godhelp

2010-04-14T08:07:00.000-07:00

The most difficult part of the exam is time maintenance. The examination must be completed
in 15 minutes. You must make the optimum use of your time.
Introduction and greeting:
l "Hello Mr. Xyz. Good morning or Good afternoon. I am Dr. xyz. It’s nice to meet you
(shake hand).
l Next ask: "What brings you to see me today?" or "What brings you in today?"
l SP will tell you the chief complaint (cc).
l Then ask one open- ended question: "Could you please describe to me exactly what is
going on or more about your problem?"
l After the S. P. gives some extra history ask about any other important facts that
haven’t been discussed.
Location:
l Your initial concern is: "Where is the problem?" or "Can you please show me exactly
where it hurts?"
Onset & duration:
l Always ask for the onset and duration of the problem so you can know whether the
problem is acute, subacute, or chronic.
l "When did it first start?" or "When did you first notice the problem/pain?"
l If the cc is chest pain: "When did it first start?"
l If the cc is vaginal discharge: "When did you first notice the discharge?"
l Then ask about the onset: "Was the onset all the sudden or progressive?"
l Next, ask follow up questions regarding the cc:
Intensity:
One should always ask about the intensity or severity of the problem, especially if the
complaint is pain.
l Ex. "On a scale of 1-10, with 1 being the least painful and 10 being the most painful,
which number would describe your pain?" or "How would you grade your pain on a
scale of 1-10?" - Ask this way and they will definitely give you a number.
l If the cc is not a pain you can assess its severity by asking questions such as: "How
bad is it?" "Does it interfere with your daily activities?" or "Does it interfere with your
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sleep?"
Quality:
l The quality of the pain may tell you the cause of the pain, i.e. a burning pain as in acid
peptic disease and GERD.
l "How do you describe your pain?"
Frequency:
l Always ask about how frequent the problem is?
l Ex." Is it constant?" or "Does it come and go?" If it is intermittent, "How often does it
occur? How long does it last? How do you feel between attacks?"
Radiation:
l If the complaint is pain ask questions like, "Does the pain move?" or " Has it changed
location?”
Aggravating & Precipitating factors :
Aggravating and precipitating factors might give you a clue as to the cause of the problem.
For example, if food aggregates the epigastric pain a gastric ulcer is most likely the cause.
l Ex1: "What were you doing when it first began? Have you ever found anything that
makes your problem/pain worse? "
l Ex2: "Do you have any idea of what might have brought this on?" or "What brings it
on?"
Relieving factors (alleviating) factors:
Along with aggravating and precipitating factors these will also help you in making a
diagnosis. For example: food will relieve pain in duodenal ulcer.
l Ask questions like, " Have you ever found anything that makes your problem better?"
or "Have you ever successfully treated yourself?”
Associated problems:
Ask another open- ended question:
l Ex." Have you had any other problems?" or " Do you have any other symptoms besides
chest pain?"
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l When you ask the SP like this, the SP may ask you "Like what?" That's why you have
to continue with all the pertinent positives and negative symptoms.
Fever:
If you think SP’s fever is due to infectious origin, or the suspecting condition is associated
with fever, you need to ask questions about it:
l "Do you have a fever? Have you had a fever?" (If yes), "How long have you had a
fever?"
l "How high did your fever get? Was it a low-grade or high-grade fever?"
l "Is it a continuous or intermittent fever?"
l "Is it accompanied with chills and/or sweating?"
Cough:
l "Do you have a cough?"
l "Is it a dry cough or productive cough?" or "Do you bring up sputum?"
l If it is productive then "what color is/was it?"
l "Is/Was there any blood in it?"
l "Is/Was it foul smelling?"
l "How much is/was it?" "Is it a teaspoon (tsp), tablespoon (tbsp), or a cupful (cp)?" (for
quantity assessment always use these measurements, even bleeding per rectum).
l In all chronic cough patients don't forget to ask about HIV status and tuberculosis.
They will not tell you until you ask about his HIV status*. You should also ask about
drug intake especially about the use of ACE inhibitors*
Shortness of breath:
l "Have you ever had any problems with your breathing? Have you had
wheezing?" (They know what wheezing is.).
l "How far do you walk on level ground before you have trouble breathing? Do you have
to stop to rest to catch your breath?"
l "Have you had any attacks of breathlessness in the night?" (PND)
l "Do you need to be sitting up in order to get to sleep?" (orthopnea) or "Do you have
trouble sleeping while laying down?"
Nausea and vomiting:
l "Have you felt nauseated? Do you feel nauseated?"
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l "Have you been vomiting or throwing up? "
l If yes then "How many times? What does the vomitus look like? What color was it? Was
there any blood?"
l Ask the nature of the vomiting. Example: "Have you had projectile vomiting?"
Headache:
l "Have you had headaches? How often and how severe are they?"
Edema:
l "Have you had swelling in your arms or legs?" or "Do your ankles swell?"
l If ‘yes’ ask, " Where did you first notice it? "
l Ask them about any diurnal variation, " Do they swell more in the day or night?"
Thyroid:
l "Have you ever had problems adjusting to temperatures?"
l "Has your voice changed recently?" (hoarseness in hypothyroidism)
l "Have you noticed any change in your bowel movements?" (constipation in hypo and
diarrhea in hyperthyroidism)
l "Have you had any weight change lately? Have you lost or gained any weight lately?"
Previous episodes of chief complaint:
l "Have you had similar problems in the past?".
Past Medical History:
Here we give you an example of how to elicit past medical history (This would mainly give
you an idea of how to frame questions and save time).
You have to use transition sentences often during this part of history taking. Below is an
example of a transition question (you would tell the patient what you are going to ask instead
of directly jumping into other topic)
l Example: "Ok Mr. Brown, now I would like to ask few questions regarding your past
medical health. Is that ok with you?"
Allergic history:
l Bear in mind that most of the SPs have some sort of allergic history though it is not
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related to the chief complaint. Therefore, you have to take the allergic history.
l In brief, if the patient’s complaints are not mainly related to allergies, as would be in
menopause or psychiatric cases - Just ask, "Are you allergic to anything?" or "Do you
have any allergies?"
l If the case is related to allergies, (i.e. shortness of breath, rash, arthritis etc.) you can
elicit the history in the following way: "Are you allergic to pets?" (pause then ask for the
next allergen) "Are there any drugs you are allergic to? Are there any specific foods you
are allergic to? Are you allergic to dust?"
l If the SP gives you any positive history then ask follow-up questions: Start off with an
open-ended question like: "Could you please describe more about your allergic
problem?" If he doesn’t open up properly then ask the following questions "How often
do you have allergic episodes? Are you taking any medication for that? What kind of
allergic reactions did you have?"
Medical problems in the past:
In general, when taking medical history from patient avoid using medical terminology. Use
words they are familiar with, i.e. 'high blood pressure' instead of 'hypertension'. (diabetes is
ok)
In cases related to specific systems the following questions are to be asked:
l CNS - "Have you ever had a stroke? Do you have a history of migraine headaches?"
"Have you ever had any seizures?"
l CVS - "Have you ever had heart problems like a heart attack or heart failure?"
l RS - "Have you ever had tuberculosis? Do you have a history of asthma? Have you
ever had any lung problems?"
l GIT - "Have you ever had stomach problems or ulcers? Have your ever had any
problems with your gallbladder or liver?"
l RENAL- "Have you ever had any history of kidney infections? Have you ever had any
kidney stones? Have you ever had any problems with your prostate?"
l THYROID PROBLEMS (Never forget to ask about the thyroid as many cases (Ex: SP
with C/O weight loss/weight gain, depression, amenorrhea etc) are related to the
thyroid. They will be ready to tell you if you just ask them. They might also give you
precisely the name of the disease, like Hashimoto’s Thyroiditis or Goiter.
l Cancers - "Have you ever been diagnosed with any type of cancer?"
Hospitalization:
Ask about any past h/o hospitalization, trauma and h/o surgeries.
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l "Have you ever been hospitalized? What for? When?"
l "Have you ever had surgery? What for? When?"
l "Have you ever been involved in a serious accident? Have you broken any bones? Have
you had any serious head injuries?"
Urinary complaints:
If the case is not related to the urinary system just ask: "Have you had any problems with
your urination?" or "Do you have any trouble urinating?"
If related to the Genitourinary system, take a detailed history.
l H/O Burning micturition ("Have you had any burning sensation after you urinate? Does
it burn when you go to the bathroom?")
l H/O Urgency ('Do you have to rush to the bathroom to urinate? Do you have trouble
holding your urine? Do you often feel like you just can’t wait to go to the bathroom?")
l H/O Frequency/Nocturia ("How frequent do you have to pass urine? Do you have to
wake up in the night to go to the bathroom?")
l H/O Hesitancy ("Do you have to wait before you start urination?")
l H/O Hematuria ("Did you notice any blood in your urine?")
l H/O Pyuria ("Was there any pus in your urine?")
l H/O Straining ("Do you have to strain during urination?")
l H/O Changes in stream of urine ("How is your flow of urine? Is it continuous or is there
any dribbling after urination?")
l H/O Incomplete emptying ("Do you feel fullness of bladder even after passing urine?")
l H/O Incontinence ("Have you ever been unable to control the passing of your urine?
Are you generally able to ‘ hold it’ until you get to the bathroom?")
Gastro intestinal problems:
If the case is not related to GIT then just ask: " Have you ever had any problems with your
bowel movements?"
l "How often do your bowels move?"
l "Have your bowel movements changed?"
l "Are they hard or soft? What consistency? What color?"
l "Have you noticed any black or tarry stools?
Sleep:
Inquire whether he has any problems sleeping. ("Do you have any problems sleeping?")
If so, ask whether he has difficulty falling asleep, staying asleep, or waking up early?
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This is mainly required in all psychiatric cases.
Family History:
Before taking the history let the patient know that you will be asking him about his family
health, i.e., pose a transition question.
l "Ok Mr. Brown, now I would like to ask few questions regarding your family's health.
Is that ok with you?" And continue as follows:
l "Does anyone in your family have similar problems?"
l "Are your parents living?"
l If SP says, 'YES', ask, "How is their health?"
l If SP says, 'NO', show some empathy like "Oh, I am sorry to hear that. Could you
please tell me the cause of their death?"
l If necessary ask for the family history of diabetes, high blood pressure, stroke, and
heart problems.
Obstetric and Gyn History:
Before taking the history let the patient know that you will be asking about her Obstetric and
Gynecological history, (so you will be posing a transition question here.)
l "Ok Mrs. Smith, now I would like to ask few questions regarding your gynecological
health. Is that ok with you?" continue as follows:
If it is not a Obstetrical/Gynecological case just ask:
l "When was your last menstrual period?"
l "Are/Were your cycles regular?"
If it is a OB/Gyn case inquire about:
l "How old were you when you had your first period?"
l "Are your periods regular?"
l "How many days does your period last?"
l "Have you ever bled between cycles?"
l "How many pads do you use in a heavy day?"
l "Do you have abdominal cramps/pain with your period?"
l "Did you ever notice any bleeding after intercourse?"
l "When was your last menstrual period?"
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Vaginal discharge:
l "Have you ever had any vaginal discharge?"
l If YES, then ask "What is the color of the discharge? Does it have any bad odor? Do
you have any vaginal itching?"
l "Have you had any sores or infections around the vagina?"
Pregnancy:
l "Have you ever been pregnant? How many times? Any miscarriages or abortions?"
l If YES, "How many times did you miscarry? In which month/week of your pregnancy?"
"Do you know the reason (s) for the miscarriage?"
l "Have you had any other problems or complications with your pregnancies?"
l "How were the births? Did you have any complications during delivery?"
Abdominal pain:
l "Have you ever had any pain in your belly?"
l If 'YES' continue with all the questions given under ‘pain ’ in Present History.
Pap smear:
l "Have you been getting regular pap smears? When did you have the last Pap smear?"
Sexual History:
Before taking the history let the patient know that you would be asking about her/his sexual
history, so you will be posing a transition question.
l "Ok Mr. Brown, now I would like to ask few questions about your sexual history. Please
understand it will be kept confidential between you and me. Try to be as honest as
possible. Is that ok with you?" Continue as follows: "Are you sexually active?"
l If 'YES', "Who is your sexual partner? Do you have any other sexual partners?" or "Do
you relate sexually to men, women or both? Are you satisfied with your sexual life?"
l If 'NO', inquire the reason. "Do you have any problems in your sexual life? Any loss of
interest in sex? Are you able to reach a orgasm?"
l "Do you use any means of contraception?"
l If 'YES', "What type of contraception do you use? Do you use it regularly? "
l For high risk groups, like patients who are not using barrier methods of contraception,
patients with multiple sexual partners, and patients with homosexual history, continue
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with following questions: (Note: most of the time they have this history and so never
miss it.)
¡ "Have you ever been tested/treated for sexually transmitted diseases?"
¡ "Have you ever been tested for HIV?"
Social history:
You need to pose a transition question: "OK Mr. Brown, now I would like to know about your
social habits and personal life style. Is that ok with you?"
Appetite:
l "How is your appetite?"
Diet:
l "Can you please tell me about your diet"
l "What does your diet mainly consist of?"
l "Are you on a special diet?"
l For peri/postmenopausal women ask, "Do you take calcium supplements?"
Weight:
l "Has your weight changed recently?"
l If ‘YES’, "How much? In what period of time?"
Smoking:
l "Do you use tobacco? Do you smoke?"
l If ‘NO’, "Have you ever smoked in the past?" (Most of the SP’s have a past history of
smoking)
l If ‘YES’, "How many packs/cigarettes do you smoke per day? How long have you been
smoking?"
l "Have you ever thought about quitting/attempted to quit?"
Alcohol:
l "Do you drink any type of alcoholic beverages?"
l If ‘NO’, "Have you ever consumed alcohol in the past?"
l If ‘YES’, "What type of alcohol do you drink? How much do you drink per day? How long
have you been drinking?"
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Always keep in mind about the CAGE questionnaires for suspected alcohol abuse cases (Ex.
upper GI bleeding, right upper quadrant pain, epigastric pain.)
l "Have you ever tried to cut down on alcohol drinking?"
l "Have you ever been annoyed by other people for your drinking?" or "Have you ever
annoyed other people by your drinking?”
l "Have you ever had guilty feelings about your alcohol drinking?"
l "Do you drink alcohol early in the morning?"
Drugs:
l "Are you currently taking any type of over the counter medications? Any prescription
medications?"
l "Have you ever tried any recreational type of drugs?"
l If ‘YES’ to any of the questions ask, "What kind of drugs? How long have you been
taking them? Have you ever injected drugs?"
Occupation & exposure :
l "Do you work? What type of work do you do? Is it a stressful job?" (Analyze whether it
is mentally / physically stressful Ex: mental: depression; physical: carpel tunnel
syndrome (key board users ).
l "Are you exposed to any health hazards in your work or personal life?"
l "Are your work conditions safe?"
l "Does your job involve prolonged sun exposure?" (in case of rash)
l "Are you exposed to loud noises at work?" (in case of hearing loss)
Exercise:
l "Do you exercise regularly?"
Stress :
l "Do you have any stresses from your family?"
Travel:
l "Have you traveled outside the United states in recent years? When? Where?"
Special Situations:
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Angry Patient:
l "Mr. xyz, you seem to be very angry. Could you please tell me why that is so? Is there
any way that I can help you?"
Uncooperative patient:
l "Mr. XYZ, to properly understand your problem, I have to do this test. It won't take
more than a minute. I am here to assist you, ok?"
Pain in hand:
l "Does your job involve repetitive hand movements like key board operation?" (Carpal
tunnel syndrome).
Insect bite:
l "Do you remember being bitten by any insects like ticks and/or mosquitoes?" (in any
rash case)
Trauma patient:
l Sometimes you will see trauma patients with serious injuries, bruises, or gunshot
wounds. Avoid painful maneuvers while diagnosing their injuries. Also, be aware that
some severely injured patients without insurance will try to refuse expensive
treatments. For example, a trauma patient with significant injury to the chest, who has
the signs and symptoms of hemothorax, may say he doesn't want to have a chest X –
ray. In a case like that, explain that, "We have a social worker. She will help with the
financial details. Right now we must take an X-ray to diagnose your condition." In the
USA almost every hospital will have a social worker to deal with these kind of
problems.
Over talkative patient:
l Sometimes the patient may talk endlessly about irrelevant topics. If so respond like
this, "Excuse me Mr. Xyz, sorry to interrupt you. I know these things have really been
bothering you. However, I need to focus completely on you right now. (or on your
present situation)."
l Some patients will respond normally but some patients will say, "Are you interrupting
me?" (Don't worry they have been told to act like that.) Say the same thing again and
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say sorry once again.
General:
l If you have to say, " I don't know ", say, "I don't know yet" or, "I don’t know but I’ll
find out and will let you know."
Finally there are 2 popular mnemonics for history taking:
LIQOR AAA (LIQOR is Associated with Alcoholic Anonymous) especially if the chief
complaint is a pain.
L - Location
I - Intensity
Q- Quantity
O - Origin & Duration & Frequency
R - Radiation
A - Aggravating Factors
A - Alleviating Or Relieving Factors
A - Associated Problems
The other mnemonic used for the same purpose is "O P Q R S T"
Onset
Provocation/Palliation
Quality
Radiation
Site
Temporal profile
The following is very good for past history for all cases.
"PAM HUGS FOSS"
Previous episodes of chief complaints/Past medical problems.
Allergic history
Medications
Hospitalization (Trauma, surgery…)
Urinary complaints
Gastro intestinal problems
Sleep
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Family History
Obstetric and Gynecological History
Sexual History
Social History
Or you can simply prioritize like this (HRP ASS FM)
C.C
HPI
Review of systems
Past medical history
Allergies
Social history
Sexual history
Family history
Medications
Note: This is a general way to take case histories. We have included questions for general
history taking, as well as questions for specific health issues. You don't need to ask all these
questions for every case. Prioritize what you need to know, and ask those questions. The
ability to prioritize becomes easier the more cases you practice.
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Psychiatry History Print
l Ask what brings the patient in today.
l Ask what the patient thinks the problem could be due to (This would give you a
concrete answer if the psychiatric manifestations were due to reactive causes. Be
prepared for a negative answer in most of the cases.)
l Ask if the patient has anybody to talk to when she is in distress. (Support systems)
l Ask if the patient has had any unusually traumatic episodes during the past few months
or in the remote past. (PTSD)
l Ask about any changes in appetite.
l Ask about any changes in sleep patterns, i e, problem falling asleep; problem
maintaining sleep; problem with early morning awakening; Ask also about nightmares
and dreams.
l Ask about any weight loss/gain.
l Ask about the daily routine of the patient. ("Could you describe to me a typical day in
your life?")
l Ask about the patient’s interests and hobbies. Ask if they give her the same kind of
pleasure that they gave her earlier.
l Ask about her mood most of the day.
l Ask about the duration of these symptoms.
l Ask if the patient is frequently forgetting things or feels that she is losing her memory
l Ask the patient about her general attitude towards life. ("Do you tend to look at things
In a positive frame of mind or in a negative frame of mind?")
l Ask about the patient’s sexual life.
l Ask if the patient has ever considered ending her life.
l Ask if the patient has any plans regarding how to end her life.
l Ask if there are pills or guns at home.
l Ask about family life and the affinity of the patient towards her family members.
l Ask about any excessive coffee intake.
l Ask about drugs, alcohol, and recreational drugs. If yes then ask about the last time
that the patient took these drugs. (The psychiatric manifestation may be due to a
withdrawal syndrome.)
l Ask about any delusions or hallucinations. ("Do you listen and see what others can’t?
Have you heard voices talking to you only and nobody else around you does?")
l Ask about heat or cold intolerance and other thyroid manifestations.
l Do a Mini Mental Status Examination. ( Look up the CNS history taking for the MMSE )
l Ask if the patient realizes that she has a problem.
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l Ask if the patient is willing to get help.
Challenging psychiatric situations
l "The Silent Patient": If the patient is not answering you, stay silent for a minute;
establish eye contact. Put a hand on her shoulder and say, "I know that this is very
hard for you. Will you share it with me? I am here to help you. We can do it together."
l "The Over- talkative Patient":If you are not able to get a word in edgeways, stop the
patient and firmly say, "I know that all these things bother you but my number1
priority right now is you. So lets talk about you for now."
Sample documentation of a psychiatric patient note
l Patient disheveled
l Speech: scant, goal directed
l Mood: dysthymic
l Affect: mood congruent
l Memory: Recent and remote: Intact
l Delusions and hallucinations: none
l MMSE results
l Concentration:
l Suicidal intent
l Abstraction and Judgment
l Insight
l Duration of symptoms
l Precipitating factors
l Thyroid: not palpable
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Physical Exam Videos Print
We tried to give as much necessary exam possible. Because of the problems with bandwidth
we had to abruptly end some clippings which has no needed information. However we have
provided almost all the necessary information. Even though we tried to simulate the CS exam
as closely as possible, there are still some very minor corrections. We encourage you to read
the following with the video clippings and correlate them with the physical examination
section of the site.
Note: We have provided two different formats of video clippings (avi and rm format). Please
click on the selected links to view with each specific format. Install the latest version of Real
player (http://www.real.com/ ) from its official website before you download the video
clippings. Some formats may not play with Windows player. So, please download Real
player first, right click on the link, click "Save target as", then save the file onto your
desktop. These clippings should play automatically if you have downloaded the Real player
software installed on your computer. The avi format is very clear but the size of the files is
very big so it takes a lot of time to download, especially if you have a dialup modem. The
ram clips are a little bit faster to download but they are not very clear because they are in
the streaming format. If you don't want to download the files onto your computer and want
to play the video on the web, use ram clip as they are in streaming format. We prefer that
you have a cable modem instead of a dial-up connection to download the files. All files are
working fine so, before you contact us please make sure you follow all the above- mentioned
steps. If you are still unable to play any of the below mentioned formats feel free to contact
us at, support@usmleworld.com and we will try to help you.
Click Here to Download/Play the Clips
HEENT:
l Draping
l Inspection & Palpation
l Oropharynx
Eye exam
l Clip 1
l Visual acuity
l Opthalmoscope
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Ear exam
l Weber's test. : Please perform Weber's test after testing by whisper and Rinnes test
l Whisper test
l Rinne's test
Lung examination corrections:
Use the words "front of the chest and back of the chest instead of anterior and posterior
aspect of the chest respectively". Some people put both hands simultaneously to compare
the TVF. Presence of increased TVF indicates consolidation. Tell him, "I am going to tap on
your lungs".
l Anterior chest
l Posterior chest
Heart examination corrections:
"When you try to hear for carotid bruit "Ask the patient to hold the breath" Elevated JVP
(JVD) can be performed with 30 to 45 degree head elevation.
l Heart
Abdomen examination corrections on the video:
You have to percuss all the 5 quadrants of the abdomen. Usually for any underlying fluid or
mass effect, which gives dull note rather than a tympanic. Before you tap the belly "Say I am
going to tap your belly".
For the palpation of the kidney you place a hand on the back of the flank/rib cage. While
examining for Psoas and Obturator sign please do not use that I am going to flex your knee.
Tell I am going to bend your knee and rotate towards the other knee.
l Abdomen
l CVA tenderness
Extremities:
l Peripheral pulses: Posterior tibial pulses are palpated by placing the hand
posteroinferior to the medial malleoli.
l Shoulder exam
l Knee exam sag sign is for posterior cruciate ligament injury
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l Straight leg raising
l Carpal tunnel syndrome Pain, tingling and numbness will be noted in lateral 3 and half
fingers.
CNS:
Cranial Nerves
l Clip 1
l Clip 2
Motor
l Upper extremities
l Lower extremities
Sensations
l Upper extremities
l Lowe extremities
Cerebellar signs
l Clip 1
l Clip 2
Meningeal signs:
l Clip 1
We missed Babinski and clonus. We hope everyone knows how to do those.
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Communication Skills Print
Things you need to bear in mind through out your encounter with the SP’s: (A quick glance)
l Always knock on the door before entering the room.
l Once you enter the room introduce yourself by name and greet the SP warmly.
l Always use SP’s name to address him/her.
l Maintain good eye contact. This demonstrates your self-confidence and creates a
sense of trust and credibility. For example, during abdominal palpation, observe the
patient’s face for any signs of pain or discomfort. During most of the encounter, you
should maintain eye contact.
l Before you ask any specific question always ask a few open-ended questions. This is
the best way to elicit history from the patient. You may ask three or four open-ended
questions on the whole for each case. You can start off your case like this: “ What
caused you to come in today?" “Could you please tell me more about what's going on?”
And so on.
l Ask non leading questions.
l Ask only one question at a time. Do not ask too many questions at a time. Ask a
question, pause and wait for the answer then proceed to the next one. Example: “Does
anyone in the family have high blood pressure? (pause and wait for the answer)
Diabetes?” (pause and wait for the answer)
l Always pay attention and listen to SPs patiently without interrupting them in between.
l Try to acknowledge their emotions.
l Use layman’s language. Try not to use medical terms like hypertension for high blood
pressure.
l Use appropriate transition sentences.
l Wash your hands before starting physical examination.
l Tell the SP what you are going to do (one at a time, not the whole procedure)
l Do not examine through the gown.
l Ask SP’s permission before untying the gown. Help him/her undo the buttons..
l Use appropriate draping techniques. The rule of thumb is: As little of the body should
be exposed as necessary for a set of maneuvers to be performed. For instance, to
auscultate the heart or lungs, you should NOT raise the gown up from the waist,
exposing the entire torso. Rather, she/he should lower the gown from the top, exposing
only the upper chest and shoulders.
l Offer help to SP’s during examination. (On and off the table) .
l Never repeat painful maneuvers and always apologize immediately for any pain it
caused.
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l Summarize the history and explain physical findings.
l Express empathy. Make appropriate reassurances. Do not give false reassurance.
