TSH, FT4,FT3
v. CBC
9. Middle age man c/o not feeling like himself
a. He is wearing black glasses
b. Onset is 3-4 months
c. He feels very angry about work
d. SIGECAPS are all positive
i. No suicidal thoughts or homicidal thoughts
e. Problems w/ sleep
f. Doesnt feel fresh during the day
g. Weight loss
h. He is a salesman at Best buy, angry because people are buying from
amazon
i. Mother had mood disorder
j. He doesnt want to have sex
k. DIGEFAST is negative
l. Make sure to ask how his personality was befor these few months
m. CQ: How could I be depressed if I feel angry all the time?
n. PHYSICAL EXAM:
i. Thyroid, DTR, CVS, MMS
o. DDX:
i. Major Depression
 ii. Hyperthyroidism
iii. Bipolar (aggression, irritable, mother has history of psych
issue, insomnia)
p. Workup:
i. Polysomnography
ii. CBC
iii. Beck depression inventory
iv. Full mental status examination
v. TSH, FT4, FT3
vi. CT of head/MRI of brain
10. Old lady w/ low back pain
a. Lower abdominal pain (but not tender)
b. Previous episode of UTI 25 yrs ago
c. Nausea
d. Vomiting
e. Fever
f. Wants to go on a trip
g. Has hematuria
h. PHYSICAL EXAM:
i. Abdominal, CVA (positive bilateral CVA tenderness)
ii. Eyes, check for edema
i. DDx:
i. Pyelonephritis
ii. Nephrolithiais
iii. Cystitis
j. Workup:
i. CBC w/ diff and electrolytes
ii. UA and urine culture and sensitivity
iii. BUN/Cr
iv. Non contrast CT of abdomen and pelvis
v. Genitopelvic exam
11. Young black guy c/o night sweats
a. Night sweats
b. Talking really fast
c. Sexually active
d. DDx: Acute HIV, TB, lymphoma
12. Elderly man c/o abdominal discomfort
a. Denies any wt. loss or gain
b. But reports that his trousers no longer close (has a bigger stomach)
c. Nausea
d. No bowel
e. Decreased appetite
 f. SH: chronic alcoholic and IV heroin abuser for 20 yrs
g. PHYSCIAL EXAM:
i. Abdomen (ascities and organomegaly), eyes for sclera, LE for
edema, skin for discoloration
ii. Skin for rash and needle marks
h. DDX:
i. Alcoholic cirrhosis
ii. Viral Hepatitis induced Cirrhosis
iii. Liver cancer
i. Workup:
i. AST, ALT, INR, Albumin
ii. CBC and electrolytes
iii. Abdominal ultrasound
iv. Paracentesis for ascites
v. EKG
vi. Total bilirubin, indirect bilirubin
13. Woman c/o insomnia
a. Found wandering around the room, not smiling
b. Sisx of depression (ask about SIGECAPS)
c. When asked further she admits that her cousin has recently died
i. Cousin was abusing her sexually since age 12
1. She had never told anyone about it (did not inform the
police)
d. Shes been living alone, managing fine
e. She wants to kill herself (counsel her because she has a plan)
i. Screen for depression, hypothyroidism
ii. Do a minimental (AOx3), thyroid gland, DTR
iii. DDx: Major depression, PTSD,Hypothyroidism
1. Maybe ask about PTSD (when did the abuse stop)is
she having flashbacks, nightmares, reliving the abuse in
her mind, avoiding certain stimuli

Any flash back

Have you tried avoided
14. 18 YO c/o missed menses for 3 months
a. for last 6 months has had irregular periods
b. menarche at 12, had irregular periods until 15 yrs of age when she
started having normal menses
c. sexually active w/ bf, no condoms
d. no nausea or vomiting
e. no hirsutism
f. no exercise or dieting
 g. DDx: Pregnancy, PCOS, ???

15. ADHD SOB*2 Shoulder pain constipation upper abd pain domestic abuse heel
pain head injury burning urine chest pain chest and neck pain
16.