(You can convey empathy in a number of ways, including attending to the patient's
physical comfort. For example: You should extend the leg rest when the patient lies
back and push it back in when the SP sits back up. If the patient is in pain, ask if there
is anything you can do to help to feel more comfortable.)
l Ask whether he/she has any concerns/ questions. (“Do you any questions or
concerns?”)
*This is the most important thing that you should never forget to ask.
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Closing the encounter Print
All right, Mr. xyz, thank you so much for your kind cooperation. Now, I'd like to sit down and
talk over what I think so far. First, let me summarize." (transition).
l You just told me that __ and __. Also, you said that __ and __, Is that right?
l According to the information I got from you and the examination, I am considering a
couple of possibilities. It may be __ (your probable diagnosis) or possibly __
(differential diagnosis).
l I need to run some tests in order to find out exactly what the problem is.
l As soon as I get the results, let’s meet again to go over everything. At that time, I'll
explain the details and we will talk about your options for treatment? Does this sound
OK?”
l If it is a psychiatric case, like depression, grief, anxiety, or dementia, ask this question:
l Miss xyz, would you be willing to talk to a counselor or go to a support group?
l If Mr./Miss xyz smokes, drinks alcohol, eats fatty food, does not exercise, uses
recreational drugs, has multiple sexual partners, does not use condoms, etc, give the
following suggestions:
l Mr./Miss xyz, I have noticed that you__(address the problems) Are you willing to quit?
If you need any more help from me, just let me know. I'll be glad to help you.
l Miss xyz, do you have any concerns or questions you'd like to ask before I go?
l Ok then, I ‘m glad that I was able to work with you. I will do my level best to make you
feel better.
Thanks for your cooperation, have a good day. Bye for now, take care.
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Documentation of Case Print
Use these shortcuts to save time:
HPI (History of Present Illness):
Write the present history with other positive and negative symptoms.
PMH (Past Medical History):
Follow this acronym so you won’t miss any points (In the exam you will still miss
some points, so practice well)
PAM HUGS FOSS
P- Past medical problems
A-NKA (No Known Allergies)
M-Medications
H- Hospitalization
U- Urinary Problems
G- GI Problems
S- Sleep
FH (Family History):
Family History
Obg/Gyn:
Sex H:
SH (Social History)
Physical examination
First, write vital signs
Then, focus on main systemic examination
Lastly, write about review of other systems
Tips:
Always write vital signs first
Give a brief comment about Pts general appearance
Note abnormal findings
Note relevant positive and negative findings
Investigations
Always write most specific tests first
List the tests in order of priority
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Write all related tests in a single line Ex:: CBC, ESR...
Do not write referrals or consultations
Do not write Rx
Write about breast, renal, pelvic, or genital examinations, if done.
Documentation of normal respiratory examination:
Breathing:
Normal rate
Rhythm
Trachea central
No accessory muscles are acting
Lungs are clear to percussion
Auscultation:
Normal vesicular breath sounds
No wheezes/rales/rubs
TVF is WNL (Within Normal Limits)
Documentation of normal cardiovascular system examination:
Inspection:
No visible scars, heaves
Palpation:
PMI non-displaced/no pedal edema
No thrills
No heaves.
Auscultation:
S1/ S2 heard
No S3 /S4
No murmurs/gallops/rubs.
Lungs are clear
No additional sounds
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Documentation of normal abdominal examination:
Inspection:
No scars
No swelling
No visible peristalsis
No visible pulsations
Auscultation:
Bowel sounds are heard
No bruit
Palpation:
Abdomen is soft, non tender
No masses felt
No organomegaly
No CVA tenderness
No rebound tenderness
Percussion:
Tympanic in all 4 quadrants
Liver span is normal
No free fluid.
Documentation of examination of spine:
Inspection:
No obvious abnormalities
Palpation:
No prominent spinous process
No paraspinal tenderness
Range of motion is WNL (with in normal limits).
Gait:
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WNL
Reflexes:
2 +
Documentation of normal central nervous system examination:
Mental status:
Pt is alert
Oriented in time, place, person, and intact memory.
Cranial nerves:
II to XII intact
Motor:
5/5 in all muscle groups
DTR:
2 +, symmetric
Sensations are intact to sharp and dull
Cerebellar:
No positive signs
Babinski negative
No meningeal signs.
Documentation of normal HEENT Examination
Head:
Atraumatic
Normocephalic
Eyes:
Visual acuity and visual fields WNL
EOM-intact
PERLA (Pupils Equal, Reacting to Light and Accommodation)
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Fundus is normal
Ears:
No tenderness
No ear canal and tympanic membrane abnormalities
Nose:
No external abnormalities
Turbinates are not congested
No masses seen
Throat:
No ulcers
No erythema or exudates
No patches
Tonsils are N
No dental or gum abnormalities
Neck:
Supple
Thyroid is not palpable
No palpable lymph nodes.
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Case Investigation Print
These are the common investigations that you should keep in mind while writing Pt notes.
HEENT
X-ray, CT, MRI of head
Eye- Snellen’s chart, Visual acuity
Ear- Complete audiometry and tympanometry, Culture/Sensitivity for any
discharge
Routine CBC with diff, ESR
CNS
Routine CBC with diff, ESR
X-ray, CT, MRI
Lumbar puncture
Carotid Doppler study
EEG
Electromyography and Nerve conduction studies.
Echocardiogram for suspected embolic phenomena.
Musculoskeletal
Routine CBC with diff, ESR
X-ray
Joint aspiration for culture/ sensitive, cytology, crystals
Rheumatic factor, HLA-B27,
Serum uric acid levels
Antinuclear antibodies, anti dsDNA
Muscle biopsy
CVS
EKG and echocardiogram
Cardiac enzymes (CPK-MB, Troponin, LDH)
Chest X-ray
Lipid profile
Thyroid screen
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Serum electrolytes
Respiratory
Routine CBC with diff, ESR
Chest X-ray
Sputum studies (culture/sensitivity, gram stain, AFB)
Pulmonary function tests and spirometry
PPD
ABG and pulse oximetry
Abdominal
Routine CBC with diff, ESR
Abdominal X-ray
Ultrasound of abdomen
LFTs
CT abdomen/pelvis
Upper GI series-Barium swallow, endoscopy, ERCP
Lower GI series- enema, Colonoscopy
Test for fecal occult blood/rectal examination
Pancreatic enzymes (amylase, lipase)
Renal function tests
Endocrine
Routine CBC with diff, ESR
Blood sugar
Serum electrolytes
Serum calcium
Thyroid screen T4/T3/TSH
24hr urinary catecholamines and metabolites
Urine for ketones and sugar.
Psychiatry
CBC and ESR
CT and MRI of brain
Thyroid screen
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Electrolytes
Urine analysis
Drug screen / HIV
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Abbreviations Print
Note: This list is intended to cover the most of the abbreviations widely used in the hospitals
of USA.
A
Abd Abdomen
ACEIs Angiotensin Converting Enzyme Inhibitors
ACTH Adrenocorticotropic Hormone
ADH Antidiuretic Hormone
AF Atrial Fibrillation
AFB Acid Fast Bacilli
AIDS Acquired Immune Deficiency syndrome
AML Acute myeloid leukemia
ALL Acute Lymphoblastic leukemia
ALS Amyotrophic lateral sclerosis
Acute MI Acute Myocardial Infarction
ANA Anti nuclear antibody
ANCA Antineutrophil cytoplasm antibody
Anti SMA Anti smooth muscle antibody
AP Anterioposterior
aPTT Activated Partial Thromboplastin Time
AR Aortic Regurgitation
AS Aortic stenosis
ARDS Acute Respiratory Distress syndrome
ARF Acute renal failure
ASLOtiter Anti streptolysin O titers
ATN Acute tubular necrosis
B
BCG Bacillus Calmette Guerin
bid/tid two times a day/three times a day
BMP Basic metabolic profile
BS Breath sounds/Bowel sounds
BUN Blood urea nitrogen
C
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Ca. Carcinoma
Ca +2 Calcium
CABG Coronary Artery Bypass Grafting
CAD Coronary artery disease
CBC Complete Blood Count
CBD Common bile duct
cc cubic centimeter
CEA Carcinembryonic antigen
CHF Congestive heart failure
CCF Congestive cardiac failure
CK Creatine kinase
CK MB Creatine kinase myocardial band
cm centimeter
CML Chronic myelogenous leukemia
CMV Cytomegalovirus
CNS Central nervous system
c/o complaining of
COPD Chronic obstructive lung disease
CPAP Continuous positive airway pressure
CPK Creatine phosphokinase
CPR Cardiopulmonary resuscitation
Cr Creatine
C/S Culture and sensitivity
CSF Cerebrospinal fluid
C-sec Cesarean section
CT scan Computed tomography
CVA Cerebrovascular accident
CVA tenderness Costovertebral angle tenderness
CXR Chest X ray
D
D&C Dilation and Curettage
DIC Disseminated Intravascular Coagulation
DKA Diabetic Ketoacidosis
DM Diabetes Mellitus
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DPT Diptheria Pertussis Tetanus
DTs Delirium Tremens
DUB Dysfunctional Uterine Bleeding
DVT Deep Venous Thrombosis
D5W Dextrose 5% in water
Dx Diagnosis
E
EBV Epstein Barr Virus
ECG/ EKG Electrocardiogram
ED/ER Emergency Department/Emergency Room
EEG Electroencephalogram
ENT Ear Nose Throat
EGD Esophago gastro duodenoscopy
EIA Enzyme immunoassay
ELISA Enzyme linked immunoassay
EMG Electromyography
EOMI Extraocular movements Intact
EPS Extrapyramidal symptoms
ERCP Endoscopic retrograde cholangiopancreatography
ESR Erythrocyte Sedimentation rate
ETOH Ethanol
Ext. Extremities
F
F female
FDPs Fibrin degradation products
Fe Iron
FFP Fresh frozen plasma
FH Family History
FHR Fetal Heart Rate
FNAC Fine needle aspiration cytology
FSH Follicle stimulating hormone
FTA ABS Flourescent treponemal antibody absorbed
5-FU 5 fluorocil
FUO Fever of undetermined origin
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Fx. Fracture
G
gm gram
GB Gall Bladder
GERD Gastroesophageal reflux disease
GFR Glomerular filtration rate
GGT Gamma glutamyl transferase
GI Gastrointestinal tract
AGN Acute Glomerulonephritis
G6PD Glucose 6 phosphate dehydrogenase
GTT Glucose Tolerance test
GU Genitourinary
GVHD Graft versus Host disease
Gyn. Gynecology
H
H2 Histamine –2
Hep.A Hepatitis A Virus
Hb Hemoglobin
HBcAg Hepatitis B core Antigen
HbsAg Hepatitis B surface Antigen
HBIG Hepatitis B immunoglobulin
HBV Hepatitis B virus
Hco3 Bicarbonate
Hct Hematocrit
HCV Hepatitis C virus
HDL High density lipoprotein
HEENT Head, eye, ear, nose, throat
hCG Human Chorionic gonadotropin
HIV Human immunodeficiency virus
H/O history of
HPI History of presenting illness
hr Hour
HR Heart rate
HSV Herpes simplex virus
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HTN Hypertension
Hx. History
I
IBD Inflammatory bowel disease
IBS Irritable bowel syndrome
IHD Ischaemic heart disease
IDDM Insulin dependent diabetes mellitus
Ig Immunoglobulin
IM Intramuscular
Inj Injection
INR International normalized ratio
IQ Intelligent quotient
IUD Intrauterine device
IV Intravenous
J
JVD Juglar venous distension
JVP Juglar venous pulse
K
Kg Kilogram
KUB Kidney ureter bladder
L
Lt Left
LAD Left axis deviation
LAHB Left anterior hemi block
Lb Pound
LBBB Left bundle branch block
LDH Lactate dehydrogenase
LDL Low density lipoprotein
LES Lower esophageal sphincter
LFTs Liver function tests
LGV Lymphogranuloma venereum
LH Luteinizing Hormone
LLQ Left lower quadrant
LMP Last menstrual period
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LP Lumbar puncture
LPHB Left posterior hemiblock
LSB Left sternal border
LUQ Left upper quadrant
LVH Left ventricular hypertrophy
M
M Male
MAC Mycobacterium avium complex
MCP Metacarpophalangeal
MCV Mean corpuscular volume
MVP Mitral Valve prolapse
MS Mitral stenosis
MR Mitral regurgitation
MDS Myelo Dysplastic syndromes
MRSA Methicillin Resistant Staphylococcus aureus
MSSA Methicillin Sensitive Staphylococcus aureus
MVA/RTA Motor vehicle accident/ Road Traffic Accident
N
NA Not applicable
NaHCO3 Sodium Bicarbonate
Neuro Neurologic
NIDDM Non Insulin dependent diabetes mellitus
NG Nasogastric
NKA No known allergies
NKDA No known drug allergies
NL Normal limits
NPH Normal pressure hydrcephalus
NPH Neutral Protamine Hagedorn (insulin)
NPO Nothing by mouth
NS Normal saline
NT Non tender (Abdomen)
ND Non Distended
NSR Normal sinus rhythm
NSAIDs Nonsteroidal anti-inflammatory drugs
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O
Obg & Gyn Obstetrics & Gynecology
Ophth. Ophthalmology
OR Operating room
Ortho. Orthopedics
oz ounce
P
PR Pulse Rate
P2 Pulmonic second sound
PA Posterior anterior
Pap smear Papanicolaou smear
para Number of pregnancies
PCP Pneumocystitis carnii pneumonia
PCR Polymerase chain reaction
PCWP Pulmonary capillary wedge pressure
PE Physical examination/Pulmonary embolism
ped pediatric
PERRLA
Pupils equal, round and reactive to light and
accommodation
PFTs Pulmonary Function tests
PMH Past medical history
HPI History of Present Illness
PID Pelvic inflammatory disease
PIP joints Proximal interphalangeal joint
PKU Phenylketonuria
PMI Point of maximal impulse
PMR Polymyalgia rheumatica
PND Paroxysmal nocturnal dyspnea
PO By mouth
PPD test Purified protein derivative
PPD Packs Per Day (Sigarettes)
PROM Premature rapture of membrane
prn As needed
PSA prostate specific antigen
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PSGN Poststreptococcal glomerulonephritis
PSVT Paroxysmal Supraventricular tachycardia
Psych Psychiatry
Pt. patient
PT Prothrombin time
PTT Partial prothrombin time
PTC Percutaneous transhepatic cholangiography
PTCA Percutaneous transluminal coronary angioplasty
Path Pathology
PTH Parathormone
PUD Peptic ulcer disease
PVC Premature ventricular contraction
Q
q Every
qd Everyday
qid Four times daily
R
Rt. Right
R.R Respiratory Rate
RBBB Right Bundle Branch Block
RBC Red Blood Cell
REM sleep Rapid eye movement sleep
Rh Rhesus factor
RLQ Right lower quadrant
ROM Range of motion
ROS Review of systems
RPGN Rapidly progressive glomerulonephritis
RPR Rapid Plasma reagin
rt-PA Recombinant tissue plasminogen activator
RTA Renal Tubular acidosis
RUQ Right upper quadrant
RVH Right ventricular hypertrophy
S
S Soft (Abdomen)
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S1 First Heart sound
S2 Second Heart sound
S3 Third Heart sound
S4 Fourth Heart sound
SA Sinoatrial
SAH Subarachnoid hemorrhage
SABE Subacute bacterial endocarditis
SQ Subcutaneous
SGA Small for gestational age
SGOT Serum glutamic oxaloacetic transaminase
SH Social History
SIADH
Syndrome pf inappropriate secretion of antidiuretic
hormone
SGPT Serum glutamic pyruvate transaminase
SL Sublingual
SLE Systemic lupus erythematosus
SLR Straight leg raising test
SOB Shortness of breath
Stat immediately
STD Sexually transmitted disease
Surg. Surgery
SVT Supraventricular tachycardia
T
Temp. Temperature
T3 Triiodothyronine
T4 Thyroxine
Tab. Tablet
TAH Total abdominal hysterectomy
TB Tuberculosis
TIA Transient ischemic attack
TIBC Total Iron binding Capacity
TSH Thyroid stimulating hormone
Tx Therapy
U
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U/A Urinanalysis
Upper GI Upper Gastrointestinal Tract
USG Ultrasonogram
URI Upper Respiratory Tract Infection
UTI Urinary Tract Infection
UV Ultraviolet
V
VDRL Venereal disease research laboratories
VF Ventricular fibrillation
VLDL Very low-density lipoprotein
W
WM White Male
WF White Female
WBC White blood cell
WNL Within normal limits
WPW syndroem Wolff Parkinson White syndrome
Wt. Weight
X
x Times
Z
ZDV Zidovudine
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Pt Note template Print
Patient Name: Physician’s Id #:
History: (Include significant positive and negative history.)
Physical Examination: ( Only relevant findings.)
Differential Diagnosis: Diagnostic workup:
1. 1
2. 2.
3. 3.
4. 4.
5. 5.
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Key to Success Print
Why do students fail? Every student who appears for the CSA is capable of passing.
Then, why do certain students pass and certain students fail?
l Based on my observations there are several apparent reasons why certain students fail.
Becoming aware of these reasons you can avoid potential pitfalls while taking the CSA.
l TIME MANAGEMENT is key!
l The best way for success is repeated timed practice of simulated cases on real people.
Practice, practice, and more practice...
l Most of the candidates who appear for CSA mess it up by becoming nervous and
anxious. Don't do that. Maintain your cool and composure.
l Don't be over confident. Some of my friends who got above 90 in both the steps
flunked the CSA. They thought that they could easily pass the CSA and they did not do
the preliminary preparation required for the CSA. That doesn't mean the CSA is tough.
If you think you speak English well and you will pass because you are fluent, think
again. This exam not only tests your communication skills, but how you collect and
digest info to reach a diagnosis, and your writing proficiency.
l If you fail, don't feel depressed. It's not the end of the world. It just means you need
to regroup, brush up on your technique, and try again. Don't give up!
l If you are poor in English, try to improve it. You don't have to speak like a Native
American but you should be able to communicate clearly with the patient. You might
want to consider having several sessions with an ESOL teacher who could evaluate your
dialogue and help you with pronunciation and the word order of your sentences.
l Read the CSA orientation manual well. The exam is very similar to it.
l The exam is a very basic assessment of your data gathering ability (history taking),
communication, and interpersonal skills.
l You need to know how, and become proficient at, taking a highly focused history and
P/E in 15 min.
l When they say focused, they mean focused. If you overdo the history taking your
communications part will suffer. Remember: manage your time well.
l Try to be half way through the P/E when they announce that five minutes are
remaining.
l Unfortunately, up to 80% of student’s failure of the exam is due to data gathering. So,
don't neglect that part.
l The way you introduce yourself to your patient is very important. The following
introduction appears good, but is not: “Hi, my name is Dr. . How are you doing
today? What brings you here?“
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1. The main fault with the above introduction is that the patient is never
addressed by name.
2. The correct way to introduce yourself is, “Hello Mr.____ (patient’s last
name) I'm Dr.____ (your last name). What brings you here today?”
3. Always address the patient by name and never introduce yourself without
addressing the patient.
l Keep as close as possible to the CC and related history. When asking the family history
or past history, use broad open questions. If there is anything significant, they will tell
you. In fact, they will be anxious to answer the questions.
l Expect every day common cases only.
l Remember to knock on the door, shake his hand, and show him your teeth!!! SMILE!
l You may be nervous with the first S.P. Never panic.
l The first S.P may be the hardest because you don't know what to expect. Remember
to concentrate, make the best use of your time, don't leave the room early, and don't
rush the patient.
l Take a good history and make a mental note of the questions you must ask for a
particular symptom.
l Most patients are spontaneous up to a point, but then ask them specific questions to
further explore the symptoms.
l Study the differentials of common symptoms, two to three of the most common in
America will do. You can't rule out more in 7-8 minutes time.
l Prepare differentials of common symptoms not diseases.
l Always be polite and smile, even if the patient is acting difficult.
l Use common sense, and try to communicate effectively. Getting the message across is
more important than talking endlessly.
l If a patient is in pain, don't immediately start interrogating him like an FBI agent. But
ask him if he can answer some questions so you can better understand the cause of his
pain.
l Do a focused history and always address the patient’s concerns as you go. Always be
honest with him.
l Don't waste time on a complete history; move from stage to stage quickly and
efficiently.
l Always wash your hands before the physical examination.
l Always remember to drape the patient well.
l Try to have a running commentary with the patient. This means explain what you are
going to do before actually doing it and if possible explain things as you go. For
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example: “Now, I’m going to listen to the heart sounds by placing the stethoscope on
different areas of your chest.”
l Keep your thoughts flowing. You cannot stop, even for a second, in front of the patient
to think.
l A good technique to help you review whether you've asked all of the important
questions or not is to concentrate on them while you're listening to the patient’s heart
or breath sounds. That is, pretend you are listening to these things but mentally be
going over your checklist of the history intake. Most of the vital signs of the
standardized patient will be normal so don't worry that you will miss findings.
l Help the patient move from one position to another.
l Make sure the P/E is focused on the chief complaints.
l Stay focused and calm throughout the exam.
l At the end of everything, help the person tie the gown, sit up, and then seat yourself
on the footstool. Good closure is extremely important. Good closure involves discussing
your possible deferential diagnosis (Don't panic if you have only one. Never say that
you know the diagnosis. Instead, tell the patient the several possibilities you are
considering and that you will need to wait for the test results before giving your
diagnosis.)
l Take time to explain your findings and your diagnostic plan of management with the
patient at the end of the encounter.
l Tell the patient that you are concerned about him and would like to discuss his
condition further with him when his tests get back.
l Make sure the SP understands every thing you have planned for him.
l Be sure to talk about risk factors with the patient and offer the appropriate counsel.
l The standardized patient definitely asks you certain questions. Don't evade them. Be
ready to answer challenging questions with common sense. It's very important that you
be honest with your answers. If you’re not sure, tell the patient that you don’t know at
this time but will get back to him with the answers to his questions and concerns at
your next meeting.
1. Ex. Like when you are dealing with a case of pericarditis the patient may ask, "Is
this an episode of heart a attack?"
l Your reply should be: “It really doesn't look like an episode of a heart attack because
the pain is chronic, postural, and increased by breathing. Although, I can’t rule out the
possibility completely. I’m going to do some investigations, and will get back to you.”
l Before leaving, ask if there is anything else they would like to talk to you about.
l A difficult patient is one who will not answer your questions in a polite manner. This is
by design to see your response. Remain calm, smile, and try to extract the best
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history possible. Behave like a professional doctor doing your job and move on from
there. Remember that they have been told to act like that. Try to determine why he is
behaving in a particular fashion. For example, if he is angry, you could say, "Mr. xyz,
you seem to be angry. Could you please tell me what’s wrong and is there anyway I
can help you?"
l Be confident. Confidence is the key to success, Never lose your cool.
l Avoid the temptation to be overly friendly with the patients. Remember, you've spent
$1,200+ to take this exam, {not to mention a few $1000 more to get to Philly or
Atlanta and for accommodations etc.}, so there's a lot at stake.
l Memorize the patient note format in the CSA orientation Manuel.
l Know the abbreviations given in the ECFMG booklet/USMLEWORLD and practice using
them.
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On the Day of Exam Print
l First of all, keep in mind, and try to stay calm about the fact, that you will be just a
number in a herd being put through the thing. You completely give up your
individuality when you take the exam. Try not to take that personally. It’s just the way
it is.
l Everything is well organized and timed. The CSA proctors are very friendly but also
efficient.
l Allow plenty of time to get to the test site so when everything goes wrong and you
think you’ll be late… You won’t be! Don’t have being late be one of your worries.
l They don’t start the registration before 8.30am. At 8.30am.you have to present your
permit (The one you got after you confirmed your exam date via phone or internet)
and one ID (passport or driver's license).
l If you do not have the permit with you, no sweat, you will just need two forms of ID.
Your name is on their list.
l Registration is at 9:00am.
l They offer lab coats, stethoscopes and watches in case someone forgets them.
l They will show an orientation slide show of some new and some familiar information,
i.e. You are allowed to palpate axillary and inguinal lymph nodes including the femoral
pulse. Postural signs and BP repeat can be ordered in the work-up. Don't waste your
time measuring those things.
l Although it was emphasized that using the gloves is fine, I would still recommend
washing your hands. (They have only one size of gloves, and seriously, in my whole
career as a doctor I have never seen anybody use gloves to palpate the abdomen or
percuss the lung.... so why do it now? I was able to wash my hands within 20
seconds.)
l At one side of the orientation room an exam room was set up and there was ample
opportunity to use the instruments, try out the bench, the drape, the forks etc.
Questions were welcomed and answered nicely.
l The only thing you can bring yourself is the lab coat and stethoscope, everything else is
provided.
l In the examination room there will be a Snellen's visual chart at the wall, two tuning
forks with different frequencies, cotton swabs/toothpicks, tongue depressors, reflex
hammer, ophthalmoscope, otoscope, and a blood pressure cuff.
The actual exam
l The examinees will face the doors and a plastic box will be hanging on each one. It
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contains the information about the patient inside. That includes his name, age, setting
(ER, office), chief complaint and vital signs (BP, pulse, temperature, and respiration.)
When everybody is settled and ready, the signal is given to start the encounters.
l This is when the fifteen minutes start!!! You have to open the box at the door and read
the info about the patient.
l At the bottom they tell you what to do, just like in the info booklet. The time you spend
reading and taking notes DOES count toward the 15 minutes.
l Do not rush into the room, because once you enter, you will be totally occupied by the
SP.
l Try to spend about 45 seconds in front of the door to make a mental note of differential
diagnosis. This is extremely important.
l When you are in the room time flies. So budget your time accordingly.
l You do NOT have to write everything down. There is a second copy of the doorway
info in the room.
l All patients will be sitting on the exam table in their gown when you enter the room.
l The rooms are small. There is a chair right in front of the bench where you can sit
down.
l Also, to the side of the bench there is a little stool with the drape folded on top of it. In
the corner there is a little workstation with computer on it, but it’s not for you. It is for
the SP's to grade your performance.
l Ten minutes into the encounter, you will hear the signal alerting you that there are five
minutes remaining. Then at 15 minutes there is a signal that this encounter is over and
you have to leave the room. However, be professional. You can finish your sentence
then say good-bye to the patient. Ten seconds later there will be a knock on the door
and you will leave the room
l Immediately as you leave the room you have ten minutes to write the patient’s note.
After eight minutes, (this was very helpful), there is a signal to let you know that there
are two minutes remaining..
l After the ten minutes you have to put the pen down and wait for the proctors to collect
the patient note and the piece of notepaper. (While writing the note you can still get
up, open the doorway info again and read it. I did that twice and it was fine to do as
long as you slide it shut again.)
l The next encounter starts after everybody has walked up to the next -door and is
positioned again. (This gets into a nice routine and it is over sooner than you think.)
l Most of the people have no idea how they did. There is just no time at all to get
everything asked and done the way you would like to. Just remember this, no matter
how well you did, you will still feel frustrated afterwards.
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l It’s completely normal and I think a definite part of the test function. It measures how
well you can cope with time pressure and frustration.
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Guidance for practice Print
The guidance we give here will be very helpful for you if you can manage to get a partner.
(Not necessarily a medical student, any friend will do, i.e. your wife/ husband).
l You need to ask your partner (SP) to read his/her notes first. It is even easier if he can
mark all the positive things.
l Time your practice session. This is very important. Most important to remember is that
your time starts before you enter the room. You have 15min starting outside the
room.
l After the session is completed (i.e. within 15 minutes) you go and see the checklist for
that case. If you do more than 65% usually you will pass in the exam. But, we advise
you try to make at least 75% during the practice session. In the exam obviously you
will miss many things more easily because of tension. So, don't worry if you miss in the
practice session but not in the exam. The only way to overcome this problem is
practice, practice and practice ... We advise everyone to practice these cases at least 3
times in a timed manner.
l Please do not skip any part, as you need to time everything for each case.
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FAQ Print
Do the SP's show you cards as in OSCE exam?
l The SP's do not use cards to tell you what the abnormal finding should be. The vitals
are posted outside the door. If there's an abnormal vital sign, i.e. high blood pressure,
as instructed during the introduction, these values as accurate.
Will we be able to detect any physical findings (like bruises, redness etc.) on SP's?
l Some of the abnormal physical exam findings can be acted out, like abdominal pain,
weakness, etc. Some may get a patient with a big bruise secondary to trauma. His
knee will be painted red to show an inflammatory condition. In some instances the SP
(case of sore throat) can have real enlarged tonsils. So look carefully.
I have a problem of stuttering, will that have any effect on my exam?
l Let the CSA people know about your condition. You can do this either by filling in the
handicapped section in the CSA application or by sending them a letter describing your
problem. They will respond to you and will also inform the SP's. Just to be on safe side,
tell the SP's about your problem before you start (of course after you greet and
introduce yourself).
I heard there is a problem accommodating couples in a few hotels. Is it true?!!!
l The only problem accommodating couples is at the Divine Tracy hotel. It is run by a
religious order and has specific dress code rules and houses men and women on
separate floors. The prices can’t be beat. However, if this isn’t of interest to you, the
other more expensive hotels are readily available if you make your reservation soon
enough or try the Internet.
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Alcoholism Case Print
History Taking:
l When did you start drinking?
l On average, how many drinks do you have per day?
l On average, how many days per week do you drink alcohol?
l Who referred you here?
l Have you ever tried to cut down on your drinking?
l Did anyone ever criticize your drinking?
l Have you ever felt bad or guilty about drinking?
l Have you ever had a drink first thing in the morning?
l How do you feel about yourself? Any mood changes?
l Do you get anxious over small things?
l What kind of work do you do for a living?
l Do you have any marital or sexual problems?
l Have you had any family problems?
l Do you have any financial problems?
l Do you have any other complaints?
Past Medical History:
l Do you have any other medical problems (diabetes mellitus, peptic ulcer disease)?
l Have you ever been admitted in the hospital?
Social History:
l Do you smoke?
l Do you use recreational drugs (IV drugs)?
Family History:
l Who else lives with you at home? How are they doing?
Medications:
l Do you take any medications?
Physical Examination:
l Wash your hands.
l Perform observe proper draping techniques.
l Examine the skin.
l Check the conjunctiva for pallor and jaundice.
l Check the oral cavity and dentition.
l Auscultate the lungs and heart.
l Palpate and percuss the abdomen. Check for hepatomegaly. Rule out ascites and
hepatic tenderness.
l Examine the extremities for edema.
l Examine without the gown, not through the gown.
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Investigations:
l CBC
l Liver function tests
l Gamma-glutamyl transpeptidase (GGT)
Counseling:
l Review the quantity and frequency of current drinking.
l Explain the risks associated with alcoholism.
l Explain the patient’s responsibility to reduce or stop drinking.
l Set up a drinking diary.
l Self-motivate the patient. Inform him about available resources/support groups which
could help him.
l Set up a follow-up appointment.
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Backpain Case Print
Case of an Elderly patient (>50 years) with Back Pain
History Taking:
· When did the pain start?
· Can you show me exactly where the pain is?
· What were you doing when the pain began?
· On a scale of 1 to 10, how severe is the pain?
· How do you describe the pain? Is it a sharp, burning, crushing, or heavy feeling?
· Does anything make the pain better?
· Does anything make the pain worse?
· Does it radiate to another region of the body, such as your legs?
· Do you have any numbness or tingling in the legs?
· Do you have any weakness in your legs?
· Do you leak urine without your knowledge?
· Have you ever had bowel movements without your knowledge?
· Do you have a fever?
· Have you had any trauma to your back?
· How is your appetite? Have you lost any weight?
Past Medical History:
· Have you had similar problems before? Was it diagnosed? Was it treated?
· Have you had any bone fractures?
· Do you have any other medical problems? (Especially cancer or recent infection)
· Do you have pain in any other joints?
· Did you use any steroid medications in the past?
Family History:
· Do any of your family members have osteoporosis or back problems?
Social History:
· What kind of work do you do?
· Do you smoke? Have you ever smoked? How much and for how many years?
· Do you drink alcohol? How long have you been drinking?
· Have you tried any hormone replacement therapy?
Medications:
· Do you take any prescription medications? Any over-the-counter medications
(calcium and vitamin D)?
Allergies:
· Are you allergic to any medication?
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Physical Examination:
· Wash your hands.
· Perform proper draping techniques.
· Check for spinal tenderness.
· Check for paraspinal tenderness.
· Check lower extremity pulses.
· Check sensations of both lower extremities.
· Do complete motor and reflex testing of both lower extremities.
· Do straight leg raising test.
· Check the lumbosacral spine range of motion.
· Check the gait.
· Examine without the gown, not through the gown.
Counseling:
· Explain physical findings and differential diagnosis.
· Explain further workup.
· Advise the patient to take (or continue to take) Vitamin D and calcium.
· Demonstrate and explain the importance of doing range of motion exercises.
Sample Patient note
CC: 60 yo WF c/o back pain
HPI:
This is a 60 yo WF c/o lower back pain that has been present for 2 months. Pain first began
while lifting a waste bag. It is described as constant, with a sudden onset, 5-6/10 in severity,
radiates laterally down both legs, aggravated by doing work, minimally alleviated by overthe-
counter analgesics (Tylenol). She denies numbness, tingling, weakness, urinary
incontinence, fecal incontinence, fever, and trauma to the back. She denies prior history of
back pain. PMH: She has a history of ankle fracture with trivial trauma. SH: Denies smoking,
alcohol. FH: Osteoporosis +. Med: None All: NKDA
PE:
VS: BP 122/80 mmHg, PR 98/min, RR 16/min, T 38.3oC (101oF)
Skin over back: normal appearance, no atrophy, no deformity
Limited ROM with flexion, secondary to increased pain; minimal tenderness present over L1 -
L2
Straight leg raise: negative at 90 degrees; Patrick’s test: negative
Neuro exam: DTR'S + 2 bilaterally - lower extremities; strength and sensation: symmetric
bilaterally; normal gait
DD:
1. Disk prolapse
2. Osteoporosis with vertebral body fracture
3. Muscle strain
4. Pathologic fracture
5. Degenerative joint disease
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Investigations:
1. X-ray of lumbar spine
2. DEXA scan
3. Calcium, phosphate, alkaline phosphatase, protein electrophoresis, and acid
phosphatase, as needed
4. MRI spine, as needed
5. CBC and ESR, as needed
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Chest Pain Case Print
History Taking:
· When did the chest pain begin?
· Do you still have the chest pain or has it resolved?
· For active chest pain:
n What were you doing when the pain began?
n Did any event or activity cause the pain?
· For resolved or intermittent chest pain:
n How long has the pain been present?
n How often do the episodes of pain occur?
n How long do the episodes of pain last?
n Does any event or activity cause the pain, for example, walking or
exertion?
n How far can you walk before you experience chest pain or shortness of
breath (SOB)?
· Can you show me exactly where the pain is?
· Does it radiate to another region of the body, such as your jaw, arms, or neck?
· On a scale of 1 to 10, how severe is the pain?
· How do you describe the pain? Is it a sharp, burning, crushing, or heavy feeling?
· Does anything make the pain better?
· Does anything make the pain worse?
· Do you have any other symptoms associated with the pain? Do you have shortness of
breath, palpitations, nausea, vomiting, sweating, or lightheadedness?
· Do you have a fever? Do you have a cough?
· Have you had any recent chest trauma or exertion involving the arms?
· Do you have any swelling in the legs? Do you experience any pain in your legs while
walking?
· Have you used any recreational drugs, such as cocaine, in the past 96 hours? If the
patient answers ‘no,’ ask: Have you ever used these substances?
Past Medical History:
· Have you ever had similar problems before? Was it diagnosed? Was it treated?
· Have you ever had any heart problems?
· Have you taken any medications? Did it help? When was the last dose?
· Do you have any other medical problems like high blood pressure or DM? How about
high cholesterol?
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Family History:
· Do any of your family members have heart problems? At what age were they
diagnosed?
Social History:
· What kind of work do you do?
· Do you smoke? Have you ever smoked? How much and for how many years?
· Do you drink alcohol? How long have you been drinking?
· If the patient is female and between the ages of 12 to 50 years: When was the first
day of your last menstrual period?
Medications:
· Are you taking any prescription medications? Any over-the-counter medications?
Allergies:
· Do you have allergies to drugs or foods?
Physical exam:
· Wash your hands.
· Perform proper draping techniques.
· Check for JVD.
· Check the eyes for anemia/pallor.
· Auscultate the heart.
· Auscultate the lungs.
· Check for PMI.
· Check legs for tenderness and edema.
· Palpate peripheral pulses.
· Check for carotid bruit.
· Palpate the abdomen.
· Examine without the gown, not through the gown.
Differential Diagnosis:
· Angina
· Acute MI
· Aortic stenosis
· Pericarditis
· Aortic dissection
· Pulmonary thromboembolism
· Pneumonia
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· GERD
· Costochondritis
· Panic attacks
Investigations:
· BP in both arms
· CBC with diff
· 12 lead ECG
· Cardiac enzymes
· CXR
· 2D-echo
· Fasting lipid panel
· V/Q scan (if you suspect a PE)
· ABG/Pulse oximetry (if SOB is present)
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Chronic Cough Print
History Taking:
l When did the cough start? (Cough of < 3 weeks' duration is defined as acute, whereas
cough of > 3 weeks is considered chronic)
l Is it a dry cough, or do you bring up some sputum? Is the sputum purulent?
l Was there blood in the sputum at any time?
l Have you noticed any dripping sensation in your throat, or the frequent need to clear
the throat? (postnasal drip)
l Do you have any facial pain or tooth pain? (sinusitis)
l Do you get short of breath?
l Did you notice any wheezing? Any nighttime wheezing?
l Have you had frequent heart burn? Regurgitation, or sour taste (water brash)? (GERD)
l Do you have any chest pain?
l What kind of work do you do? Does your cough get worse when you are at your
workplace?
l Is there anything that makes your cough worse?
l Is there anything that makes your cough better?
l Do you ever get a fever? Chills? Any night sweats?
l Have you lost any weight? How is your appetite?
l Have you been exposed to any patient who has tuberculosis?
Past Medical History:
l Do you have any other medical problems? (allergic rhinitis, asthma, sinusitis)
Social History:
l Do you smoke? Have you ever smoked? How much and for how many years?
l Do you drink alcohol? How long have you been drinking?
l Have you ever used recreational drugs?
l Do you have multiple sexual partners?
Family History:
l Do you have any family member with a history of lung cancer?
Allergies:
l Are you allergic to anything, like dust? Pets? (detailed history needed)
Medications:
l What medications do you take? (especially ACE inhibitors)
Physical Examination:
l Wash your hands.
l Perform proper draping techniques.
l Examine the nasopharynges and oropharynges.
l Check for tenderness over the sinuses.
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l Look for enlarged cervical lymph nodes.
l Auscultate the lungs.
l Percuss over the lungs.
l Check for tactile vocal fremitus.
l Auscultate the heart.
l Examine without the gown, not through the gown.
Counseling:
l Explain the physical findings and differential diagnosis.
l Explain the further workup.
Differential Diagnosis:
l Postnasal drip syndrome and sinusitis
l Asthma
l Gastroesophageal reflux disease (GERD)
l Chronic bronchitis
l Bronchiectasis
l Cough secondary to Angiotensin-converting enzyme inhibitors (ACEI) use
l Malignancy
l Cough secondary to occupational exposure
l Tuberculosis (rare in USA)
Investigations:
l CBC with differential
l Chest x-ray
l Sputum gram stain/AFB and culture, as needed
l Pulmonary function tests, as needed
l High resolution CT scan, as needed
l ELISA for HIV, as needed
l PPD placement, as needed
Copyright @2002 -2007 All Rights Reserved www.usmleworld.com
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Chronic Diarrhea Print
Case of a 34 yo M who presents with Chronic Diarrhea (more than 4 weeks)
*Note: Follow the same approach even if the diarrhea is of 2 weeks duration.
History Taking:
· Please explain to me, what do you mean by diarrhea? Do you mean an increased
frequency, an increased volume, or an alteration of stool consistency?
· When did the diarrhea start? (differentiate whether it is acute or chronic)
· Can you tell me about the pattern of diarrhea? Do you have episodes of normal bowel
movement in between? (continuous or intermittent)
· How frequent do you have diarrhea?
· If you were to choose between mild, moderate, or severe, how would you rate the
severity of your diarrhea?
· Can you describe your stool? Is it watery? Bloody? Fatty?
· Do you have abdominal pain? (inflammatory bowel disease and irritable bowel
syndrome)
· Have you lost weight? (malabsorption or malignancy)
· Can you tell me about your diet?
· Are you exposed to anything, which you might find stressful?
· Does anything make your diarrhea worse?
· Does anything make your diarrhea better?
· Do you have a history of recent travel?
Past Medical History:
· Did you ever have similar episodes in the past?
· Do you have other medical problems? Do you have diabetes mellitus? HIV?
Hyperthyroidism? IgA deficiency?
· Were you ever hospitalized? When? Why?
· Did you ever have any abdominal surgery?
· Were you ever exposed to radiation?
Social History:
· What is your occupation?
· Do you drink alcohol? How much do you drink? How long have you been drinking?
· Have you ever used recreational/illicit drugs? How? Are you sexually active? Are your
partners male, female, or both? (assess risk for HIV)
Family History:
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· Does anyone in your family have a history of diarrheal disease?
Allergies:
· Do you have any known drug or food allergies?
Medications:
· Are you currently taking any medications?
· Have you recently taken any medications, especially any antibiotics?
Physical Examination:
· Wash your hands.
· Perform proper draping techniques.
· Examine the oral cavity.
· Examine the neck for thyroid masses.
· Auscultate the lungs. (Check for wheezing.)
· Auscultate the heart. (Check for murmurs.)
· Auscultate the abdomen.
· Palpate the abdomen superficially.
· Palpate the abdomen deeply.
· Examine the skin. (Check for flushing and rashes.)
· Examine the extremities for edema.
· Examine without the gown, not through the gown.
Counseling:
· Explain the physical findings and differential diagnosis.
· Explain the necessary workup. (blood tests, stool examination)
· Ask to perform a rectal examination.
· Advise the patient to drink plenty of fluids.
Differential Diagnosis for Chronic Diarrhea:
· Secretory diarrhea (bacterial toxins, ileal bile acid malabsorption, endocrine diarrhea)
· Osmotic diarrhea (osmotic laxatives, carbohydrate malabsorption)
· Inflammatory diarrhea (inflammatory bowel disease, infectious diseases – Giardia)
· Fatty diarrhea (celiac disease, short bowel syndrome)
Investigations:
· Rectal examination and FOBT (Fecal occult blood testing)
· CBC with differential count
· Basic metabolic panel (NA, K, Cl, CO2, BUN, Cr, glucose)
· Stool analysis (weight, pH, fat staining, osmotic gap, laxative screen)
· Stool for fecal leukocytes and ova and parasites; stool culture
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Copyright @2002 -2007 All Rights Reserved www.usmleworld.com
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Confusion Case Print
Case of a 62 yo M with Confusion
¨ The chief complaint of “confusion” has a very broad differential diagnosis. Try to narrow
down your differential diagnosis based on the SP's other complaints.
History Taking:
· Start with a formal greeting.
n "What brought you in today?" (Answer: "I don't think I have any problem, but
my wife says I am very confused these days.")
n "How long has she been concerned about this?" (Answer: "I think for the past
two or three months.")
n "Is she saying that you are confused all the time or is there any specific time
or related specific situation?" (Answer: "All the time, Doc.")
n "I understand that you are not much concerned about this, but let me ask a
few more questions to find out what exactly is going on. Is that okay with
you?" (Answer: "Sounds great, Doc.")
n "Do you have any problems with your memory?" or "Has she ever complained
about your memory?" ("No.")
n "Do you feel any weakness in your extremities?" ("No.")
n "Do you feel abnormal sensations like tingling or numbness in your
extremities?" ("No.")
n "Do you feel dizzy?" ("No.")
n "Have you ever had any jerky hand movements or seizures?" ("No.")
n "Do you have any history of head trauma?" ("No.")
n "Do you have any fever?" ("No.")
n "Do you have a headache?" ("No.")
n "Have you ever passed out?" ("No.")
n "How are your bowel movements?" ("They are pretty good.")
n "How is your bladder function?" ("Good.")
n "Have you noticed any increased frequency of urination?" ("Yes, I ’ve had this
problem for a long time; I usually pee a little bit more.")
· Remember to ask about the Katz Activities of Daily Living (ADLs) - "DEATH" i.e.
Dressing, Eating, Ambulating, Toileting, Hygiene, as well as the Instrumental
Activities of Daily Living (IADLs) - "SHAFT" i.e. Shopping, Housekeeping, Accounting,
Food preparation, and Transportation.
n "Can you please describe to me a typical day for you? What are your routine
activities of daily living? "
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Past Medical History:
· "Do you have a history of diabetes?" ("Yes")
n "When were you diagnosed with diabetes?" ("About 25 years ago.")
n "Are you on any medication?" ("Yes, I am on insulin.")
n "Do you know how much insulin you take daily?" ("Usually, my wife or my
daughter gives me my insulin shots.")
n "How often do you check your blood sugar?" ("Rarely, like once or twice a
year.")
n "Is your blood sugar under control?" ("Sometimes.")
n "Have you ever been admitted to the hospital for any diabetic-related
complications?" ("No") "For any other reason?" ("No, never.")
· "Do you have any other medical problems?"("Yes, I have high blood pressure.")
n "For how long?" ("Same as my diabetes.")
n "Are you taking any medications for that?" ("Yes. I ’m on atenolol, 25 mg twice
daily, I guess.")
n "How long have you been on this medication?" ("Around 18 years.")
n "How often do you check your blood pressure?" ("Once or twice a year.")
n "Is your high blood pressure under control?" ("Not always. Only some times.")
· "Have you ever had any heart problems?"("No")
· "Have you ever had stroke?"("No")
Medications:
· "Other than insulin and atenolol, are you taking any other medications?" ("No.")
Allergies:
· Every patient must be asked about his/her history of allergies. Do not get a detailed
allergy history if the case does not seem related to it, as in this case.
n "Are you allergic to anything?"("Yes; to penicillin.")
Family History:
· “Do any of your family members have similar symptoms?”
· “Does anybody in your family have high blood pressure? Diabetes?”
· “Did anybody in your family ever have a heart attack? Stroke?”
Social History:
· "Do you smoke?"("No.")
· "Do you drink any type of alcoholic beverages?" ("No.")
· "Have you ever been diagnosed with any sexually transmitted disease, especially
syphilis?" ("No, never.")
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¨ If you ask this much in the history, it is more than enough. Because of the limited time,
you may not get enough from your history for any particular diagnosis. Don't worry.
Physical Examination:
· Wash your hands.
· Perform proper draping techniques.
· Perform the mini mental status exam (MMSE). The patient will usually have a normal
MMSE.
· Do an ophthalmoscopic examination.
· Do a quick cranial nerve examination.
· Check the gait, muscle strength, reflexes, and sensations.
· Auscultate the heart and lungs.
· Examine without the gown, not through the gown.
¨ Examinees usually run out of time because of the MMSE and CNS exams; therefore,
practice performing these exams quickly and efficiently. Practice repeatedly, so that you
won’t have any difficulty in managing your time during the exam.
Counseling:
· We don't think you will have enough time to give counseling; however, it is very
important to formally close or conclude the encounter.
n Ask, "Do you have any questions?"
· Explain the importance of tight blood sugar and hypertension control.
n "I am sorry to hear that your blood sugar and blood pressure are not under
good control. Controlling blood sugar requires determination. Let’s discuss your
treatment plan, which involves having a proper diet, exercising, and using
medication regularly. High blood pressure could indicate that your blood
vessels are having trouble. Hypertension/high blood pressure could complicate
a diabetic ’s problem. It could cause stroke, affect the functioning of the heart,
and even the kidneys. Again, regular exercise, reduction of weight (if the
patient appears overweight), and limiting salt in your food could help in
keeping your hypertension in check. I strongly advise you to take regular
health maintenance examinations to help control your blood sugar and blood
pressure. What do you say, Mr. xyz?" (Sounds great, Doc.)
Differential diagnosis:
· Insulin induced hypoglycemia
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· TIA
· Multi-infarct dementia
· Electrolyte abnormalities
· Medications
· Alzheimer's dementia
Investigations:
· CBC with differential
· Urinalysis
· Serum electrolytes or basic metabolic profile (BMP)
· EKG and 24 hr Holter monitoring if there is any history of spells
· Carotid doppler
· CT scan of the head
· Chest-X ray
Copyright @2002 -2007 All Rights Reserved www.usmleworld.com
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Dark urine Print
Case of a 20 yo M complaining of Dark Urine
History Taking:
· What do you mean by dark urine?
· What color is the urine?
· When did you first notice the dark the urine?
· Did it occur suddenly?
· Is/was there any blood in it?
· Is/was there an odor?
· Is it consistently the same color throughout the day?
· Is the quantity of urine per day decreased or increased?
· Do you have you any pain associated with urination?
· Have you had any abdominal pain or back pain?
· Have you had any fever? Chills?
· Do you have any nausea? Vomiting? Diarrhea?
· Have you eaten any food that could cause this change in color, such as berries,
colored candy, or beets?
· Was there a recent history of trauma?
Past Medical History:
· Have you had similar problems in the past?
· Have you had any recent infections, such as a sore throat?
· Have you ever had any previous urinary problems or kidney problems?
· What other medical problems do you have?
Social History:
· Do you smoke?
· Do you drink alcohol?
· Has there been any change involving your recent sexual activities?
Family History:
· Does anyone in your family have a history of kidney problems?
Allergies:
· Are you allergic to any medication?
Medications:
· Are you taking any medication? (Some medications can cause a change in urine
color.)
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Physical Examination:
· Wash your hands.
· Perform proper draping techniques.
· Examine the oropharynx.
· Auscultate the heart.
· Palpate the abdomen superficially and deeply.
· Check for costovertebral angle tenderness.
· Examine without the gown, not through the gown.
Counseling:
· Explain the differential diagnosis and necessary workup.
· Explain the need for a genital exam.
· Advise the patient to drink plenty of fluids.
Differential Diagnosis:
· Urinary tract infections
· Glomerulonephritis
· Kidney or bladder stones
· Tumors of the kidney and bladder
· Acute tubular necrosis
· Medication-induced
· Food-induced
Investigations:
· Urinalysis
· Urine culture and sensitivity
· CBC with differential
· Cystoscopy, as needed
· KUB, as needed
· CT scan of the abdomen, as needed
Copyright @2002 -2007 All Rights Reserved www.usmleworld.com
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Depression Case Print
Case of a 40 yo F with Depression
¨ During the whole patient encounter, the SP will be in a disinterested mood and talk
in a feeble voice. The doctor should always make eye contact with the patient.
¨ The bored responses from the patient should not frustrate the doctor.
History Taking:
· "Hello Mrs. Jones. My name is Dr. Smith. I’d like to ask you a few questions and do a
physical exam. Is that ok with you?" (The SP will nod feebly)
· "What brings you in today?" ("I don’t know, Doctor. I feel a bit down.")
· "How long have you been feeling this way?" ("Maybe three months.")
· "Mrs. Jones, do you have any idea why you’re feeling this way?" (She remains silent.)
· "Mrs. Jones, I know that you’re in a lot of emotional stress. Will you talk with me
about how you’re feeling and what’s worrying you?" (The patient looks at the doctor
and then away.)
· "Is there anything in particular that has brought this on?" ("I don’t think so.")
· "Do you have anybody to talk to you when you feel down?" "(I have an aunt. She
lives far away.")
· "Mrs. Jones, how’s your appetite?" ("I don’t feel like eating.")
· "Mrs. Jones, have you lost or gained any weight lately?" ("I’ve lost about seven
pounds this past month.")
· "How have you been sleeping?" ("I get up early in the morning.")
· "Are you feeling guilty about anything?" ("I don’t think I am being a good mom for
my children.")
· "Do you feel abnormally tired?" ("I have no energy at all. I don’t even want to get out
of the couch.")
· "Mrs. Jones, tell me about your daily routine." ("I am a house wife. I do the
housework and cook for my children. That’s about it.")
· "Can you tell me about your hobbies and interests?" ("I play the violin and sing in the
choir on Sundays. However, I don’t feel like doing that anymore.")
· "Do you have trouble concentrating?" ("Mmm, I don’t know.")
· "Do you find yourself forgetting things?" ("Yeah, I’m forgetting to pay the bills on
time. ")
· "What’s your favorite thing to do?" ("Spending time with my children.")
· "Are you still feeling that way?" "(I don’t feel like I want to be with anybody right
now.")
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· "Mrs. Jones, have you ever felt like life wasn’t worth living? Have you ever thought
about killing yourself?" ("Yeah, a couple of times.")
· "Do you ever think about how you would do it" ("No.")
· "Do you have guns or pills at home?" ("Yeah, I have a .32 at home.")
· "Do you feel cold when others don’t?" ("No.")
· "Are you losing any hair?" ("No.")
· "Do you have any problems with your urination?" ("No.")
· "Are your bowel movements regular?" ("I have been constipated lately.")
· "Have you ever had any shortness of breath." ("No.")
· "Have you had any chest pain?" ("No.")
· "Have you had a cough that just wouldn’t go away?" ("No.")
· "Do you hear or see things that other people don’t?" ("No.")
· *Do an MMSE at this juncture.
· "Do you think something is wrong with you?" ("Yeah.")
· "Are you willing to get help from a counselor?" ("I don’t know.")
· "Would you talk with a counselor if I set it up?"("If you think that would help me.")
Past Medical History:
· "Now, I need to ask you a few questions about your health in the past. Is this okay
with you?" ("Yeah")
· "Have you ever been hospitalized?" ("No, except when I had my children.")
· "Have you ever felt like this before?" ("No.")
· "Are you on any medication?" ("No.")
Allergies:
· "Do you have allergies of any kind?" ("None that I know of.")
Sexual History:
· "Now, I need to ask you a few personal questions. Please don’t feel embarrassed.
Everything you say will be kept confidential."
· "Are you sexually active?" ("Yes.")
· "How many sexual partners do you have?" ("A couple of them.")
· "Your sexual preference is…?"("Males." )
· "Do your sexual partners use condoms?" ("Yes, they do.")
· "Have you ever been diagnosed or treated for an STD?" ("No.")
· "Have you ever been tested for HIV?" ("No.")
Family History:
· "Now, I need to ask you a few questions about your family so that I can get a clearer
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picture of your health."
· "Are you married?" ("I was. Got a divorce 10 years ago.")
· "Are your parents alive?" ("No, they died of old age.")
· "Was anyone in your family ever diagnosed with a psychiatric disorder?" ("No.")
· "How many children do you have?" ("I have two children, 14 and 11 years old.")
Social History:
· "Now, I need to ask you a few questions about your lifestyle."
· "Do you smoke?" ("No.")
· "Do you drink any type of alcoholic beverages?" ("Yeah. I have two shots of scotch on
the rocks every night. I’ve been doing that for the past 10 years.".)
· "Do you use any recreational drugs?" ("No.")
· "Do you drink coffee?"("Yeah, one cup every morning.")
Physical Examination:
· "Now, I need to do a physical. Excuse me for a few seconds while I wash my hands."
· "I’m going to check your thyroid gland." (Not palpable)
· "I’m going to check your reflexes." (2+)
· "I’m going to check your pulse now."
· "I’m going to listen to your heart and lungs now."
· "Thank you, Mrs. Jones, for your cooperation."
· Remember to examine without the gown, and not through the gown.
Counseling:
· "I’d like to sit down and tell you what I think so far."
· "It appears that you are having an episode of depression. However, I’m going to run
some tests first."
· "I am going to order a blood test to see if you have any problems with your thyroid.
Once we get the results I’d like to talk with you again and see if we can help you to
start feeling better."
· "Do you have any questions for me?"
Differential Diagnosis:
· Depression
· Hypothyroidism
· Occult carcinoma
Investigations:
· Serum TSH
· CBC with differential
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· Urine and serum toxicology screen
Copyright @2002 -2007 All Rights Reserved www.usmleworld.com
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Diabetic Drug Refill Print
Case of a 50 yo M Diabetic who came for Medication Refill
Vital Signs:
· BP 135/70 mm Hg
· Pulse 73/min
· RR 16/min
· T 36.7C(98F)
History taking:
· When were you diagnosed with diabetes?
· Are you currently taking any medications for diabetes?
· Are you taking your medications regularly?
· Do you think that your medicine is controlling your diabetes effectively?
· Have you ever taken insulin?
· How often do you check your blood sugar? or Do you check your blood sugar
regularly/according to your previous physician’s advice?
· How has your blood sugar been lately? How high did it go? Can you tell me the usual
range of your blood sugar?
· Do you have any problems that you would like to talk about?
· How is your vision? Do you think there is any change in vision lately?
· Do you feel any abnormal sensations in your legs, like pins or needle prick
sensations? Any tingling or numbness?
· Have you ever had any chest pain?
· Do you have any breathing problems?
· Are you sexually active? Do you have any problems during sexual intercourse?
· How are your bowel habits? (Or) Do you have regular bowel movements?
· Do you have any problems with urination?
· How is your appetite? Have you lost or gained any weight lately?
Past Medical History:
· Have you ever been hospitalized for diabetic complications or for any other reason?
· Do you have any other medical problems like high blood pressure?
Allergies:
· Are you allergic to anything?
Medications:
· Are you taking any medications besides diabetic drugs?
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Social History:
· Do you smoke?
· Do you drink alcohol?
· Do you exercise regularly?
Physical Examination:
· Wash your hands.
· Perform proper draping techniques.
· Do an ophthalmoscopic examination. (Check for DM retinopathy).
· Auscultate the neck to check for carotid bruit.
· Palpate the precordium for PMI. (Check for cardiomegaly.)
· Auscultate the heart.
· Test sensation in both legs.
· Check distal pulses in at least two places
· Even if the SP is wearing shoes or socks, please don't forget to instruct him to take
them off to examine the feet!
· Examine without the gown, not through the gown.
Investigations:
· CBC with differential count
· Blood glucose
· HbA1C
· BUN and Serum Creatinine
· Lipid Profile
Copyright @2002 -2007 All Rights Reserved www.usmleworld.com
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Dizziness Case Print
Case of a 65 yo F with Dizziness
¨ In real life (as well as in the step 2 CS!), evaluating a patient with dizziness can be
challenging and frustrating for the clinician. “Dizziness ” is a nonspecific term. When a
patient complains of being dizzy, he/she may be experiencing vertigo, non-specific
"dizziness", disequilibrium, presyncope or near syncope. It is therefore very important to
obtain an extensive history in order to narrow down your differential diagnosis.
History Taking:
· "What brought you in today?" ("I feel dizzy.")
· "Can you please explain to me a little bit more about your dizziness?" ("I always feel
dizzy. I don't know what you want me to explain.")
· Make good eye contact and say, "Well Mrs. XYZ, it looks like you are not in a good
mood. I am here to help you. Are you comfortable? Is there anyway that I can help
you?" ("My mood is fine. Just help me get rid of this dizziness.")
· "Ok, I do understand that most people with dizziness are not happy. It’s miserable
feeling dizzy all of the time. I want to help you. To clearly understand your problem I
need to quickly ask a few questions. Is that ok with you?" (Note that she won’t be
happy at all during this encounter. She could be your ‘uncooperative’ patient. )
· "Tell me, what do you mean by dizzy?" ("Dizzy means exactly that… dizzy.")
· "Well, many people describe their problem as ‘dizzy’ when in reality it’s not really
‘dizziness ’. Anyway, when you get dizzy, do you feel like the room is spinning around
you?" ("No.") “Or, do you think that you are spinning inside?" ("Yeah.")
· "Is your dizziness constant or does it just come and go?" ("Comes and goes.")
· "When did the dizziness first occur?" ("Two weeks ago.")
· "How often do you feel dizzy?" ("Once or twice a day.")
· "How long does it last?" ("One to five minutes.")
· "Do you have any warning signs that the attack is about to start?" ("No, not really.")
· "Does it occur at any particular time of the day or night?" ("I‘m not sure.").
· "Does change of motion make you dizzy?" ("I don't know.")
· "Do you know of any possible cause for your dizziness?" ("I don't know.")
· "Do you know anything that will stop your dizziness or make it better?" ("No.")
· "Do you know anything that will make your dizziness worse?" ("No.")
· "When you get dizzy, do you have a tendency to fall?" ("Yes.") "To which side? Is it to
the right or left?" ("I don't remember.")
· "Have you ever lost consciousness?" ("No.")
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· "Do you have loss of balance when walking?" ("Yeah, sometimes.")
· "Have you had any headaches when you get dizzy?" ("Yah, light headedness.") "Do
you have it now?" ("No.")
· "Have you had any vomiting when you get dizzy?" ("No.")
· "Have you had any palpitations?” ("No.") “Shortness of breath?” ("No.") Feelings of
panic when you get dizzy?" ("No.")
· "Have you noticed any difficulty with your hearing?" ("No.")
· "Do you hear any ringing in your ears?" ("No.")
· "Do you have any problems with double or blurry vision?" ("No.")
· "Have you ever noticed any weakness in your arms or legs?" ("No.")
· "Do you have any numbness in your face, arms, or legs?" ("No.")
· "Do you have any problems with your bowel movements?" ("No.")
· "How is your bladder function?" ("Good.")
· "How has your appetite been lately?" ("Good.")
Past Medical History:
· "Do you have any other medical problems, other than dizziness?" ("I have low blood
pressure.")
· "Have you had any heart problems?" ("No.")
· "Have you ever been hospitalized?" ("Yes, for a stroke a few years ago.")
· "Have you ever had a history of trauma to your head or neck?" ("No.")
Allergies:
· "Are you allergic to anything?" ("No.")
Medications:
· "Are you taking any prescription medications now?" ("Yes, aspirin.")
· "Any over-the-counter medications?" ("No.")
Family History:
· “Did anybody in your family ever have similar symptoms?”
· “Does anybody in your family have a history of high blood pressure? Heart disease?
Diabetes? Stroke?”
Social History:
· "Do you smoke?" ("No.")
· "Do you drink alcohol?" ("Yes, social drinking. One to two beers on weekends.")
Physical Examination:
· Wash your hands.
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· Perform proper draping techniques.
· Check for orthostatic hypotension.
· Do a quick, complete CNS exam, which must include nystagmus, gait, Romberg's test,
and cerebellar function tests.
· Auscultate the neck to check for "carotid bruit."
· Auscultate the heart.
· Hearing tests - if you get a positive history of hearing loss
· Do otoscopic examination if you get any positive history like ear discharge, pain in the
ears, ringing in the ears and aural fullness.
· As long as memory is intact, you don't need to do MMSE and obviously, you don't
have time. Always do most important things first.
· Examine without the gown, not through the gown.
¨ People with dizziness are often reluctant to move because of the fear of falling, though
they are able to walk. Before you check the gait or perform Romberg's test, say, "I can
imagine how uncomfortable it is, but I am here to assist you. I will help you in every
aspect of the examination. This won’t take more than a couple of minutes."
Differential diagnosis:
· Benign positional vertigo
· TIA
· Stroke
· Postural hypotension/Orthostatic hypotension
· Arrhythmias
· CNS tumors/Meniere's disease
· Drug induced/Polypharmacy
· Nonspecific dizziness
· Peripheral neuropathy
· Thyroid abnormalities
· Anemia
· Metabolic disturbances, like hypoglycemia
Investigations:
· CBC with differential
· Basic metabolic profile (Na, K, Cl, CO2, BUN, Cr, Calcium and blood sugar)
· Thyroid function tests
· Carotid Doppler - if you get a relevant history for stroke/TIA
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· MRI of brain - for suspected acoustic neuroma or any CNS tumor
· 24 hr Holter monitoring - In patients with h/o palpitations and cardiac disease
¨ If you get an uncooperative patient, it will be very difficult to get everything done in 15
minutes. This SP will refuse to cooperate and fail to do all the tests properly. Don’t
panic. Try to do as much as you can, and remember that they were told to act like that.
This problem will be encountered by all the Step 2 CS takers.
¨ To be very efficient during the exam, here’s what you have to do: practice, practice and
practice some more!
Copyright @2002 -2007 All Rights Reserved www.usmleworld.com
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Domestic Violance Print
· There are many ways to ask direct questions that can elicit a history of domestic
violence or an abusive relationship. It is very important, however, to always be
sensitive and supportive when you encounter cases like these. No single question is
right, as long as you are sensitive and supportive.
· In real life, many battered women may hesitate to initiate information about abuse,
but are relieved to answer when some one asks. This is why you are expected to
recognize these kinds of cases during the step 2 CS exam. You will usually get a
patient encounter involving abuse or domestic violence; therefore, it is necessary to
know how to ask the key questions, in order to elicit a proper history.
History Taking:
· If you are suspecting domestic violence or a case of abuse (ex. patient with bruises
and/or depression), you can start with a good screening question like this:
n "I don't know if this is a problem for you, but because so many people we see
are dealing with abusive relationships, I have started to ask about it routinely.
Are you currently in a relationship where you are physically hurt, threatened or
feel afraid?"
· If you notice multiple bruises (nice painting by CSA people), and the patient does not
give any history of abuse, ask like this:
n "I noticed that you have a number of bruises. Did some one do this to you?”
n “It looks like someone hurt you. Can you please tell me what happened to
you?"
· If the chief complaint itself is an abuse, you can ask direct questions like:
n "What happened? How were you hurt?”
n "Was alcohol or drugs involved? How? By whom?” or “Does your partner use
drugs or abuse alcohol?"
n "Have you ever been attacked with a weapon?"
n "How long have you been in this abusive relationship? Has it happened ever
before? Are you afraid it will happen again?"
n "Has your partner ever made you have sex when you didn't want to?"
n "You mentioned that your partner loses his temper with you. How are things
between him and your children?"
n "Have you ever left home? When?” If not: “Have you ever wished you could
leave? What has prevented it?"
n "Are you planning to leave/divorce your partner?"
n "Has your partner ever threatened or tried to commit suicide?"
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n "Do you, yourself, think of suicide as a way out of the relationship?" If the
answer is 'yes,' ask, "Do you have a plan or method by which you would kill
yourself or your partner?"
n "Do you have an emergency plan, if needed?"
n "Are your family or friends aware of your situation?"
· During the whole encounter, tell her repeatedly that she does not deserve to be
beaten. Battering is against the law.
Physical Examination:
· Wash your hands.
· Follow proper draping techniques.
· Examine the injured parts (painted parts!!).
· Auscultate the heart and lungs (no percussion necessary, unless patient has a big
bruise over the chest or has breathing problems).
· Auscultate and palpate the abdomen.
· Examine without the gown, not through the gown.
Counseling:
· Counseling is a major part of any abuse case in the exam.
· Assure your patient that you will do everything possible to maintain her safety.
Assure her that her medical condition will be treated appropriately, and that she will
not be forced to do anything against her will.
· Tell her that her children will be cared for and kept safe (if present).
· Assure her confidentiality. Explain to her that only with her signed consent will her
medical records be released to any other source.
· Tell her that violence never ends on its own, and that the violence almost always
escalates in severity and frequency over time. Explain that the only way to end the
abuse is to get away from the batterer.
· Always be respectful and non-judgmental. Say, "I believe you. It’s not your fault.
You’re not crazy and you are not alone. Help is available for you."
· Before you leave, ask, "Do you think it’s safe to go home? Do you have a safe place
to stay? Would you like to speak with a domestic violence counselor?"
Copyright @2002 -2007 All Rights Reserved www.usmleworld.com
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Forgetfulness Case Print
Case of a 70 yo F Complaining of Forgetfulness
Vital Signs:
l BP 150/85 mm Hg
l Pulse 76/min, regular
l RR 16/min
l T 36.1C(97F)
History Taking:
· Hello, Mrs. Thomson. I am Dr. Jones. How are you doing today?
· How have you been feeling lately? Are you feeling sad or lonely ?
· Are you having any problems with your memory?
· Do you have any problems sleeping?
· Tell me about your typical diet. What do you eat?
· Do you have any problem eating or making meals for yourself?
· Do you have difficulty walking?
· Do you have any trouble with your toiletry habits?
· Do have any problems getting your shopping and housekeeping done?
· Are you able to find your way through your house?
· Do you have any problem driving to the grocery store?
· Do you have any difficulty managing your accounts?
· How are your bowel habits?
· Have you noticed any weight loss over the past few months?
· Do you have any dizzy spells?
· Did you ever feel that your heart was pounding?
· Have you noticed any cold or heat intolerance?
· Do you have somebody to take care of you, in case of an emergency? If not, would
you like me to get you in touch with a social organization that would be happy to help
you?
Past Medical History:
· Did you have any medical problems in the past?
Family History:
· Do you have any family members who had a hereditary medical condition?
Social History:
· Do you smoke?
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· Do you drink any type of alcoholic beverages?
· Have you ever had any sexually transmitted diseases?
Medications:
l "Are you taking any prescription medications now?"
Physical Examination:
l Ask the following as part of the mental status exam:
n Mrs. Thomson, can you tell me what your full name is?
n Can you tell me what day it is today?
n Can you tell me where we are now?
n Spell the word ‘WORLD’ backwards for me.
n I’m going to say three words. As soon as I’m finished, please repeat the three
words I said. We will talk for a while, then I’ll ask you to repeat those three
words again.
n Please put your left hand on your right hand. Bring both hands towards your
chest, and then back to their original position.
· Wash your hands.
· Perform proper draping techniques.
· Do an ophthalmoscopic examination.
· Do a focused neurological exam.
· Do a fast heart and lung exam.
· Do the ‘Get Up and Go’ test.
· Examine without the gown, not through the gown.
Counseling:
· Tell her the diagnostic possibilities, necessary workup, and prognosis.
· If you suspect Alzheimer's, talk with the patient about it. Stress the importance of a
structured home environment, and the precautions that need to be taken to avoid
falls.
· Explain the necessity of taking her medication regularly.
· Make sure the patient understands her problem.
· Ask her about her social support and offer any help, if needed.
Differential Diagnosis:
· Alzheimer's Disease
· Vascular dementia
· Normal pressure hydrocephalus
· Vitamin B12 deficiency
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· Hypothyroidism
· Masked depression
· Chronic subdural hematoma
Investigations:
· CBC with differential
· CT scan of the head
· Serum TSH and Vitamin B 12 level
· Basic metabolic panel (Na, K, Cl, CO2, BUN, Creatinine, Calcium)
· Syphilis serology
Copyright @2002 -2007 All Rights Reserved www.usmleworld.com
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Headache Case Print
Case of a 27 yo WF complaining of a Headache
Vital Signs:
· BP 120/70 mm Hg
· T 98.6 F
· RR 19/min
· HR 80/min
Simulated encounter:
Knock on the door:
History Taking:
· "Good morning, Mrs. Jamie. My name is Dr. XYZ. How are you doing today? What brought
you in today?"("Doc, I have a headache.")
· "Can you tell me a little bit more about your headache?"("Doc, my head hurts so much.")
· "How long have you had your headache?"("For several hours.")
· "How did the pain start? I mean, was it all of a sudden or gradual?"("It started
suddenly.")
· "Is it a constant or intermittent type of pain?" ("It’s pretty much constant.")
· "Can you please show me exactly where the pain is?" ("All over my forehead.")
· "Does it hurt anywhere else? Like your jaw or the back of your neck?" ("No.")
· "What were you doing before you noticed the headache?" ("I was in my office.")
· "How do you describe your pain?" ("It’s a band-like sensation.")
· "On a scale of 1 to 10, which number would best describe your pain?" ("I would say
probably between 7-8.")
· "Is there anything that relieves your pain?" ("Yes, staying in a dark room.")
· "Is there anything that makes it hurt more?" ("Yes, bright light and moving around.")
· "Have you felt nauseated or been vomiting? ("I’ve been a little bit nauseated, but I
haven’t thrown up.”)
· "Have you ever had this type of pain before?" ("Yes, a couple of times about three months
ago.")
· "You said you’ve had headaches like this before. When you get these headaches, how
long do they last?” (“I think they last for an hour. I ’m not sure.”)
· “Do you have any warning signs before they come? For example, do you get blurry vision
or do you see flashes before the headache?" (Ask the premonitory symptoms) ("No, I
have no prior warning. They just hit me like a ton of bricks.")
· "Do you have any blurriness or double vision now?" ("No.")
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· "Are these episodic headaches affecting your daily activities?" ("No, I’m working as
usual.")
Review of Systems: (For the exam, make the ROS very focused.)
· “Ok, let me quickly ask you some other questions:”
· "Do you have any fever?" ("No.") "Chills?" ("No.")
· "Is your neck stiff?" ("No.")
· "Have your eyes been watery?" ("No.")
· "Have you had a runny nose?" ("No.")
· "Have you noticed any ear discharge?" ("No.")
· "Have you had any head trauma?" ("No.")
· "Have you had any weakness in your arms or legs?" ("No.")
· "Have you noticed any sensory changes, like tingling or numbness in your hands or
legs?" ("No.")
· "Do you have any urinary complaints?" ("No.")
· "Do you have any problems with your bowel movements?" ("No.")
· "Has there been any change in your appetite?" ("No.")
· "Have you lost or gained weight lately?" ("No.")
Past Medical History:
· "Do you have any other medical problems?" ("No.")
· "Do you have a history of high blood pressure?" ("No.")
· "Have you ever been hospitalized before?" ("No.")
Allergies:
· "Are you allergic to anything?" ("No.")
Medications:
· "Are you taking any prescription or over-the-counter medications?" ("Yes, Tylenol.")
· "Have you ever taken recreational drugs?" ("No.")
· "Do you use any hormonal contraception?" ("No.")
Family History:
· "Can you please tell me something about the health of your family members?" ("They
are fine.")
· "Does anyone in the family have habitual headaches?" ("Yes, actually my sister has
migraines. She wanted me to see you. She thinks my headaches might be migraines,
also. What do you think?") "Ms. Jamie, from what you just told me, there is a
possibility that they might be migraine headaches. But, I need to ask a few more
questions, and then give you a physical examination. That will help me better
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determine what the problem is. Is that okay with you?" ("Sure, doc.")
Social History:
· "What do you do for a living? Where do you work?" (“I’m a sales clerk. I work in the
mall.”)
· "Do you feel any stress at work or home? Are you stressed out about anything?" (“Not
really.”)
· "Do you smoke?" ("No.")
· "Have you ever smoked?" ("No.")
· "Do you drink alcohol? How much and how often?" (“Yeah. I guess around 1-2 beers a
month.”)
· "Are you sexually active? Are there any problems in your sexual life?" (“No.”)
Physical examination:
· Wash your hands.
· Perform proper draping techniques.
· Auscultate the neck to check for a carotid bruit.
· Palpate the head, neck, and shoulder regions.
· Check the temporal arteries in elderly patients.
· Examine the spine and neck muscles.
· Do a functional neurological examination including:
n cranial nerve examination
n ophthalmoscopic and otoscopic examination
n assessment of sensation, muscle strength, and reflexes
n cerebellar (coordination) tests
n tandem gait
n Romberg test
· Examine without the gown, not through the gown.
Counseling:
· Call the patient by her name.
· Tell her the possible diagnosis and need for further workup.
· Acknowledge the discomfort of the patient.
Differential Diagnosis:
· Migraine
· Cluster headache
· Tension headache
· Subarachnoid hemorrhage/CVA
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· Sinusitis
· Brain tumor
· Meningitis/Encephalitis/Infections
· Temporal arteritis (in the elderly patients)
· Refractive errors (if they give any positive history and PE)
· Medications/Drugs
Investigations:
· CBC with differential
· ESR
· Temporal artery biopsy (in elderly patients)
· Sinus X-ray
· CT head without contrast
· LP (Not in this patient. If the patient appears sick and presents with fever or
confusion, you should also take blood cultures for suspected meningitis.)
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HeelpainCase Print
Case of Heel/Foot pain
History Taking:
· What brings you in today?
· Where exactly do you feel the pain?
· On a scale of 1 to 10, with 10 being the worst, how would you rate the severity of
your pain?
· How would you describe the quality of the pain?
· When did this pain begin?
· How long does an episode of pain last?
· When you get the heel/foot pain, do you feel pain in any other part of your body?
· What makes the pain worse?
n Walking?
n Standing? After standing, how long does it take for the pain to start?
· Does anything make the pain better?
· Did you ever experience this before? When? How long would an episode last? How
frequent would they occur?
· Did you ever have any accidents/trauma involving your foot/heel?
· Do you have fever?
· Do you have joint pains? Where?
· Did you ever have morning stiffness?
· Did you ever have a history of (h/o) diarrhea or any acute illness? (for possible
reactive arthritis)
· Did you ever have any urethral discharge? How about an eye infection/conjunctivitis?
(for possible Reiter's syndrome)
· Did you ever get any rashes? (For psoriatic arthritis)
· What type of work do you do?
· Does your work involve any prolonged standing?
· Do you have to walk a lot at your work?
Past Medical History:
· Do you have any other medical problems?
Allergies:
· Do you have any allergies?
Medications:
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· Are you currently taking other medications?
Family History:
· Does anybody in your family have a history of rheumatoid arthritis? How about any
other joint diseases?
Social History:
· Do you smoke?
· Do you drink alcoholic beverages?
· Have you ever used recreational or illicit drugs?
· Are you currently sexually active? Do you use any form of contraception? Did you
ever have a sexually transmitted disease?
Physical Examination:
· Wash your hands.
· Perform the proper draping technique.
· Check the eyes for possible conjunctivitis. (if you suspect Reiter's syndrome)
· Inspect the foot. (let the SP know that you are inspecting)
· Palpation of the entire foot (not just the heel) for any point of tenderness.
· Check for the range of motion of the ankle & forefoot joints. Check for pain and
restriction of movements.
· Ask the patient to do active dorsiflexion and plantar flexion. Check for any tendon
tenderness. (for tendonitis)
· Examine without the gown, not through the gown.
Counseling:
Before closing the encounter, you may counsel the SP like this:
"I have to order an x -ray of your foot and ankle and some basic blood tests before we
come to a proper diagnosis. Meanwhile, I will try to help you get relief for your pain.
· Rest your foot for two or three days.
· Ice it for 30 minutes. Do this every four hours.
· Use soft heel pads.
· Avoid excess weight on your heel.
· Try over-the-counter ibuprofen for pain relief.
· You can also try using a padded foot splint. (These splints are available in pharmacies
that feature orthopedic supplies.)
Most of the time people will get better with these measures. If you don't get better, or if
your tests show abnormal results, we will sit together and discuss the other possible
options. Is that okay with you?” (“Sounds great, Doc.”)
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Investigations:
· CBC with differential
· ESR
· X-ray of foot and ankle, 3 views
· Rheumatoid factor assay
Differential diagnosis:
· Plantar fasciitis
· Calcaneal periostitis
· Calcaneal spurs
· Painful heel pad syndrome
· Bone tumors
· Rheumatoid arthritis
· Reiter's syndrome
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Hemoptysis Case Print
Case of a 45 yo M with Hemoptysis
History Taking:
l Good morning, Mrs. Reeves. I am Dr. Lopez. What brings you in today?
l When did it happen?
l How many times?
l Was it bright red blood or streaked with sputum? Or rust-colored sputum?
l How much was it?
l Do you have cough? Is it a productive cough? Is it foul-smelling sputum?
l Do you have any breathing problems?
l Have you had any chest pain?
l Have you had fevers? Chills? Night sweats?
l Have you lost any weight?
l How is your appetite?
l Have you had contact with a tuberculosis patient?
l Did you travel to any country?
l Have you had multiple sexual partners?
Past Medical History:
l Do you have any other medical problems? (HIV, tuberculosis, recurrent pneumonia)
Social History:
l What do you do for a living?
l Do you smoke?
l Do you drink alcohol?
l Do you use IV drugs?
Family History:
l Do you have any family history of lung cancer?
Allergies:
l Are you allergic to any medication?
Medications:
l What medications do you use on a regular basis?
Examination:
l Wash your hands.
l Perform proper draping techniques.
l Examine the oral cavity.
l Check for cervical lymph nodes.
l Percuss the lungs.
l Palpate the lungs. (Tactile Vocal Fremitus/TVF)
l Auscultate the lungs.
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l Auscultate the heart.
l Palpate the abdomen.
l Check for finger clubbing.
l Examine the skin for any evidence of vasculitis.
l Examine the legs for deep vein thrombosis, as needed.
l Examine without the gown, not through the gown.
Differential Diagnosis:
l Bronchiectasis
l Acute or chronic bronchitis
l Pneumonia
l Bronchogenic carcinoma
l Lung abscess
l Tuberculosis
l Connective tissue diseases (Wegener’s disease, Goodpasture’s, Lupus)
l Pulmonary embolism
l Pseudo hemoptysis (Hematemesis)
Investigations:
l CBC with differential, ESR
l PT/INR/PTT
l Sputum for AFB and gram stain
l Chest x-ray
l PPD, as needed
l Urinalysis
l BUN and Creatinine
l CT of the chest, as needed, for bronchiectasis
Copyright @2002 -2007 All Rights Reserved www.usmleworld.com
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Insomnia Case Print
Case of Insomnia
¨ Insomnia is one of the most common problems in the USA; therefore, it is worthwhile to
study this case for the Step 2 CS.
¨ Insomnia has numerous - and often concurrent - etiologies, including medical conditions,
medications, psychiatric disorders, and poor sleep hygiene. Sleep apnea should also be
considered in the differential diagnosis.
¨ The evaluation usually requires detailed history taking in order to narrow down your
differential diagnosis.
History Taking:
· "What brought you in today?" ("I have problem with sleep, Doc.")
· "Can you please tell me more about your problem?" ("I used to work as a truck driver
during the night and now I switched to daytime work. Since then, I am having
problems with sleep. I think this all is due to the shift work. Please give me some
sleeping pills, Doc.")
· "I understand that your problem might be due to your change of working schedule.
However, there are some other common things and conditions that can cause sleep
problems. Most can be easily treated, if found. So, I need to ask a few more
questions about your sleep patterns, your general condition, and some other things.
Is that ok with you?" ("Sure, go ahead Doc.")
· "How long have you been having problems with sleep?" ("Around three-four weeks.")
· "Do you have problems falling asleep? ("Yeah, most of the times.")
· "Do you have any problems staying asleep? ("Yeah, some times.")
· "Do you have problems with waking in your sleep?" ("No.")
· “You said that most of the times you are having problems with falling asleep.”
n “When do you usually go to bed?" ("Between 8 - 9 PM")
n "How much time does it take you to fall asleep?" ("1 to 2 hours")
n "What do you do before you go to bed? I mean, some people do exercise in the
late evening and drink alcohol before going to bed. Do you do any exercise like
that?" ("No.")
n "Do you drink any alcohol before you go to bed?" ("Yeah.") "How much do you
drink?" ("A couple of beers, usually.")
n "Do you smoke before you go to bed?" ("Yah, mostly after having dinner.")
n "Do you drink caffeine or excess coffee before you go to bed?" ("Not really.")
· "Do you watch television while lying on the bed?" ("Yeah, usually.")
· You said you also have some problems staying asleep."
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n “Do you wake up several times during the night?" ("Not several, but 2-3 times,
and if I wake up, it takes awhile to get back to sleep again.").
n "Okay, you said you wake up 2-3 times in a night. Do you have any idea what
might be causing it?”
n “I mean, do you wake up often to urinate? ” ("No.")
n “Do you experience any problems with breathing?” ("No.")
“Coughing?" ("No.")
¨ If you are asking several questions, always pause after each question.
· "Have you or any of your family members noticed that your sleep is restless, or that
you move around a lot in your sleep?" ("No, not that I know of.")
· "Do you have pain anywhere?" ("No.")
· "How is your mood?" ("Pretty good.") (If the SP appears depressed, you have to ask
all depression questions. It is very unlikely to get a case with 2-3 problems like
depression, shift in work, etc., since it would be very difficult to manage in 15
minutes.)
· "How are your bowel habits?" ("Pretty good.")
· "How is your bladder function?" ("Pretty good.")
¨ Sometimes the major cause of sleep disturbance in middle-aged women is the
menopause-related "hot flush". Recent studies indicate that nearly every hot flash
promotes an arousal from sleep. So, please keep this in mind if you get a female patient
of menopausal age.
Past Medical History:
· "Do you have any other medical problems?" ("No, I’m pretty healthy.")
· "Have you ever been hospitalized for any reason?" ("No, never.")
Allergies:
· "Do you have any allergies?" ("No.")
Medications:
· "Are you taking any prescription medications?" ("No.")
· "Any over-the-counter medications?" ("No.")
· "Are you using any recreation type drugs?" ("No.")
Social History:
· "You said you have a habit of smoking and drinking alcohol.”
n “How long have you been smoking?" ("15 yrs.")
n "How many cigarettes do you smoke in a day?" ("5-10.")
n "How long have you been drinking alcohol?" ("Same as smoking.")
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n "How much do you drink per day?" ("About 2-3 beers a day.")
· "Are you sexually active?" ("Yes.") "Do you have any problems with sexual
performance?" ("No.")
· "Is your work stressful?" ("No.")
Family History:
· Does anybody in your family have the same symptoms?
Physical Examination:
· Wash your hands.
· Perform the proper draping technique.
· Check the thyroid.
· Auscultate the lungs and heart quickly.
· Examine without the gown, not through the gown.
Counseling:
· "Based on your history I think your problem is most likely due to multiple factors.
n Obviously, your shift work plays a big role in your sleep pattern, as there is no
consistency in your schedule. I would like you to maintain a sleep diary for
two weeks to record your sleep patterns. Please keep regular bedtimes and
wake times, even on weekends and days off from work.
n Limit or stop the use of nicotine, caffeine, and alcohol.
n Exercise regularly, but no later than late afternoon or early evening.
n Do not use the bed as a place to worry, especially about not sleeping. If you
feel it’s necessary, write down all your worries and concerns before you go to
bed, and place the list on your dresser to examine it the next morning.
n Use the bedroom only for sleep. Don't read, watch television, eat, or do other
activities in bed.
n Try to avoid daytime naps. But, if you must nap, do so in the early afternoon
and for no longer than 30 minutes per day.
n Eat a light snack before bedtime if food is needed because of hunger.
n Get regular exposure to outdoor sunlight, especially in the late afternoon.
· If you follow these guidelines, your sleep problems may be eliminated. We usually
don't recommend medication for insomnia, as this problem often resolves itself with
behavioral modifications. Okay?"
· "Do you have any questions?"
Diagnosis :
· Circadian rhythm sleep disorder
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¨ Discussion of insomnia:
· Certain medical conditions, such as COPD, GERD, peptic ulcer disease, BPH (resulting
in overflow incontinence), and congestive heart failure with associated paroxysmal
nocturnal dyspnea, frequently disturb sleep, and may be interpreted by the patient as
insomnia.
· Patients with chronic pain, such as that resulting from chronic pain syndromes,
fibromyalgia, and cancer, may have insomnia and early-morning awakening.
(Remember: The SP won’t tell you about any associated pain unless you ask.)
· A psychiatric disorder, such as depression, is frequently a cause of chronic insomnia,
especially in the elderly.
· Periodic leg movements during sleep are common in persons over 65 years of age.
Although these limb movements are often associated with brief arousals, many
patients have no sleep symptoms.
· Regardless of the cause of insomnia, most patients benefit from behavioral
approaches that focus on good sleep habits. Exposure to bright light at appropriate
times can help realign the circadian rhythm in patients whose sleep-wake cycle has
shifted to undesirable times.
· Chronic insomnia may reflect a disturbance in the normal circadian sleep-wake
rhythm, as in this patient.
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Menopause Case Print
Case of a 52 yo F complaining of Hot Flashes
Vital Signs:
· BP 140/80 mm Hg
· Pulse 80/min, regular
· RR 16/min
· T 98.8oF
History Taking:
· "Hello Mrs. Armstrong; I am Dr. Jones" ("Hello, Dr.") "Good morning." ("Good
morning, Dr.") "Nice to meet you." ("Nice to meet you too.")
· "What brings you in today?" ("I keep having hot flashes and they’re driving me
crazy.")
· "When did they start?" ("Around three months ago.")
· "How often do they happen?" ("About 10 times a day.")
· "Do you feel anything else when these flashes occur?" ("I sweat a lot and I feel my
heart racing.")
· "Do you have any warning beforehand? I mean do you feel it coming on before it
really starts?" ("Yes Dr., I do. It sometimes even disturbs my sleep.")
· "How do you feel on most days? How has your mood been the last three
months?" ("I don’t know Dr. I feel dull, sometimes I can’t control my temper, and
most of the time I just want to be left alone. I don’t feel on top of things. This whole
thing is driving my husband crazy.")
· "Do you feel any burning or pain when urinating?" ("Yes, I do. I find that I have to
rush to the bathroom both day and night.")
· "When did you have your last menstrual period, Mrs. Armstrong?" ("About a year
ago.")
· "Do you have any problems with your bowels?" ("No")
· "Have you had any thyroid problems in the past?" ("Yes Dr., I had a goiter 10 years
ago but it was surgically removed.")
· "Do you have any other problems like high blood pressure or diabetes?" ("No.")
· Make eye contact and then say, "Mrs. Armstrong, I’m going to ask you some sensitive
questions. It might be embarrassing to you, but it’s for your best interest."
· "How has your sexual life been lately?" ("I don’t know, Dr. I get a lot of burning
sensation and I generally don’t show much interest because of the pain, even though
my husband wants to do it.")
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· "Is he supportive?" ("Yeah, I guess, but he is frustrated with the way I have been
behaving.")
· "Have your arms and legs ever been swollen and painful?” ("No.")
· “Have you had any blood clots in your legs?" ("No.")
· "Have you ever had any pain in the legs or back (for osteoporosis)?" ("No.")
Past Medical History:
· "Do you have any other problems for which you’ve needed counseling or
medication?" ("No, Dr. This is the first time that I’ve been sick.")
Social History:
· "Do you smoke?" ("No.")
· "Do you drink any type of alcoholic beverage?" ("No.")
Allergies:
· "Do you have any allergies?" ("No.")
Family History:
· "Do any of your family members have a history of clotting disorders?" ("No.")
· "Have any of your relatives been diagnosed with breast or uterine cancer?" ("Yes, Dr.
My sister had one breast removed.")
Physical Examination:
· Wash your hands.
· Perform the proper draping technique.
· Do a heart, lung, and abdominal exam very quickly and superficially.
· Check for muscle pain in the back.
· Check for hyperactive reflexes.
· Palpate the neck. (thyroid and lymph nodes)
· Examine without the gown, not through the gown.
Counseling:
· Tell the patient that the most probable diagnosis is menopause.
· Offer help to educate the husband about the possible diagnosis .
· Tell her about the risks and benefits of hormone replacement therapy (HRT).
· Offer her estrogen cream for the vagina, to ease her dyspareunia and her dysuria .
· Inform her that she needs to supplement calcium in her diet to reduce the risk of
osteoporosis. Inform her of the beneficial effect of adequate weight bearing exercise.
Differential Diagnosis:
· Menopause
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· Hyperthyroidism
· Occult malignancy
· Factitious disorder
· Chronic fatigue syndrome
Investigations:
· CBC with differential
· Serum TSH
· Serum FSH and LH (only in some doubtful cases)
· Pap smear (yearly)
· Screening mammogram
· Annual FOBT
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Miscellaneous Cases Print
Other Important Cases
1. Upper extremity pain
¨ In the history, just follow LIQOR AAA and PAM HUGS FOSS.
¨ Consider these issues during your history taking:
· Carpal tunnel syndrome (ask about the occupation)
· Cervical spondylitis
· Herniated cervical disc
· Thoracic outlet syndrome (ask whether the symptoms worsen with the above
head activities, like combing)
· Tenosynovitis
· Trauma
· Referred pain from coronary ischemia
Physical Examination:
· Wash your hands.
· Check the thyroid gland.
· Check the neck movements and the range of motion.
· Do thoracic outlet test. (Adson's test)
n Ask him to take a deep breath. Extend the neck and turn the chin
towards the opposite side.
n Repeat the test with the chin on the opposite side.
n In the presence of thoracic outlet syndrome, the radial pulse will
disappear.
· Do Phalen's test (for carpal tunnel syndrome)
n Hold the patient’s wrists in acute flexion for 30-60 seconds.
n Patient will complain of pain, numbness, and tingling over the
distribution of medial nerve, if the test is positive.
· You can also elicit Tinel's sign, if you want.
§ With your finger, percuss over the course of the medial nerve in the
carpal tunnel.
§ Patient will complain of pain, numbness, and tingling over the
distribution of the medial nerve, if the test is positive.
· Check sensations, muscle strength, and reflexes of both upper extremities.
Investigations:
· CBC with differential, ESR
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· EMG and nerve conduction studies
· X-ray of the cervical and thoracic spine
· ECG
· MRI of the spine
2. A 34 yo F who came for a bronchial asthma drug refill
¨ This case is not that important, but there is always the possibility that you may
encounter this in the step 2 CS, so just take a look.
¨ Start with a formal greeting. Ask open-ended questions like, "What brought you in
today?"
¨The things that you need to ask specifically for this case are:
· "Can you please tell me more about your asthma? When were you diagnosed
for the first time? How have you been doing since then?"
· "Can you please tell me about your current medications?" or "What
medications are you on?"
· "Did you notice any problems or side effects with your medications?"
· "Do you have any trouble breathing during the day or night with regular
activity?"
· "How often does this occur on a weekly basis?"
· "Do you have any trouble breathing with exercise?"
· "How often does this occur on a weekly basis?"
· "Do you have episodes of excessive coughing during the day or night time?"
· "How often does this occur on a weekly basis?"
· "Have you ever been admitted to the hospital for an acute or severe attack?"
· "Tell me, what do you think about the severity of your asthma? Do you think it
is getting better or worse?”
· “Do you know what precipitates your asthma?"
· "Are you taking any precautions to avoid those?"
¨ After this you, will just have to follow PAM HUGS FOSS. Make sure you ask about her
smoking history, and talk about the importance of smoking cessation.
Physical Examination:
· The PE basically requires:
§ an HEENT exam to look for any sinus tenderness (sinusitis), or signs of
upper respiratory tract infection, which can aggravate or precipitate
asthma.
§ a complete lung examination
§ looking for JVD and pedal edema (for signs of cor pulmonale, even
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though it is a very rare complication of asthma)
Investigations:
· Spirometry or pulmonary function tests are usually not required, unless the
patient is elderly and having persistent asthma.
· For chronic, persistent, and refractory asthma, request:
§ CBC with differential
§ Aspergillus serology
§ Chest x-ray
§ X-ray of paranasal sinuses
§ 24 hour pH for GERD
§ Skin tests
¨ Differential diagnosis for chronic, persistent asthma in a smoker includes:
· Bronchial asthma
· Chronic obstructive pulmonary disease
· Bronchopulmonary aspergillosis
· Sinusitis
· Atypical GERD
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Nightsweats Case Print
Case of a 22 yo M African American with Night Sweats
History Taking:
l How long have you had night sweats?
l Have you had any fevers or chills?
l Have you lost any weight unintentionally?
l Do you have any weakness or fatigue?
l Do you have itching? (pruritus)
l Do you have pain anywhere? (back pain and fever suggest osteomyelitis)
l Do you have a cough?
l Do you have any breathing problems?
l Have you had any headaches?
l Have you had any palpitations? (racing or pounding heart beat)
l Have you had any diarrhea?
l Do you have problems adjusting to temperatures (heat intolerance)?
Past Medical History:
l Do you have any other medical problems?
l Have you ever been tested for tuberculosis with PPD?
l Have you had any exposure to a tuberculosis patient?
Social History:
l What do you do for a living?
l Do you smoke?
l Do you drink alcohol?
l Have you used any recreational or illicit drugs?
l Do you have multiple sexual partners? Do you use condoms?
Family History:
l Is there a family history of cancer or thyroid problems?
Medications:
l Are you currently using any medications, including over-the-counter drugs?
Allergies:
l Are you allergic to any medication?
Physical Examination:
l Wash your hands.
l Perform the proper draping techniques.
l Examine all lymph nodes.
l Examine eyes for lid lag or exophthalmos.
l Examine oral cavity for thrush.
l Check for hand tremors.
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l Examine the skin (peripheral stigmata of infective endocarditis).
l Auscultate the lungs.
l Auscultate the heart.
l Examine the abdomen for hepatomegaly and splenomegaly.
l Examine without the gown, not through the gown.
Differential Diagnosis:
l Malignancy (lymphoma, solid tumors)
l Infections (tuberculosis, HIV, endocarditis)
l Endocrine disorders (hyperthyroidism, pheochromocytoma)
l Medications (antidepressants, cholinergic agonists, hypoglycemic agents)
Investigations:
l CBC with differential
l ESR
l Blood cultures
l Chest x-ray and PPD
l TSH
l ELISA for HIV, as needed
l CT scan of the chest and abdomen for lymphoma, as needed
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Obesity Case Print
Case of Obesity
Doorway information
A 40 yr old white female (Mrs. Kelly) came for obesity evaluation
Vital Signs:
· BP 150/90 mm Hg
· HR 68/min
· RR 16/min
· T 36.7C(98F)
History Taking:
¨ How do you approach this patient?
¨ This is a quick glance of questions that you have to ask in a case of obesity. Don't forget
to use appropriate transition sentences and open-ended questions.
¨ Knock on the door and enter the room with a smiling face.
· "Hello Mrs. Kelly, I am Dr. Robert Walker. Good morning. Nice to meet you." ("Nice to
meet you, doctor.")
· "How are you doing today?" ("Good.")
· "Excellent. So, what brings you in today?" ("You know doctor, I am really worried
about my weight. I just keep gaining, more and more.")
· "I am glad that you came here for an evaluation. We will work together and try to fix
it, okay?" ("Yes doctor, thank you.")
· "I know you are concerned about your weight gain. Would you please describe to me
a little bit more about your problem?" ("I don't know anything specific doctor, but I
am concerned about my weight.")
¨ Remember, the SPs reveal only a few things. They really won't tell you until you ask
specific questions. Before you ask, make a mental checklist of problems associated with
obesity.
¨ Here are the common problems associated with obesity:
1. Type II diabetes
2. Heart disease
3. Stroke
4. Hypertension
5. Osteoarthritis
6. Sleep apnea
7. Breathing problems
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8. High cholesterol
9. Gall bladder disease
10. Increased incidence of cancer like endometrial, colon, postmenopausal
breast cancer, etc.
11. Menstrual irregularities
12. Stress incontinence (due to weak pelvic floor muscles)
13. Psychological disorders like depression
14. Psychosocial difficulties like social stigmatization
¨ How do you ask all of these?
· "Mrs. Kelly, I am going to ask a few specific questions about your present and past
medical health. Just let me know if you have any problems. Okay?" ("Oh sure, Doc.")
· "How long have you really been concerned about your weight gain?" ("Maybe for the
past 6-7 months.")
· "What do you think is the major reason for your obesity?" ("I really don't know.")
· "How is your appetite?" ("It's too much, Doc. I want to stop eating junk food, but I
can’t control myself.")
· "How long have you been having this increased appetite?" ("For the last 2-3 years.")
· "Can you describe to me more about your diet? What does it usually consist
of?" ("Pretty much cheese and junk food doctor, some times fruit.")
· "How is your mood, Mrs. Kelly? Are you feeling okay?" ("I am feeling a little bit down
these days.")
· "Do you have any problems with your breathing, especially at night?" ("No.")
· "How is your urination?" ("Pretty good.") "I mean, have you noticed any increased
frequency?" ("No.") "Have you ever leaked without your knowledge?" ("No")
· "Do you have any problem with your bowel movements?" ("They are pretty regular.")
¨ You have to consider hypothyroidism and Cushing's syndrome in your differential
diagnosis for a case of obesity.
· "Have you ever had any problems adjusting to temperatures?" ("No.")
· "Have you ever been on any steroid medications for any reason?" ("No.")
¨ You already know that she did not have any problems with bowel movements.
(constipation in hypothyroidism)
· "Did you notice any joint pain, especially at the level of the hips or knees?" ("Some
pain in both knees.")
Past Medical History:
· "Have you ever been diagnosed with high blood pressure?" ("No.")
· "When was your last visit with your primary care physician?" ("A couple of years
ago.")
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· "Have you ever had any heart problems?" ("No.")
· "Have you ever been tested for diabetes?" ("No.")
· "Okay Mrs. Kelly, when was the last time your cholesterol level was checked?" ("I
think five years ago. It was slightly elevated, so I did some exercises. They didn’t
really help much.")
· "Have you had any surgeries in the past?" ("Yes Doc, cholecystectomy nine months
ago.")
Allergies:
· "Are you allergic to anything?" ("No.")
Medications:
· "Are you taking any prescription medications?" ("No.")
· "Do you take any over-the-counter medications?" ("No.")
Sexual History:
· "Okay Mrs. Kelly, now I would like to ask you a few personal questions. Everything
you say will be kept confidential." ("Okay Doc, sure.")
· "How has your menstrual cycle been?" ("They have become irregular these days, but
they are not bothering me much.")
· "How long have you been having these irregular periods?" ("For the past 2-3 years.
Seems like everything started then.")
· "When was your last menstrual period?" ("20 days ago.")
· "Are you sexually active?" ("This is one more problem for me doctor. These days I
don't feel like having sex.")
Social History:
· "Do you smoke, Mrs. Kelly?" ("No.")
· "Do you drink any type of alcoholic beverages?" ("Occasionally, 1-2 beers on the
weekend.")
· "Have you ever used recreational drugs?" ("No.")
· "What do you do for a living?” or “Do you work?" ("Yes doc, I am working as a desk
clerk.")
Physical Examination:
· Wash your hands.
· Perform the proper draping techniques.
· Just do some focused lung and heart examination.
· Check the thyroid gland.
· Check extremities for any edema.
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· Examine without the gown, not through the gown.
Counseling:
· "There is a possibility of a thyroid problem (even Cushing's syndrome, if the patient is
on steroids) in your case, although it is very unlikely. First, let me run some tests on
you. Then, we will sit together and go over the treatment options available.”
· "Meanwhile, try to restrict fatty foods and start regular exercise."
· "Most people will not succeed if they radically change their current eating and cooking
habits. However, you will probably have greater success if you try to modify only one
aspect of your eating habits at a time. Eventually, you will find yourself eating a
healthier diet."
· "If you would like more specific advice for diet changes, there are many excellent
books available, or you may wish to ask for a formal consult with a dietitian."
Differential Diagnosis:
· Obesity
· Hypothyroidism
· Cushing's syndrome
Investigations:
· CBC with differential
· Fasting blood sugar
· Serum TSH
· Urine cortisol levels
· Fasting lipid profile
· Consider annual PAP smear
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Palpitations Case Print
Case of a Patient with Palpitations
History Taking:
¨ Start with a formal greeting and introduce yourself.
l "What brought you in today?" (I am having palpitations.)
l "Can you please describe exactly what you mean by palpitations?" (My heart is
pounding.)
l "Do you get any other symptoms other than the palpitations?"
l "When was the first time you noticed them?"
l "Do they occur continuously or intermittently?"
l "Are they regular or irregular?"
¨ Tap on the table and show the patient the difference between regular and irregular beats.
Ask him to demonstrate/tell exactly what he’s feeling.
l "How long do they last?"
l "Approximately how many times do you notice them a day? Has there been a change
recently?"
l "Have you noticed any particular circumstances which might cause these?"
l "Have you had any chest pain?"
l "Have you had any breathing problems?"
l "Do you feel any dizziness or light-headedness?"
l "Have you ever passed out?"
l "Do you have a fever?"
l "Do you get tremors in your hands?”
l “Do you sweat excessively?"
l "Do you get headaches with these?"
l "Have you noticed any swelling in your legs?"
Past Medical History:
l "Do you have any other medical problems?"
l "Do you have any heart problems? DM? High blood pressure? High cholesterol? Thyroid
problems?"
l "Do you have any anxiety disorder?"
Allergies:
l "Do you have any allergies?"
Family History:
l "Any family h/o heart problems? Palpitations? Thyroid problems? Panic or anxiety
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disorder?"
Social History:
l "Do you smoke? How much and for how long?"
l "Do you drink alcohol? How much and for how long?"
l "Do you drink caffeinated beverages?"
l "What do you do for a living?"
l "Do you experience any stress at home or work?"
Medications:
l "Are you taking any prescription medications? Over-the-counter medications?"
l "Have you ever used any recreational drugs like cocaine or marijuana?"
Physical Examination:
l Wash your hands.
l Perform the proper draping technique.
l Examine the eyes/hands for pallor.
l Check the thyroid.
l Auscultate the heart.
l Auscultate the lungs.
l Quickly palpate the abdomen.
l Check for leg swelling/calf tenderness.
l Check hands for tremors.
l Examine without the gown, not through the gown.
Differential Diagnosis:
l Cardiac arrhythmias
l Valvular heart disease
l HOCM (Hypertrophic obstructive cardiomyopathy)
l Hyperthyroidism
l Hypoglycemia
l Pheochromocytoma
l Fever
l Anxiety/Panic attacks
Investigations:
l CBC with differential, ESR
l 12 lead EKG
l Serum TSH
l Blood glucose, serum electrolytes (Na, K, Cl, CO2, BUN, Cr)
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l Holter monitoring/loop monitor
l 2D-echo
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Pre-emp Checkup Print
Case of a 25 yo M who came for Pre -employment Check-up
¨ You may get these kinds of cases as either "Pre-employment check-up” or as an
"Insurance check-up". They will tell you everything you have to do. Some may ask you
to fill out a form (It will be provided for you.). If they want you to do any specific
examination, do that, but do all the things that are mentioned in the form first.
¨ You can fill out the form after you leave the room. If the SP asks about the form, tell him
that you will mail it to his home.
¨ After you finish the examination, ask, "Do you have any questions?" Answer any
questions, and then take a relevant history.
¨ In case you were not provided with a form, you will have to take a simple general history.
Ask cardinal symptoms of each system.
· "Do you have any cough?" ("No.")
· "Do you have any problems with breathing?" ("No.")
· "Do you have any chest pain?" ("No.")
· "Do you have headaches?" ("No.")
· "Do you have a fever?" ("No.")
· "Do you have any pain?" ("No.")
· "Do you have weakness in the extremities?" ("No.")
· "How is your bowel habit?" ("Pretty good.")
· "How is your bladder function?" ("Good.")
¨ Then you must ask PAM HUGS FOSS.
¨ Please do not forget to ask about allergy, smoking, alcohol, and sexual history.
¨ Here is the sample of the form that you might get. It may not be exactly like this. You
may get some of the components of this form.
¨ If they ask you to measure blood pressure (on the form/doorway information), you have
to measure it. This is different from all other cases where you don’t need to check blood
pressure.
¨ After finishing the case, you just have to fill out this form. You don't need to write any
history, or things that they have not asked you. All you have to do is fill out the form.
Height
Weight
Blood
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pressure
Pulse rate
Lung
auscultation
Heart
auscultation
CNS
reflexes
Abdomen
Spine
examination
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Shoulder pain Case Print
Shoulder pain sample case
Door way information:
Case: 56 year old Scott comes with left sided shoulder pain; vitals were normal.
Simulated encounter
l Once you see the doorway information all you need to do is just note the name of the
patient. Take 15-30 seconds to make a mental checklist of differential diagnosis of
shoulder pain.
l Knock on the door.
l Make comfortable eye contact - empathic
l Patient will be on the table in an awkward position, in pain.. Don't change the position
of the patient. Stand in front of the patient about two or three feet away.. You adapt to
his position.
l We advise you to stand instead of sitting.
l Say, "Hello Mr. Xyz. It’s nice to meet you. I ’m here to ask you some questions and see
what I can do to help you." (Speak in a reassuring tone)
l Don't shake his hand because he will be supporting his painful hand with the opposite
hand. (You will lose points if you cause the patient unnecessary pain.)
l Patient says, "My shoulder hurts so much, I can’t even sleep."
l First, ask an open ended question: "Mr. Scott, can you tell me something about your
pain?" His answer will cover some aspects of pain like - location, quality, and some
others of LIQOR AAA. Make a mental note and don’t ask those aspects again. If you
are caught asking again tell him that you were just checking.
l Ask all pain questions (LIQOR AAA) plus the functional impairment questions, i.e.
occupational impairment, sleep, and help at home. (Remember all three will be in the
check list.)
l The patient will respond to all LIQOR AAA questions. Ask specifically whether he took
any medications and did he get any relief with them.
l Always ask the precipitating factor of pain: SP may say that he fell down the stairs at
night while going to the kitchen to get a drink of water.
l Then ask about deficits:
l "Do you have tingling (pause) or numbness?" (no)
l "Did you notice any swelling or redness after the fall?" (no)
l "Do you have pain in any other part of your body?" (yes; palm hurts.)
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l "Are you able to use your arm?" (No; because painful)
l "Do you feel any weakness?" (No, only pain)
PMH:
Then ask PAM HUGS FOSS
l "Now, I need to ask you a few questions about your health in the past. Is that ok with
you?" ("Yeah")
l Ask the second open ended question "How has your health been until now?"
l "Have you ever had any problems with your shoulder?" (Yes, I had an injury to my left
arm three yrs ago. I had a humerous fracture)
l "Do you have any other medical problems?" ("Yes, I did have acid peptic disease.")
l "Are you allergic to anything?" ("Yes; I am allergic to penicillin..")
l "Have you taken any medications?" ("Yes, only Ibuprofen for pain.")
l "Do you have any problems with your digestion or your bowels?" ("I have been
constipated lately.")
l "Do you have any problems with your urination?" ("No.")
l "Now, I need to ask you a few questions about your family health. Is that ok with
you?" ("Yes")
l "Are your parents living?" ("No, they died of old age.")
l "Has anyone in your family had medical problems?" ("Yes, my father and brother had
pulmonary fibrosis.")
l "Now, I need to ask you a few personal questions. Please do not feel embarrassed.
Everything you say will be kept confidential.".
l "Are you sexually active?" ("No")
l "Now, I need to ask you a few questions about your lifestyle."
l "Do you use tobacco?" ("No")
l "Do you drink any type of alcoholic beverages?" ("Yeah. I have 2 shots of scotch on the
rocks every night. Been doing so for the past 10 years.")
l "Do you use any recreational drugs?" ("No")
l Here, ask another open- ended question for social and occupational history. Example:
"Tell me something about your life at work and home."("Cannot go to party today
because not able to drive.")
Examination:
l After taking history, ask " All right; thank you for being cooperative. Now, I’m going to
give you a physical. Before I do, is there anything you would like to ask me? I would
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be happy to answer any questions" (Remember, he may tell you like this: ' Please be
gentle with my arm doctor’). *Bonus point! Console him saying, "I know that you are in
pain. I will try to do my exam as gently as I can. Does that sounds good?' (You will
see the relief on the patient’s face and the importance of an open ended question. This
question will help you to ask and counsel the patient more effectively.)
l "Please excuse me for a few seconds while I wash my hands."
l Always start with local examination i.e. painful shoulder
l Expose the joint properly while draping the other parts.
l Before inspection tell the patient what you’re looking for, i.e. redness and swelling.
Don’t just look. He should know that you are looking. Palpate and compare both joints.
l Palpate for swelling, warmth, and crepitus. Tell him first that you will be very gentle.
Say sorry if he complains of tenderness during the examination.
l Most of the times SP will have tenderness on the anterior part of his shoulder joint.
l Check range of motion (ROM) in abduction, adduction, flexion, extension, and internal
and external rotation. (Obviously SP will have restricted abduction beyond 60 degrees
i.e. he will complain of pain after 60 degrees). Always adduct the patient's arm across
the chest (crossover test).
l Check reflexes: pin prick sensations
l Check the opposite arm
l Check hand in detail
l Look at the legs very quickly
l Listen to the heart and lungs for 10 to 15 seconds.
Counseling:
l Explain the probable diagnosis, follow-up after investigations, and the availability of
physiotherapy.
Diagnosis
l Shoulder dislocation
l Shoulder fracture
l Rotator cuff tear
l Subacromial bursitis
l Ligament sprain
Work up
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l CBC
l X-ray of shoulder joint two views, including elbow
l X-ray hand two views
l MRI of shoulder
l ANA and Rheumatic factors
Note: *You may get a case very similar to this in the real exam. The important thing
that you need to remember from this case is: "You have to ask all PAM HUGS FOSS for every
case no matter what the complaint is because they will have those in the check list.
Copyright @2002 -2007 All Rights Reserved www.usmleworld.com
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Smoking Cessation Print
Mrs. Jacobson (55 years old)
Basic questions to ask smoking patient:
l "Can you please tell me more about your smoking?"
l "When did you start smoking?" ("When I was in college")
l "As you know, some people smoke and some people don't. What were the
circumstances that caused you begin smoking?" ("I was in college and everyone
smoked. My father had smoked my entire life.")
l "How do you feel about smoking? I mean do you like smoking?" ("Yes, I love
smoking. It’s a social time and it relaxes me.")
l "How many cigarettes do you smoke a day?" ("About two packs.")
l "Are you concerned about your health?" (" No, I don’t inhale. I just as soon could get
run over by a truck tomorrow.)
l "Is stress or depression a reason for your smoking?"("When I’m tense or nervous
smoking helps me relax.")
l "Have you ever had any smoking related problems, like any cough or shortness of
breath?" ("Well, when I get a cold it goes into my chest and I get very congested. I
have a deep cough. Also, I used to play tennis a lot and find it difficult now because I
start breathing so hard.")
In your counseling with a smoking patient, don’t begin by attacking her negatively. Rather
than beginning with, "Mrs. Jacobson, you must stop smoking, you’re killing yourself." The
patient is being told to stop a habit/addiction that is incredibly difficult to do. There are
social, emotional, and physical aspects all involved in this decision. Depending on how you
pose your comments and questions, the patient could feel defensive and angry, or
comfortable and willing to open up. Always start in a non-judgmental manner.
l You: "Most patients I’ve counseled have tried to stop smoking at some point. Have you
ever tried to quit?" ("Yes, once.") " Why?" ("Because my children told me I should and
they didn’t want second hand smoke.") "What happened?" ("I gained weight and
became very irritable.") How did you deal with it?" (" I decided my father had smoked
his entire life and never had a problem. He made his choices and I should make mine.
So I started again and feel better.")
l "Mrs. Jacobson, I understand those reasons, however the benefits of giving up smoking
are huge. Do you know that your chance of cancer, heart attack, or lung disease will
decrease greatly if you quit smoking? (" Yes---I know.") "Your breathing will improve.
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You will have more energy." ("I’ve had to stop playing tennis because I get too hot and
tired.") " If cigarettes are being used to manage your stress, would you consider other
stress management techniques?" (" Like what?") " Have you ever tried a nicotine
patch? ("No, I really don’t know anything about them.")"I can give you some material
to read. We have all kinds of counselors who have been exactly where you are. There
are many options they can offer you. There are really fun exercise and recreation
programs offered for you individually or with a group." ("I enjoy swimming if the water
is warm.") "That would be perfect exercise. It is one of the best ways to get your heart
pumping and every part of your body moving." ("I might be interested in talking with
someone about that.")
l "Tell me what kind of support system you have if you decided to try and stop smoking?
(I don’t have any one)
l "Would you like for me to have someone contact you or I could give you a number to
call? ("Yes, I guess I’d like that. Maybe I’ll ask another friend who also smokes to try
this with me.") "That sounds fine. Find rewards to honor and reinforce your healthy
new behaviors."("How about going out to dinner with the money we save on the
cigarettes we don’t smoke!")"Sounds great. Let’s get back together and discuss how
you’re doing?" ("Ok.")
l If the patient does not want to quit smoking you can say: "It seems you really don't
want to give up smoking right now. I wonder if you could cut back from two packs to
one pack a day?"
l Always praise the patient using positive expressions i.e. ‘Excellent" or ‘That's great’.
Finally, repeat sentences like, "I appreciate the motivation that you have to quit
smoking"
Dealing with dramatic style
l You might get a patient who may charm you, fascinate you, and even frustrate you.
They may exaggerate the symptoms. Always listen and observe as the patient talks.
Remain calm, gentle, and firm.
l A patient may compliment you on your hairstyle or your dress. He may ask about your
personal life or social relationships. You can say, "Well, we are really here to talk about
your opinion and your problems. I am interested in hearing more about you. How do
you handle this or how did you manage that, etc.?"
l Sometimes the SP may prevent you from obtaining a good history. A good history is
really important to find out the cause. It’s like obtaining H/O use of recreational drugs.
In those cases you can say, "I’ve noticed that whenever I try to ask about sexually
transmitted diseases you tend to change the topic. That really concerns me. Can you
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please answer my questions?" (Don't say, "Why don't you answer my question?")
What should you say if you suspect a STD in a patient with vaginal discharge? The
patient insists that her boyfriend has been faithful and it was impossible that he
would have had sex with anyone else?
l You need to remind the patient before counseling that you haven’t made any diagnosis
yet. (Usually you don't in most CSA cases.) So, always say that you have to run a few
tests before confirming the diagnosis and there is no way you can confirm or deny STD
in this CSA case because you haven’t done a pelvic exam. If you still want to offer
some counseling you can say, " I appreciate the trust you have in your boyfriend’s
faithfullness but unfortunately, we see these kinds of problems in our clinic often. So,
even though it’s highly unlikely, according to your history, there is always a possibility
of STD. Let me run few tests and once we get the results we can get back together
again and discuss my diagnosis and suggested treatment plan, if needed. Is this ok
with you?"
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Spells Case Print
Case Of Spells/Loss Of Consciousness
Syncope is defined as a sudden and transient loss of consciousness. Syncope has very broad
differential diagnosis. Most of the time the underlying cause of syncope can be diagnosed
with good history, physical examination and some basic labs.
The common causes of syncope include:
l Cardiac causes - Arrhythmias, CAD and acute coronary syndromes, aortic stenosis,
HOCM
l Vasovagal syncope
l Neurological causes - TIA, stroke, seizures, migraine
l Medications or toxins
l Unexplained syncope
l Psychiatric cause - Personality disorders, hyperventilation and conversion disorder
Scenario:
Basically, ask these questions:
l Ask him/her to explain the whole episode of spell (Can you please explain me more
about your spell?) - Open ended question.
l If he doesn't cover what he was doing at the time of spell and how much time he lost
his consciousness in his history, you need to take that history.
l "Do you have any idea of what might be the cause of your spell?"
l "Is this the first of these spells? Have you had similar spells before?"
l "Was there anyone around when this occurred? What did they say about your spell?"
l "Are you back to normal now? Were you feeling fine before the event and between the
spells?"
l "Did you have any nausea or vomiting before the spell?"
l "Have you had any chest pain?"
l "Have you had any breathing problems?"
l "Have you ever had any palpitations?"
l "Have you noticed any weakness in your legs and arms?"
l "Have you noticed any tingling and numbness anywhere?"
l "Has anyone told you that you had jerky type of rhythmic movements?"
l Ask about any sudden visual changes or blurriness.
l Ask about any history of head trauma.
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l Ask about bowel and bladder incontinence.
l Ask about the risk factors for stroke, diabetes, hypertension or heart problems etc.
l Ask about all of his medications including over the counter and illicit drugs.
l Ask if there was any history of seizures in the past.
l Ask about any history of anxiety or past psychiatric disorders.
These are the basic questions that you have to ask for any patient having spells (syncope).
Don't forget to ask all the general information like family history, allergic history, and social
history (smoking, alcohol), as for every other patient.
Examination:
l Order orthostatic changes (both BP and HR) in the investigations section.
l Do complete neurological exam
l Auscultate heart
l Check for carotid bruit
l Check for peripheral edema
Investigations:
l EKG/ECG
l 24 hr Holter monitoring
l Exercise testing: Order in patients with a history of exertional syncope.
l 2D-Echo
l Upright tilt table test: For neurocardiogenic syncope
l Neurological investigations: CT, MRI, EEG and carotid doppler
l If you are suspecting drug abuse, order a Toxic screen.
l Blood sugar and metabolic screen - order if you are suspecting a hypoglycemia or
electrolyte imbalance.
l FOBT or stool guaiac- If you suspect GI bleeding, which can result in hypovolemia, and
syncope.
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Telephone Encounter Print
Telephone Consultation
History:
Good morning, Mrs. Smith. This is Dr. XYZ. Tell me. What can I do for you today?
(“Doc, my son has been vomiting. I was wondering if you could give me some advice on what
I should do about it.”)
Okay, Mrs. Smith. I’d like to get a few details from you about your son.
How old is he? (“He’s 5 years old.”)
How long has he been vomiting? (“Since yesterday.”)
How many times has he vomited since yesterday? (“Around 2-3 times. ”)
Has he been vomiting large amounts? (“Yes, I would say so.”)
What does the vomitus contain? (“Mostly, it’s the food he eats.”)
Did you notice any blood in the vomitus? (“Not at all.”)
Is the vomitus forceful? (“No, it isn’t.”)
Is it preceded by nausea? (“Yes, I think so.”)
Does he have any pain in his belly? (“Yes, he did mention that his belly hurts a bit.”)
Are there any changes in his bowel movements? Any diarrhea or constipation? ( “No”)
Does he have a fever? ( “Actually I did take his temperature and it was normal.”)
How is his appetite? (“He hasn’t been eating too well. He fears he would vomit.”)
Did he ever have similar episodes in the past? ( “No”)
Did he eat out recently, like in a party or restaurant? ( “No, he didn’t.”)
Does he have any headaches? ( “He didn’t mention that to me.”)
Is he usually a healthy child or does he frequently get sick? ( “Actually, he rarely gets sick. I
would say he’s pretty healthy.”)
Was he ever diagnosed with any medical illness before? (“No”)
Has he received all the vaccinations appropriate for his age? (“Yes he definitely has.”)
Is he currently taking any medications? (“No.”)
Is there another pediatrician who takes care of him on a regular basis? ( “Yes, he had a
pediatrician in ______ before. We just recently moved here.”)
Well, Mrs. Smith, based on the information that you just provided, I think your son may be
experiencing stomach irritation. We have to determine what is causing it. I would like to
personally examine him and perform some basic labs before I make a diagnosis or give any
advice, especially since he is a new patient. Will it be convenient for you to bring him here to
the hospital? (“I’m sorry. It’s not possible for me to bring him in. Can’t you just give
recommendations over the telephone?”)
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Is there a reason why it isn’t possible for you? (“Actually, my husband is out of town and I
have no means of transportation.”)
In that case, I suggest that you call either a cab or 911, and arrange for your child to be
brought here to the hospital. That way, you won’t have to worry about transportation and
your child can be examined as well. Does that sound good to you? (“Absolutely.”)
Mrs. Smith, I hope you understand that all this is for the best interest of your child. I do not
want to jeopardize his health at any cost. (“Yes, doc, of course, I understand and appreciate
your concern.”)
Alright then, I will see you once you get to the hospital. Take care, Mrs. Smith.
*Note: It is important to convince the mother to bring her child to the hospital. Personal
assessment of the child is necessary to determine hydration status and the need for
medical/surgical intervention.
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Terminal cancer Case Print
Case of a 69 yo M with Terminal Cancer Requesting Pain Medication
¨ If you get a case like this, you really have to show empathy and care. Start with a formal
greeting, and place a hand on the patient’s shoulder. Make eye contact, and then ask an
open-ended question.
History Taking:
· "Mr. XYZ, please tell me. How can I help you today?" ("I am having pain in my
stomach.")
· "I have been informed that you have been diagnosed with cancer. Is that
correct?" ("Yes.")
· "Could you please tell me more about your cancer?" ("I have pancreatic cancer. It
was diagnosed 3 months ago")
· "I am very sorry to hear that." ("Thank you, doc.")
· "I know it’s very difficult. I can understand what you are going through. I want you to
know that I am here to help you if you need anything to make you feel
comfortable." ("Thank you very much.")
· "Can you please explain to me a little bit more about your pain?” (“It’s a stabbing
type of pain.”)
· “How severe is the pain, on a scale of 1 to 10?” (“It’s a 10.”)
· “Do you think there is anything that makes your pain less?" (“Pain medication,
sometimes.”)
· “What makes your pain worse?” (“I think it’s already at its worst.”)
· "Do you have pain anywhere else?" ("Sometimes my back hurts.")
· "Are you using any medication for your pain, especially any narcotics or
morphine?" ("Not much.")
· "Do you have any other complaints, other than pain?" ("I am feeling tired most of the
time.")
· "How is your appetite?" ("I don ’t have much of an appetite.")
· "Have you lost any weight?" ("Yes, around 12 pounds in three months.")
· "Do you have a fever?" ("No.")
· "How are your bowel movements?” (“Fine.”)
· “Do you have any problem urinating?" ( “No.”)
· "How is your mood?" ("Not good doc, I feel depressed.")
· "Have you had any thoughts of ending your life?" ("Not really, so far.")
· "Can you please tell me about your home situation?" ("I don't have anyone, doc. I
live alone.")
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· "Do you have anyone to help or support you, like any friends or family members?" ("I
have a few close friends. Yes, they’ll certainly help if needed.")
Physical Examination:
· Wash your hands.
· Perform the proper draping technique.
· Auscultate and palpate the abdomen.
· Quickly auscultate the heart and lungs.
· Examine the conjunctiva to check for pallor or jaundice.
· Examine without the gown, not through the gown.
Counseling:
¨ There is no single, correct way to give counseling. This is an example for you to give
counseling but bear in mind, it is not necessary that you follow this exactly, word for
word. This just gives you an idea to help you build your own way, in which YOU ARE
COMFORTABLE. It will be fine as long as you show that you are sensitive, supportive, and
conveying necessary information.
· "Mr. Xyz, I will certainly help you in relieving your pain. I will prescribe a narcotic, like
morphine. I would also like you to be aware of certain things that will be necessary at
some point in your life. I am very sorry to ask you these questions, but I hope you
understand the situation." ("Thank you, doc. Don't worry. Ask me.")
· "Where do you want to live? Do you want to stay at your home or at a nursing
home?" ("I want to stay at home.")
· "Do you know about ‘hospice’?" ("Not much.") "Okay, let me explain about hospice.
Hospice care is a choice you can make to enhance your quality of life in a terminal
stage. You can choose to die at home with the support of family, friends, and caring
professionals. Over 90% of hospice care is provided at your home. The advantage of
hospice care is that the providers have the skills and resources to permit you to live
as pain-free, as comfortable, and as full a life as possible. In addition to providing
pain relief, hospice care emphasizes comfort measures and counseling to provide
social, spiritual, and physical support to you and your family. All hospice care is under
professional medical supervision. So, I strongly advise you to take hospice
care." ("Thank you very much, Doc. You relieved most of my concerns.")
· "Are you aware of advance directives?" ("No, not much doc.") "An ‘advance directive’
or a ‘living will’ will enable you to give your opinion on how you should be treated
when you reach the terminal stage of the disease, or when you aren’t in an ideal
state of mind to make a decision anymore. You can give the right to a loved one to
make that decision for you. Do you understand what I am saying?" ("Yes, doc.")
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· "Do you have any other questions?" ("No, not much, doc.")
Differential Diagnosis/Investigations:
¨ You don't need to write a differential diagnosis or investigations if the problem is purely
terminal cancer.
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Vaginal Bleeding Print
Case of a 20 yo F Complaining of Vaginal Bleeding
Vital Signs:
· BP 110/70 mm Hg
· Pulse 80/min
· RR 16/min
· T 36.7C(98oF)
History Taking:
¨ Please remember that you need to use appropriate transition sentences. Below are
suggested questions to ask:
· When did the bleeding start?
· Was the onset gradual or sudden?
· Can you describe the bleeding?
§ For example, is it bright red or clotted blood?
§ Is the blood pure or does it contain tissue like substance? (A molar pregnancy
would have grape like tissue.)
· Has it been a continuous flow or spotting?
· What were you doing when it started? Were you sleeping or having sex?
· Do you have any other symptoms besides bleeding? Did you have abdominal pain?
Fever? Vomiting?
· Were you ever involved in any accident/trauma?
· Have you ever been pregnant?
· When was your last menstrual period (LMP)?
· Can you describe more about your menstrual cycle?
§ How heavy is the flow?
§ How many pads do you use per day?
§ How long are your periods?
§ Are your periods regular or irregular?
· Have you had any abortions?
· Have you ever been tested for STDs?
Past Medical History:
· Have you ever had any history of bleeding? Were you ever hospitalized for bleeding?
Medications:
· Are you currently taking any medications?
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· What medications have you recently taken?
Family history:
· Do you have a family history of bleeding disorders?
· Does anyone in your family have a history of multiple abortions?
Sexual History:
· Are you married?
· If yes:
§ Do you have any other sexual partners? (yes)
§ Do you use any means of contraception?
· If no:
§ Do you have any other sexual partners? (yes)
§ Do you use any means of contraception?
· When was your last sexual contact?
Social History:
· Do you smoke?
· Do you drink alcohol?
· Do you use illicit drugs? (Cocaine may cause bleeding.)
Physical Examination:
· Wash your hands.
· Perform the proper draping technique.
· Look for other sites of bleeding, i.e. nose or gums
· Check for orthostatic hypotension.
· Auscultate the abdomen.
· Percuss the abdomen for liver span.
· Palpate the abdomen superficially.
· Palpate the abdomen deeply.
· Check for rebound tenderness.
· Ask to perform a pelvic exam.
· Examine without the gown, not through the gown.
Differential Diagnosis:
· Regular menses
· Abortion
· Pregnancy
· Ectopic pregnancy
· Hydatiform mole
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Investigations:
· Pelvic examination
· Pregnancy test
· CBC with differential
· Transvaginal ultrasound
· Serum ß-HCG levels
· Serum TSH
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Vomiting Case Print
A 25-year-old female with nausea and vomiting
First, think about the common causes of nausea and vomiting in this age group.
Gastroenteritis (food poisoning): Ask about having food outside, i.e., travel history. Are
any other members being ill with associated symptoms, like abdominal cramps and diarrhea?
Obstructing disorders: Pyloric obstruction (classically, vomiting within one hour after
having food); Intestinal obstruction (vomiting late post prandial period); Constipation (Is she
passing gas? Do not ask about ‘flatus’. If you do, SP will say, “What is that?'*. Relief of the
pain with emesis is very characteristic of small bowel obstruction. Vomiting has no effect on
acute pancreatitis or cholecystitis.
Inflammatory diseases: Pelvic inflammatory disease (PID), Cholecystitis (pain in the right
hypochondriac region); Acute pancreatitis (severe epigastric pain radiating to back);
Appendicitis (initially, periumbilical pain, later to right lower quadrant pain); Acute
pyelonephritis.
Impaired motor function: Diabetic gastroparesis, DKA, GERD - (Ask about any history of
diabetes. This female may be, type 1).
Intracranial pathology: Malignancy and infections - Ask about fever, headaches, and the
quality of vomiting (projectile or not).
Drugs: Digoxin, cancer chemotherapy - Ask if she is taking any medications.
The two most common conditions, (you will most likely be tested on in the step-2 CS) are
pregnancy and anorexia nervosa. You should not forget to ask about the LMP, because if you
get a case of nausea and vomiting in the step-2 CS, it is most likely a pregnancy. In fact, the
SP may ask, "Doc, am I pregnant?"
HPI:
· When did the vomitings start?
· Was it a projectile (forceful) vomiting?
· What does the vomitus look like? What color was it? Was there any blood? How many
times have you had so far?
· Do you have any abdominal pain or back pain?
· Do you have any diarrhea?
· Do you have constipation?
· Do you have fever and chills?
· Have you had any headaches?
· Do you have any burning urination?
· When was your last menstrual period?
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· Is there a chance you could be pregnant?
· Have you had any vaginal discharge/bleeding?
· Did you eat food outside? Did you eat anything like unpasteurized or undercooked
food, unusual foods, dairy products, and seafood?
· Did any of the other family members get sick?
PMH:
l Have you ever had similar episodes in the past?
l Do you have any other past medical problems? (Diabetes)
l Have you ever been admitted in the hospital?
l Have you had any abdominal surgeries?
SH:
l What do you do for living?
l Do you smoke?
l Do you drink alcohol?
l Do you use IV drugs?
l Do you have multiple sexual partners? What kind of contraception do you use?
All:
l Are you allergic to any medications?
Meds:
l What medications do you use on regular basis? Did you take any over-the-counter
medications, such as ibuprofen?
Examination:
· Examine oropharynx
· Auscultation of the abdomen (decreased bowel sounds indicates ileus; increased
bowel sounds indicates bowel obstruction)
· Abdominal palpation, both superficial and deep
· Check for CVA tenderness, if needed
· Fundoscopy if you are suspecting intracranial causes
· Explain about the need of rectal examination and pelvic examination (pregnancy)
· Quick lungs and heart exam
Investigations:
· CBC with differential
· Serum electrolytes (Na, K, Co2, Cl, BUN, Cr)
· Pregnancy test (must, for this female)
· Urinalysis and culture and sensitivity, as needed
· Abdominal x-ray, once the pregnancy test is negative
· Serum amylase and lipase (if you are suspecting), as needed for acute pancreatitis
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· Liver function panel, as needed
· Ultrasonogram (acute cholecystitis)
· Blood sugar for diabetes mellitus
· Stool studies, as needed (fecal leukocytes, stool ova and parasites, stool culture, C.
difficle)
· EKG should be obtained if patient has risk factors for MI (sometimes inferior wall MI is
apparent with vomiting, especially in diabetics)
Copyright @2002 -2007 All Rights Reserved www.usmleworld.com
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List of Cases Print
Contents
History taking
Physical Examination
Physical Exam Videos
Closing the encounter
Documentation of Case
Case Investigation
Psychiatry History taking
Pt Notes
Abbreviations
Miscellaneous
Key to Success
Communication Skills
Guidance for better
practice
On the Day of Exam
CSA FAQ
Sample Cases
Alcoholism
Back pain
Confusion
Chest Pain
Chronic Cough
Chronic Diarrhea
Dark urine
Depression
Diabetic Drug Refill
Practice Cases
Case 1: 30-yearold
female
complaining of
Abdominal Pain
Case 2: 27-yearold
female
complaining of
rash
Case 3: 65-yearold
female
complaining of
arm and leg
weakness
Case 4: 29-yearold
female known
sickle cell anemia
pt c/o chest pain
Case 5: 35-yearold
male with
recent onset
cough
Case 6: 50-yearold
male complaining
of fatigue and loss
of weight
Case 7: 35-yearold
male with
acute onset
diarrhea
Case 8: 25-yearold
female
complains of sore
throat
Case 9: 56-yearold
male for BP
check and refill of
the medications
Case 10: 66-yearold
male
complaining of
constipation
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Dizziness
Domestic Violence
Enuresis
Forgetfulness/Alzheimer's
Headache
Heel pain
Hemoptysis
Insomnia
Menopause
Night sweats
Obesity
Preemployment checkup
Shoulder pain
Spells
Vaginal Bleeding
Vomiting
Terminal cancer
Telephone Encounter
Other
Palpitations
Counseling
Other imp Cases
Case 11: 50-yearold
male
complaining of
impotence
Case 12: Mother
of 1 Yr. O/Baby
With Fever
Case 13: 45-yearold
female c/o
acute, right upper
quadrant
abdominal pain
Case 14: 24-yearold
female came
for prenatal visit
for the first time
Case 15: 60-yearold
male
complaining of
acute shortness of
breath
Case 16: 40-yearold
female with
increased
urination
Case 17: 35-yearold
female for
evaluation of
jaundice
Case 18: 35-yearold
female
complaining of
Chest Pain
Case 19: 45-yearold
male
complaining of Rt
lower abdominal
pain
Case 20: 55-yearold
male with
bilateral leg pain
Case 21: 40-yearold
male with
vomiting of blood
Case 22: 55-year-
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old male
complaining of
Chest Pain
Case 23: 70-yearold
male
complaining of
Frequent Falls
Case 24: 35-yearold
male
complaining of
cough and chest
pain
Case 25: 60-yearold
male
complaining of
lower abdominal
pain
Case 26: 35-yearold
male
complains of
fatigue
Case 27: 65-yearold
female
complaining of
loss of hearing
Case 28: 53-yearold
male with right
knee pain and
swelling
Case 29: 50-yearold
male with
blurred vision
Case 30: 32-yearold
female with
multiple bruises
Case 31: 20-yearold
female with
burning urination
Case 32: 50-yearold
male with
difficulty
swallowing
Case 33: 30-yearold
male for HIV
drug refill
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Case 34: 16-yearold
female with
amenorrhea
Case 35: 35-yearold
female with
acute right lumbar
and lower
abdominal pain
Case 36: 70-yearold
male with
insomnia
Case 37: 65-yearold
male patient
with difficulty
urinating
Case38: 45-yearold
female
complains of
breathlessness
and anxiety
Case 39: 53-yearold
male with a
long history of
epigastric pain
Case 40: 45-yearold
male
complaining of
bloody vomiting
Case 41: 60-yearold
male
complains of
dizziness
Case 42: 30-yearold
male with new
onset of seizure
Case 43: 23-yearold
male with
rectal bleeding
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case1 Scenario Print
30 Yr. O/F Complaining of Abdominal Pain
Vitals
l Pulse--98/min
l B.P--120/75 mm of Hg
l Temp-101.3
l R.rate--22/min
Make a mental checklist of Differential Diagnosis
l Pelvic inflammatory disease
l Pelvic abscess
l Endometriosis
l Urinary tract infection
l Appendicitis
l Rupture/torsion of ovarian cyst
l Acute cholecystitis
l Renal colic
l Ectopic pregnancy
l Abortion
l Acute gastroenteritis
l Inflammatory bowel disease
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case1 SP Print
If the doctor asks you anything other than these just say 'no' (or) say things that
are normal in daily routine life.
l You are Mrs. Mary, age: 30yrs
l Have abdominal pain since 12 hrs
l Started slowly, progressively increasing
l 7-8/10 in severity
l Right below the umbilicus
l It’s a type of sharp pain
l All over your lower abdomen
l Began after eating a large meal
l Moving around makes it worse
l No alleviating factors
l Not associated with vomiting but have nauseating feeling
l Passing urine more number of times and have burning urination
l No bowel problems
l Last menstrual period was 3 weeks ago
l No discharge from vagina/no bleeding from vagina
l Have fever since yesterday associated with chills and rigors
l Have one episode of urinary tract infections (UTI) in the past
l No allergies
l Once hospitalized for evaluation of UTI
l Have multiple sexual partners
l Using oral contraceptive pills
l Families’ health is normal
l Smoking – No
l Alcohol- No
l Recreational drugs- No
l Occupation: Working as a receptionist
l Appetite and wt is normal
l No illicit drug intake
Ask this qt - Doc is it an appendicitis?
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case1 Pt Notes Print
C.C: A 30 Y/O WF with abdominal pain.
HPI: A 30 Y/O WF who has a H/O UTI, pyelonephrtis who is in her usual state of health until
yesterday started to have abdominal pain right below the umbilicus. The pain started after
having a heavy meal; She describes the pain as sharp, 6-7/10 in severity, gradual in onset
and progressively increasing. Later on, the pain moved to the lower abdomen. Moving around
makes the pain worse; denies any alleviating factors. The pain is associated with nausea and
2 episodes of non-bloody vomitings. She is also C/O having frequent burning urination, which
started at more or less same time. She also has fever associated with chills and rigors.
ROS: She has regular bowel movements; no diarrhea/constipation. She denies recent
change in appetite and weight. Rest is unremarkable.
PMH: UTI one episode. Hospitalized once for evaluation of possible pyelonephritis.
All: NKA
SH: Working as a receptionist. She never smoked nor had alcohol.
SxH: Multiple sexual partners, her partner doesn’t use condoms, uses oral contraceptive
pills. Never been tested for STDs.
FH: Both parents are alive and healthy
Ob & Gyn: LMP 3 weeks ago. No priors STD’s. No H/o vaginal discharge
PE:
Vitals: Pulse 98/min, B.P -120/75 mm of Hg, R.R - 22/min, Temp 101.30F
Gen: AAOx3 (Alert, Awake and oriented to time place and person), in mild to moderate
pain.
Heart: S1, S2 heard. No thrills/murmurs /gallops/rubs.
Lungs: CTA B/L (Clear to auscultation bilateral)
Abdomen: Flat, no scars and pigmentations. BS are + in all 4 quadrants. Tenderness is
present in periumbilical, RLQ and LLQ regions. Not distended. No
rebound/guarding/organomegaly. CVA tenderness is negative. Psoas and
obturator signs are -
D/D: Investigations:
Pelvic Inflammatory disease Rectal and pelvic examination
Pelvic abscess CBC with differential
Urinary tract Infection Urinalysis including C/S
Appendicitis Pregnancy test
Rupture or Torsion of ovarian cyst Ultrasound Abdomen
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case2 Scenario Print
27 Yr. O/F complaining of rash
Vitals
l Pulse--78/min
l B.P--120/75 mm of Hg
l Temp-98.3 F
l R.rate--22/min
Make a mental checklist of Differential Diagnosis
l Infections
l Insect borne diseases
l SLE
l Photo dermatitis
l Drug induced
l Occupational exposure
l Rheumatoid arthritis
l Other autoimmune diseases
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case2 SP Print
If doctor asks you anything other than these just say 'no' (or) say things that are
normal in daily routine life.
l You are a 27y/o female c/o rash since 7 days on face and neck.
l It is a flat rash appeared after gardening for 3 hrs.
l Remained same as a flat rash but is increasing in size day by day
l Increases on exposure to sun
l No relieving factors
l No new areas were involved
l No itching/burning
l No redness of eyes
l No tenderness/no numbness
l You also have joint pains since 4 days, early morning stiffness
l Have fever Since 2 days
l No breathing problems/no chest pain
l None of the family members or close contacts has similar problems
l No h/o travel
l No history of similar past episodes
l Allergic to penicillin
l Past h/o joint stiffness several times, subsides on its own
l Never hospitalized
l No urinary and G.I problems
l Family—mother has rheumatism
l Obg/gyn—Has never been pregnant, last menstrual period was 2 weeks ago.
l Sexually active with boyfriend, using condoms regularly
l No smoking, no alcohol
l No recreational drugs. Took aspirin for headache 7 days ago
l Occupation—works in chemical manufacturing company
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case2 Pt Notes Print
CC: 27 y/o WF with rash
HPI:
This is a 27 y/o nulliparous WF noticed a rash over her face and neck after 3 hours of
gardening, 1 wk back. There has been no significant change in the rash in terms of
morphology; however, the rash has progressed. Rash is limited to face and neck with no
itching, numbness, burning sensation, or tenderness. The rash gets worse with the sun
exposure. There are no specific relieving factors. No H/o eye congestion. she also noticed
joint pains for 4 days with early morning stiffness, and H/o fever for 2 days. No h/o recent
travel, or pet exposure. ROS: Denies SOB, cough, chest tightness, or diarrhea. PMH: Never
had rash before. Has a H/O of joint stiffness for couple of times. All: PCN. Med: ASA for
headaches. No other OTC medications. FH: M - Rheumatoid arthritis. SH: works in chemical
manufacturing company. No H/O smoking, ETOH, and IVDA. SxH: Single sexual partner.
Uses condoms regularly. LMP 3 weeks ago. No H/O STD’s, or vaginal discharge.
PE:
Vitals: P.R: 78/min; B.P: 120/75mm Hg; R.R 22/min; Temp: 98.3 F.
HEENT: Face & neck has multiple circumscribed erythematous lesions. No pigmentation,
scaliness, vesicles, or cysts are noted. No mouth ulcers. No pallor or jaundice noted. PERRLA.
EOMI. ENT were WNL. Musculoskeletal: Joints have normal range of movements. No
tenderness, swelling, effusion, or redness. No muscle atrophy. Chest: CTA B/L. Normal S1,
S2. No murmurs, gallops, or rubs.
D/D:
SLE
Rheumatoid Arthritis
Photodermatitis
Drug Induced
Occupational exposure
Investigation:
CBC with differential, ESR
ANA, and Anti ds DNA
Rheumatoid factor assay
Skin biopsy
Skin tests for allergen
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case3 Scenario Print
65-year-old female complaining of arm and leg weakness
Vitals
· PR: 78/min
· BP: 160/90 mmHg
· Temp: 98.3 F (36.7 C)
· RR: 16/min
Make a mental checklist of Differential Diagnosis:
· Stroke
· Transient Ischemic Attack (TIA)
· Hypoglycemia
· Subarachnoid hemorrhage
· Subdural hematoma
· Intracranial mass
· Guillain Barré syndrome
· Complex migraine
· Conversion disorder
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case3 SP Print
If the doctor asks you anything other than these, just say 'no,' (or) say things that
are normal in daily routine life.
· You are a 65-year-old woman.
· You have noticed weakness of the right arm and leg.
· It started an hour ago.
· You have noticed a gradual increase in the symptoms over the past one hour.
· The entire arm and leg feel numb.
· You do not have problem with speaking; No slurry speech.
· Also noticed mild-to-moderate headache; 5-6/10 in severity.
· Felt nauseated but no vomiting.
· No loss of consciousness.
· No fever; No visual changes, such as blurriness or double vision; No problems with
swallowing. No chest pain or palpitations.
· No bowel problems; No urinary problems; No fits/jerky movements/seizures; No
fever.
· You never had a stroke before; You do not have a history of migraine headaches; You
never had any spells or weakness like this before.
· You have been diagnosed with high blood pressure 25 years ago, and you take
atenolol 50 mg once daily.
· You have had a heart attack (MI) 6 years ago after which you have undergone a
bypass surgery. You take baby aspirin (81 mg) for the heart. You also have high
cholesterol and you take Zocor (simvastatin) 20 mg daily at bedtime.
· You quit smoking when you had the heart attack 6 years ago. Previously, you smoked
2 packs of cigarettes per day for a period of 35 years. You drink alcohol only
occasionally, like once in a month.
· You are a widow. Your husband died 8 years ago. You live alone. You have the
neighbor, Steve, who is like a son to you. He brought you to the hospital.
· You had a mother and father who both had high blood pressure and both died
because of a heart attack. There is no family history of brain aneurysms/strokes.
· You have no known allergies.
Ask this question, if he does not address about the stroke: "Doctor, is it a stroke?"
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case3 Pt Notes Print
CC: A 65 -year-old white female with weakness of the right arm and leg.
HPI: A 65-year-old white female is brought to the hospital when she started to have
weakness in her right leg and arm, for the past hour. She felt tingling and numbness, along
with the weakness. The symptoms started, more or less, suddenly and progressed gradually
over the last hour. She felt nauseated but no vomiting. She also has a 5/10 headache. She
denies any numbness on her face, disarthria, dysphagia, syncope, seizures, visual changes,
palpitations, chest pain, or bowel/bladder incontinence. Denies any fever. There is no history
of falls or head trauma. PMH: No similar episodes, strokes. Has history of hypertension for
the past 25 years, hypercholesterolemia, myocardial infarction, and S/P coronary artery
bypass graft. All: None. FH: Father and Mother died with myocardial infarction. No family
history of strokes or aneurysms. SH: Quit smoking 6 years ago. Smoked 1 pack a day for the
past 35 years. Occasionally drinks alcohol. Widow, lives alone at home. Meds: Atenolol, ASA,
and Zocor.
PE:
Vitals: PR: 78/min, regular; BP: 120/75 mmHg; RR: 22/min; Temp: 98.3F (36.8
C)
CNS: Awake, alert and oriented to person, place, and time. CN: II to XII intact. Motor: Tone -
within normal limits bilaterally/laterally; Power is 5/5 - LUE (Left Upper Extremity); 5/5 -
left lower extremity; 3/5 on the right upper extremity; 3/5 - right lower extremity. Deep
tendon reflexes: 2/4 on right side. 3/4 on left side. Babinski positive on right side. Plantar
flexion on left side. Sensations: Pain, temperature, vibration, and sharp and dull sensory
perceptions are intact. Romberg's and gait unable to perform, because of severe weakness
and unable to stand. No neck stiffness noted. Heart: S1, S2 normal; No murmurs, gallops, or
rubs. No carotid bruit.
D/D:
Evolving stroke
Transient ischemic attacks or reversible ischemic neurological deficit
Subarachnoid hemorrhage
Investigation:
CBC with differential
Basic metabolic panel (Na, K, Co2, Cl, BUN, Cr, Ca, glucose)
12 lead ECG
CT head without contrast
Carotid Doppler
Transesophageal echocardiogram
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case4 Scenario Print
29 Yr. O/F known sickle cell anemia pt c/o chest pain
Vitals
l P.R: 98/min
l B.P: 120/75 mm of Hg
l Temp: 101.3F
l R.R: 22/min
Make a mental checklist of Differential Diagnosis
l Chest syndrome due to sickle cell anemia
l Pneumonia
l Costochondritis
l Pericarditis
l Pulmonary thromboembolism
l Salmonella Osteomyelitis
l Panic attacks
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case4 SP Print
If the doctor asks you anything other than these just say 'no' (or) say things that
are normal in daily routine life.
l You are Mrs. Mary, age: 29yrs
l Have chest pain since 12 hrs, started slowly, progressively increasing, 7-8/10 in
severity. Located in midline of the chest. It’s a type of sharp pain. No radiation.
l Moving around makes it worse, respiration worsens; OTC (Over-the-counter Tylenol)
pain killers reduce the pain.
l Have mild shortness of breath.
l Not associated with nausea or vomiting.
l No urine problems. No bowel problems.
l Last menstrual period was 2 weeks ago
l Have fever since 3 days associated with chills and rigors, have cough associated with
sputum which is green in color
l No pain in the legs
l H/O pain in fingers in past, h/o pain in abdomen in past
l No allergies
l Once hospitalized for pain in abdomen and diagnosed as sickle cell anemia
l Has one sexual partner
l Using oral contraceptive pills
l Families’ health mother suffered from Sickle cell disease. No family history of heart
problems, or blood clots
l Smoking – no
l Alcohol- no
l Occupation: Working as a teacher
l Appetite is reduced and wt is normal
l No illicit drug intake
l No blood transfusion
l No exposure to hypoxic environment, dehydration, heavy alcohol intake, or severe
exercise
l No trauma to chest
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case4 Pt Notes Print
CC: 29y/o BF, known patient of sickle cell anemia, complains of chest pain.
HPI:
A 29 y/o BF who has a H/O sickle cell anemia presents with central chest pain for 12 hours that started
slowly and is progressively worsening. Pain is 7-8/10 in severity, sharp, worsened by movement and
respiration and improves with OTC painkillers. She also C/O fever and chills for three days and cough
productive of green colored sputum. Mild SOB is present. Denies nausea or vomiting or hemoptysis. No
h/o blood transfusion, exposure to dehydration, high altitude or excessive exercise. No h/o chest trauma.
Her LMP was two weeks ago. ROS: No GI or urinary complaints. All: None. PMH: Once hospitalized for
abdominal pain when her sickle cell anemia was diagnosed. Med: OCPs and Tylenol. FH: Mother - sickle
cell disease. No H/O blood clots in the family. SH: Teacher, denies smoking, ETOH, and IVDA. SxH:
Single partner.
PE:
Vitals: P.R: 98/min; B.P: 120/75mm Hg; R.R 22/min; Temp: 101.3 F
Oral cavity: No erythema, or exudates. No enlarged lymphnodes. Chest: No redness or swelling, Normal
rate and rhythm of breathing, trachea central, no accessory muscles used. No area of tenderness. Lungs
are clear to percussion. On auscultation, normal vesicular breath sounds with no crackles, rales or
wheezes. TVF is WNL. S1, and S2 +; No murmurs/rubs/gallops. Abdomen: S/NT/ND/BS+; No
organomegaly. Extremities: No edema, calf tenderness, or swelling of the fingers .
D/D:
Chest syndrome due to sickle cell anemia
Pneumonia
Costochondritis
Pericarditis
Pulmonary thromboembolism
Salmonella osteomyelitis
Investigation:
CBC with differential; U/A
Sputum Gram stain; Culture & Sensitivity
Blood cultures
CXR
ECG
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case5 Scenario Print
35-year-old male with recent onset cough
Vitals:
PR: 98/min, regular
BP: 120/75 mmHg
Temp: 38.3 C (101.0 F)
RR: 20/min
Differential diagnosis for recent onset Cough:
l Common cold
l Acute sinusitis
l Allergic rhinitis
l Acute bronchitis
l Pneumonia
l Pertussis
l Pulmonary embolism
l Drugs (ACE inhibitors)
l Asthma
In elderly patients also consider:
l Congestive heart failure
l Chronic obstructive pulmonary disease (COPD) exacerbation
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case5 SP Print
*If the doctor asks you anything other than these, just say 'no', or say things that
are normal in daily routine life.
l You are Mr. Bill, age: 35-years, a paramedic, who drives an ambulance.
l You came with complaints of cough for the past three days; it is a dry cough initially.
You also have a cold, mild sore throat, sinus pressure, mild headache, and fever. You
thought the symptoms would go away, but did not; and, in fact, they are getting
worse. Now you get a teaspoonful of yellowish sputum each time you cough.
l There is no blood in the sputum.
l Cough is there all the time.
l No breathing problem, no wheezing, and no chest pain.
l You have tried Tylenol (acetaminophen) and cough suppressants; they gave some
relief.
l You have a history of sinusitis and asthma. Both are well controlled and you take
albuterol puffs once in a while.
l You are allergic to cats.
l Father has a history of bronchial asthma. Your 8-year-old son is also sick.
l Smoking – one pack per day for 15 years.
l Occasionally takes alcohol.
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case5 Pt Notes Print
HPI: This is a 35-year-old male who presents with an illness characterized by dry cough,
fever, rhinorrhea, and sore throat. Symptoms began 3 day(s) ago and are gradually
worsening since that time. Now, he started to develop productive yellow cough. His 8-yearold
child is also sick. Past history is significant for asthma, sinusitis, and tobacco abuse. SH:
works as a paramedic; smokes 1PPDx15 years. ETOH: 1 beer/day for the last 5 years. FH:
Father has asthma. All: cats. Meds: Albuterol MDI as needed.
Examination:
VS: BP 122/80 mmHg, PR 98/min, RR 18/min, and T 38.3C (101F).
General appearance: healthy, alert, no distress
Nose: no mucosal erythema, no mucosal edema and no purulent discharge
Oropharynx: exudates present and mild erythema (or) no erythema or exudates
Neck: Small, benign anterior cervical nodes bilaterally (or) supple, no lymphadenopathy
Lungs: expiratory wheezes and rhonchi throughout both lung fields (or) normal vesicular
breathing with no crackles, rales, or wheezes.
Heart: regular rate and rhythm, no murmurs, clicks, or gallops.
D.D for this Case
· Common cold
· Acute sinusitis
· Acute bronchitis
· Pneumonia
Investigations:
· CBC with differential count
· Sputum gram stain and culture/sensitivity
· Chest x-ray, PA and lateral view
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case6 Scenario Print
50-year-old male complaining of fatigue and loss of weight
Vitals:
· PR: 78/min
· BP: 120/76 mmHg
· Temp: 98.0 F (36.7 C)
· RR: 18/min
Make a mental checklist of DD for weight loss:
· Malignancy
· Diabetes mellitus
· Hyperthyroidism
· Depression
· Infections like TB, HIV
· Malabsorption
· Addison's disease
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case6 SP Print
If the doctor asks you anything other than these just say 'no,' (or) say things that
are normal in daily routine life.
l You are Mr. Albert, age: 50 years
l Have generalized body weakness and fatigue for past 5 months.
l Started slowly, progressively increasing fatigue.
After the Doctor asked more about your complaint (or) any other complaints, you should tell
about the abdominal discomfort.
l Noticed abdominal discomfort above the umbilicus, it is more like a gas; stomach feels
full with few bites of food.
l No nausea/vomiting, no fever, no jaundice.
l Appetite has reduced. Weight has reduced about 30 pounds in last 3 months.
l Stools are normal brown in color. Sometimes they appear black, but never noticed
blood.
l No cough, breathing problem, chest pain, palpitations, swelling of the legs, or difficulty
swallowing.
l No problem with temperature, recently, but always feel hot. No tremors or sweating
noted.
l Has had constipation for several years on and off, but nothing is new.
l No interest in life and other social activities.
l Your sleep is decreased, gets up early in the morning.
l Decreased energy; feelings of guilt present; decreased concentration.
l Thought that life is not worth living. No longer feels interest in activities. However,
never had a thought of suicide.
l Lost your wife three months ago. You are more fatigued since the death of your wife.
l No allergies.
l Family health - Mother died from pancreatic cancer at the age of 60.
l Have single sexual partner. Decreased libido. Never had multiple sexual partners.
l Smoking – no.
l Alcohol - takes couple of beers every day for the past 30 years.
l Works at local restaurant and the workplace is not stressful.
l No illicit drug intake.
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case6 Pt Notes Print
CC: 50-year-old male with fatigue and loss of weight
HPI:
This is a 50-year-old previously healthy white male presenting with slowly, progressive
fatigue over a period of 5 months and a 30 pound weight loss in the last 3 months. Other
complaints include abdominal discomfort above the umbilicus, decrease in appetite, and early
satiety. He also complains of loss of interest, terminal insomnia, and feeling of
worthlessness. Three months ago, his wife died. Fatigue is worsened since the death of his
wife. ROS: He denies any dysphagia, nausea, vomiting, jaundice, melena, blood in the
stools, recent change in bowel habits, though he has a long history or altered bowel habits.
He also denies fever, chills, night sweats, cough, hemoptysis, shortness of breath, chest pain,
or leg swelling. He has no tremors, diarrhea, heat or cold intolerance. PMH: Nothing
significant. All: None Med: None FH: Mother died from pancreatic cancer at age 60. SH:
Restaurant manager. No history of smoking or IV drug abuse. Drinks a couple of beers daily
for the past 30 years. SxH: Single sexual partner, c/o decreased libido. No history of high
risk sexual behavior.
PE:
Vitals: PR: 78/min; BP: 120/75 mmHg; RR 22/min; Temp: 98.8 F (64.0 C).
HEENT: No pallor, jaundice. Oropharynx is clear. Neck is supple, no thyromegaly or
lymphadenopathy. Chest: CTA B/L. Normal S1, S2. No murmurs, gallops, or rubs. Abd:
S/NT/ND/BS+/No organomegaly. Ext: No edema. Power is 5/5 in all 4 extremities. DTR: 2 +,
symmetric.
D/D:
GI malignancy
Hyperthyroidism
Depression
Investigation:
Rectal exam and FOBT (Fecal Occult Blood Test)
CBC with differential
TSH
LFTs
Abdominal USG
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case7 Scenario Print
35-year-old male with acute onset diarrhea
Vitals:
PR: 90/min, regular
BP: 100/60 mmHg
RR: 16/min
Temp: 98.0 F (36.7 C)
Make a mental checklist of DD for acute onset diarrhea:
l Viral gastroenteritis
l Bacterial gastroenteritis
l Medication induced
l Clostridium difficle colitis
l Inflammatory bowel disease
l Irritable bowel disease
l Malabsorption
l HIV
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case7 SP Print
*If the doctor asks you anything other than these, just say 'no,' or say things that
are normal in daily routine life.
l You are Mr. Smith, age: 35-years-old
l Have diarrhea since yesterday
l Started after eating seafood and a salad in a local restaurant
l Bowel movements are 6-7 times a day; loose, watery, unformed bowel movements
l There is a sensation of incomplete evacuation and pain (tenesmus)
l Also have abdominal cramps, vomiting, and fever; all these started after diarrhea
started
l No blood or mucus in the stools
l Your mom and dad are also sick but not as bad as you
l You recently had sinusitis and have completed a course of amoxicillin 2 days ago
l Never had this before
l Feel very thirsty
l No other medical problems except sinusitis
l Never hospitalized and no surgeries
l No change in urination
l No allergies
l No family history of diarrheal disease
l Smoking – No
l Alcohol - takes couple of beers every week
l Occupation: Working as a computer programmer
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case7 Pt Notes Print
HPI: This is a 35-year-old WM who presents with symptoms of cramping, vomiting, diarrhea,
fever, and sweats. Symptoms started yesterday, gradually improving since that time. Ate
outside with family. Symptoms started 6-8 hours later. Other family members affected -
father and mother. No history of gastrointestinal disease. Also had received amoxicillin for
sinusitis 10 days ago and completed the course 2 days ago. Rest of the ROS is negative.
PMH: None. SH: School teacher; denies ETOH. FH: NS (nothing significant). All: None.
Meds: None.
Exam:
VS: T 36.7 C (98 F), BP 110/65 mmHg, PR 110/min, and RR 28/min.
General appearance: healthy, alert; mucus membranes are dry
Oropharynx: normal
Lungs: clear to auscultation and percussion (CTA B/L)
Heart: normal, regular rate and rhythm, no murmurs, clicks, or gallops
Abdomen: S/NT/ND/hyperactive BS; no guarding or rigidity present. No organomegaly, and
no masses felt
D.D for this Case:
Viral gastroenteritis
Bacterial gastroenteritis
Clostridium difficle diarrhea
Investigations:
Rectal examination and FOBT
CBC with differential count
Basic metabolic panel (NA, K, Cl, Co2, BUN, Cr, glucose)
Stool for Clostridium difficle toxin
Stool for fecal leukocytes
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case8 Scenario Print
25-year-old female complains of sore throat
Vitals:
PR: 90/min, regular
BP: 120/70 mmHg
RR: 16/min
Temp: 101.0 F (38.3 C)
Make a mental checklist of DD for sore throat:
· Viral pharyngitis (rhino virus and influenza)
· Bacterial pharyngitis
o Group A Streptococcal pharyngitis
o Mycoplasma pneumonia
o Neisseria gonorrhea
· EBV mononucleosis
· Postnasal drip secondary to rhinitis
· Chronic tonsillitis
· Primary HIV
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case8 SP Print
*If the doctor asks you anything other than these, just say 'no,' or say things that
are normal in daily routine life.
l You are Miss Alexia, a 25-year-old college student
l You came with complaints of sore throat for the past 3 days
l Symptoms started with nasal stuffiness, headache, sore throat, dry cough, and fever
l Tried over-the-counter Tylenol and Benadryl; gave some relief, but it is getting worse
l Also have difficulty swallowing
l Mild body aches and joint pains for the past 3 days
l No history of rash
l No abdominal or pelvic pain
l Boyfriend had similar complaints 2 weeks back but recovered now
l You also have similar episodes in the past, 2 times since childhood
l Have chronic tonsillitis in the past but had not undergone surgery
l No history of sinusitis
l Never hospitalized
l Sexually active only with boyfriend, using condoms regularly
l College student
l Smoking - No
l Alcohol - No
l Drugs - No
l No known drug allergies
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case08 Pt Notes Print
HPI: This is a 25-year-old female who presents for evaluation and treatment of sore throat.
Symptoms include headache, sinus pressure, congestion, runny nose, sore throat, pain with
swallowing, fever, and dry cough. Symptoms started 3 days ago, gradually worsening since
that time. Her boyfriend had similar illness 2 weeks ago. She denies nausea, vomiting, SOB,
abdominal pain, and vaginal discharge. Tried OTC (over-the-counter) Tylenol and Benadryl.
PMH: None. SH: College student; Smoking - No; ETOH - No. All: NKDA.
Examination:
VS: T 36.7 C (98 F), BP 110/65 mmHg, PR 110/min, and RR 16/min.
General: healthy, alert
Ears: R TM - normal, L TM - normal
Nose: no mucosal erythema, no mucosal edema, and no purulent discharge
Oropharynx: exudates present
Neck: small, benign anterior cervical nodes bilaterally
Lungs: CTA B/L
Heart: RRR; No murmurs, clicks, or gallops
Abdomen: S/NT/ND/No organomegaly.
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case9 Scenario Print
56-year-old male for BP Check and refill of the medications
Vitals:
PR: 80/min
BP: 150/90 mmHg
Temp: 97.0 F (36.1 C)
RR: 16/min
Make a metal checklist of complications of BP:
· Diastolic congestive cardiac failure
· Coronary artery disease (angina)
· Peripheral vascular disease
· Retinopathy
· Side affects of the medications
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case9 SP Print
*If the doctor asks you anything other than these, just say 'no,' or say things that
are normal in daily routine life.
l John, age 56
l High blood pressure for past 10 years
l Is taking medications as prescribed regularly; takes propranolol 20 mg twice a day
l No headaches
l Never had palpitations
l Never had blurred vision
l No breathing problem, chest pain, palpitations, nose bleeds, dizziness or leg swelling
l Is checking BP (self) regularly at home, usually 140-150 systolic and 80-90 diastolic
l Your last cholesterol was checked 2 years ago and it was high; you don’t remember the
exact number
l Is not doing any exercise
l No diet regulation
l Family history of high BP (father)
l Employment: works in food industry; no stress
l Smokes 1 pack per day for 30 years
l Occasionally takes alcohol (social drinking only)
l No illicit drug use
l Also have high cholesterol and takes simvastatin 40 mg at bedtime
l No known drug allergies
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case09 Pt Notes Print
HPI: This is a 56 y/o WM who presents for evaluation of hypertension. HTN was diagnosed
10 years ago and has been on propranolol. Patient denies any side effects of medication. He
states that he is feeling well and denies any symptoms referable to his high blood pressure;
specifically denies chest pain, palpitations, dyspnea, orthopnea, PND or peripheral edema.
PMH: 1. Hypercholesterolemia 2. HTN. FH: Father has HTN. SH: works in food industry; no
stress; Smokes 1 ppdx30 yrs; ETOH-occasional; No IVDA. All: NKDA. Meds: 1. Propranolol
20 mg po BID. 2. Simvastatin 40 mg po QHS (at bed time).
Exam:
VS: BP 122/80 mm Hg, PR 98/min, RR 16/min, and T 38.3C(101F).
Repeat BP R arm seated = *** L arm seated = ***.
Fundi: no hemorrhages or exudates and no AV crossing changes.
Neck: supple, no masses, no JVD, no bruits and thyroid normal
Lungs: Clear to auscultation and percussion (CTA B/L)
Heart: PMI normal. No lifts, heaves, or thrills. RRR. No murmurs, clicks or rubs
Peripheral pulses: Normal and full, radial=2/4, femoral=2/4, popliteal=2/4, post tib=2/4,
dorsalis pedis=2/4
D.D:
Essential hypertension follow-up
Investigations:
Urinalysis
Lipid panel
ALT (for statin side affects – abnormal LFTs)
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case10 Scenario Print
66-year-old male complaining of constipation
Vitals:
PR: 70/min, regular
BP: 120/70 mmHg
RR: 16/min
Temp: 98.0 F (36.7 C)
Make mental checklist for constipation:
· Functional constipation
· Obstructive lesions (bowel obstruction, carcinoma of colon)
· Metabolic disturbances (hypothyroidism, diabetes mellitus, hypercalcemia)
· Neurologic dysfunction (stroke, autonomic neuropathy, spinal cord trauma, multiple
sclerosis, and Parkinson's)
· Medication induced (iron preparations, opiates, anticholinergics)
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case10 SP Print
*If the doctor asks you anything other than these, just say 'no,' or say things that
are normal in daily routine life.
l You are Mr. Jansen, age: 66 years
l Have constipation on and off for the last 5 months, and it is getting worse for the past
2 months
l Have difficulty passing stools. They are not painful, but you have to strain a lot. The
stool caliber is okay, but they are hard.
l There is a sensation of incomplete evacuation.
l Never noticed blood in the stools; but, once in a while, black stools are seen
l Do not have episodes of diarrhea in-between
l No abdominal pain; no nausea or vomiting
l You have lost a lot of weight in the past 2 months. Appetite is reduced, too
l You feel fatigued
l You never had this before
l You also have severe knee pain from degenerative joint disease, and you were recently
started on oxycodone (narcotic) 2 months ago for pain control
l You drink enough water but that has only increased frequency of urination. Your diet
mainly has vegetables and very little bacon
l Have a history of Hashimoto's thyroiditis and on thyroxine replacement
l No history of diabetes
l Never hospitalized and never had any surgeries done
l Father died of colon cancer at 67
l You never had screening colonoscopy, but you had rectal exam done 2 years ago
l No allergies
l No other medications
l Smoking – No
l Alcohol- takes 2-3 glasses of wine every week
l Occupation: Working as a supervising technician in a pharmaceutical company
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case11 Scenario Print
50-year-old male complaining of impotence
Vitals:
PR: 80/min, regular
BP: 150/80 mmHg
RR: 16/min
Temp: 98.0 F (36.7 C)
Make mental checklist for Impotence:
· Diabetic neuropathy
· Atherosclerotic vascular disease
· Anxiety and other psychiatric disorders
· Medications, like antihypertensives
· Chronic alcoholism
· Pituitary dysfunction
· Spinal cord dysfunction
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case11 SP Print
*If the doctor asks you anything other than these, just say 'no,' or say things that
are normal in daily routine life.
l You are not able to get erections for the past 3-4 months. It is gradual in onset.
l Desire to do sex is present all the time
l Aggravated by - stress
l No associated problems
l No previous episodes of sexual dysfunction
l Sometimes you have problem with nocturnal erections
l No pain in the legs or thighs; no headaches
l You have your wife and no other sexual partners
l No previous treatment/evaluation
l Have had diabetes for past 10 years, maintaining with exercise, diet, metformin, and
glipizide. You check your blood sugar twice daily and it is around 120-200, usually.
l You also have high blood pressure and take propranolol; it was started 4 months ago
l You also have had a generalized anxiety disorder for the past 5 years for which you are
taking buspirone
l Never hospitalized; no history of trauma
l Never had any surgeries
l No other medications
l Smoking occasionally
l Alcohol 2-3 beers/day for 25 years
l Working as a truck driver
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case12 Scenario Print
Mother of 1 Yr. O/Baby With Fever
Make a mental note of differential diagnosis of fever
l Respiratory tract infections
l Ear infections
l Exanthematous diseases
l Meningitis
l Urinary tract infections
l Gastroenteritis
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case12 SP Print
If the doctor asks you anything other than these just say 'no' (or) say things that
are normal in daily routine life.
l You are Mrs. Smith, age: 26 yrs
l The 1-year-old baby is at home. Baby has fever since two days.
l It is high grade and the baby shakes once in a while but she is not drowsy or lethargic
l It never touched normal
l It responds to Tylenol
l The baby has not been feeding since two days.
l There is discharge from nose and ear. (Green in color)
l The baby has been coughing since one day and breathing very fast since then
l The baby has been passing yellow urine. And cries when he passes urine
l Vomited twice which is purely the ingested food
l No bowel problems
l There has been one episode when baby has tremors
l The whole body was jerking rhythmically and similarly on both sides
l During the episode the baby lost urine
l After the episode baby remained silent and irritable for a while then slept
l You have been using cold water tepid sponging
l The baby has completed all the required immunization
l The baby has been doing well in growing.
l The baby can stand on his feet
l Can say dada mama can hold things with his hand.
l The baby was born at full term No complication in delivery.
l The baby was breast -fed till 2 months and then formula was started.
l There is no history of recent travel.
l No history of rashes
l No history of exposure to any child with similar complaints.
l Elder siblings are doing well. No contacts with ill people
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case13 Scenario Print
45-year-old female complaining of acute, right upper quadrant abdominal pain
Vital signs:
PR: 100/min
Temp: 101.0 F (38.3 C)
RR: 20/min
BP: 130/80 mmHg
Make a mental checklist of DD for RUQ abdominal pain:
l Acute cholecystitis
l Biliary colic
l Acute hepatitis
l Perforation of peptic ulcer
l Acute pancreatitis (biliary pain)
l Right lower lobe pneumonia
l Myocardial infarction
l Congestive hepatomegaly
l Hepatic abscess
l Retrocecal appendicitis
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case13 SP Print
*If the doctor asks you anything other than these, just say 'no,' or say things that
are normal in daily routine life.
l You are Mrs. Debbie, age: 45 years
l Have abdominal pain for the past two hours
l Started suddenly, progressively increasing
l 8-9/10 in severity
l Right upper quadrant
l It is a stabbing type of pain
l Going to back of the scapula
l Began after eating a large meal
l Moving around, taking a deep breath, makes it worse
l No alleviating factors
l Associated with two episodes of vomiting
l Vomit contains food, but no blood
l Previous history of occasional black stools present
l Feeling warm, no jaundice, no cough, no breathing problem, no chest pain
l Similar severe abdominal pain five months ago; resolved spontaneously in few hours.
In general, two to three hours after eating you get epigastric pain. Usually relieves with
eating snacks and taking antacids.
l Had peptic ulcer in the past and was treated five years ago; don’t remember the name
of the medication
l Hospitalized for delivery
l Family history is unremarkable
l Smoking - one pack per day for 20 years
l Alcohol - two to three beers daily for past 15 years
l Occupation - housewife; not working outside
l Eats many fatty foods
l No allergies
l Taking antacids for pain relief
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case14 Scenario Print
24 Yr. O/F Came for prenatal visit for the first time
Vitals
l Pulse--78/min
l B.P--120/75 mm of Hg
l Temp-98.8F
l R.rate--22/min
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case14 SP Print
If the doctor asks you anything other than these just say 'no' (or) say things that
are normal in daily routine life.
l Your last menstrual period was 12 weeks ago
l Pregnancy was confirmed 6 weeks ago at home and hospital
l This is your first pregnancy
l You have not felt fetal movements yet
l You don't have any H/O abortions
l No H/O sexually transmitted diseases in the past
l Your first menstrual period was at the age of 13 yrs, periods were regular, each cycle
last for 4 to 5 days
l No H/O -
l Morning sickness/vomitings
l Abdominal pain
l Vaginal bleeding
l Fever
l Rash
l Breathing problem
l Swelling of feet
l You don't have any other medical problems
l No H/O blood transfusions in the past
l You don't have any family history of birth problems in your family
l No H/O urinary or bowel related problems
l You smoke cigarettes 1 pack per day since 5 yrs
l You drink 1 beer per week since 3 yrs
l Not taking any drugs
l You are having adequate sleep
l Not working since last month
l Your husband is very co-operative with you
l Taken rubella immunization long back.
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case15 Scenario Print
60-year-old male complaining of acute shortness of breath
Vitals:
PR: 90/min
BP: 110/70 mmHg
Temp: 98 F (36.7 C)
RR: 26/min
Make a mental checklist for acute shortness of breath:
l Pulmonary embolism
l Congestive heart failure
l Chronic obstructive pulmonary disease exacerbation
l Pneumonia
l Spontaneous pneumothorax
l Bronchial asthma
l Anxiety and panic attacks
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case15 SP Print
*If the doctor asks you anything other than these, just say 'no,' or say things that
are normal in daily routine life.
· You are Mr. Adam, age: 60 years and have had shortness of breath (SOB) for the past
two days
· You are very healthy; but, for the past year, you have had some shortness of breath
with strenuous work; but, for the past two days, it is completely different.
· You are having some trouble breathing at nighttime and you have to use two pillows.
No wheezing.
· SOB is aggravated by lying down and mild to moderate exertion
· Relieved by sitting and rest
· You also noticed swelling of your feet and ankles at the end of the day, but they
usually are normal in the early morning
· No history of chest pain or fatigue
· Never heard of racing of your heart (palpitations)
· No history of fainting attacks
· Occasional dry cough; no fever or chills
· No leg swelling or pain
· No similar problems in the past
· No allergies
· No history of bronchial asthma or any lung disease
· Had high blood pressure for 20 years; taking atenolol 25 mg once a day.
· Recently had undergone back surgery for spinal fusion and stayed in the hospital for
one week
· Family history - father died because of heart attack at the age of 60
· Smoking - one pack per day for past 30 years
· Alcohol - one glass of wine/day for past 15 years
· Occupation - Working as a fire fighter
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case16 Scenario Print
40-year-old female with increased urination
Vitals:
PR: 86/min, regular
BP: 110/70 mmHg
RR: 16/min
Temp: 98.0 F (36.7 C)
Make a mental checklist of DD for polyuria:
· Diabetes mellitus
· Central diabetes insipidus
· Nephrogenic diabetes insipidus
· Psychogenic Polydypsia
· Cystitis (Urinary Tract Infection)
· Diuretics and other drug intake
· Hypercalcemia
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case16 SP Print
*If the doctor asks you anything other than these, just say 'no,' or say things that
are normal in daily routine life.
· You are a 40-year-old female feeling tired for the past 2 months
· Increasing day by day
· You also have increased urination-8-10 times/day
· 2-3 times in nights
· Also have increased volume of urine
· No burning urination, no urgency
· Also have increased thirst - 1 month
· Drinking a lot of water and eating a lot these days
· You have also lost 10 lbs of weight during the last 3-4 months
· You have a history of minor trauma to your head 3 months back; just admitted, and
later discharged from the hospital without any intervention
· No similar problems in the past
· No history of diabetes
· No smoking, no alcohol consumption history
· Occupation – homemaker and no stress at work
· Not taking any other drugs, including recreational drugs
· Both father and mother have diabetes
· No known drug allergies
· Your only other medical problem is bipolar disorder and have been taking lithium for
years
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case17 Scenario Print
35 Yr. O/F Came for evaluation of jaundice
Vitals
l Pulse--98/min
l B.P--120/75 mm of Hg
l Temp-101.3
l R.rate--22/min
Make a mental checklist of Differential Diagnosis for jaundice
l Infectious hepatitis
l Hemolytic jaundice
l Alcoholic hepatitis
l Drug induced hepatitis
l Primary biliary cirrhosis
l Wilson's disease
l Hemochromatosis
l Malignancy
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case17 SP Print
If the doctor asks you anything other than these just say 'no' (or) say things that
are normal in daily routine life.
l You are Mrs. Catherine, age: 35yrs a house wife.
l You came with complains of fever with chills since 5days.
l You have noticed yellowish discoloration of eyes since 2 days.
l You noticed pale colored stools and dark urine since 3 days.
l There is a mild discomfort in the belly from a day.
l Traveled to India and came back 20 days back.
l Had blood transfusions 2 yrs ago for an accident ( Trauma to legs ). Has been
hospitalized
l No History of sore throat, Bleeding, or any enlarged glands.
l No similar episodes in the past.
l No specific allergies.
l No history of high blood pressure, diabetes, hepatitis, liver disorders.
l Appetite has decreased, there is no weight loss.
l No problems with urinary and bowel habits.
l Not a smoker. Consumes 3 beers / day since 20yrs
l Took medication for fever. Did not take Hepatitis B vaccine.
l Sexual history is fine and only with husband. Using condoms as contraception
l No significant family history.
Ask this qt "Doc is it a hepatitis?"
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case18 Scenario Print
35 Yr. O/F Complaining of Chest Pain
Vitals
l Pulse--98/min
l B.P--120/75 mm of Hg
l Temp-101.3
l R.rate--22/min
Make a mental checklist of Differential Diagnosis.
If a young adult female comes with chest pain think of non cardiac causes first because that
is the one that you are going to get in the exam.
l Pneumonia
l Gastro esophageal reflux disease (GERD)
l Panic disorder
l Hyperthyroidism
l Pheochromocytoma
l Hyperventilation syndrome
l Angina
l Costochondritis
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case18 SP Print
If the doctor asks you anything other than these just say 'no' (or) say things that
are normal in daily routine life.
l You are Mrs. Luis, age: 35yrs
l Have episodes of chest pain since 2 yrs
l Progressively increasing number of episodes
l Usually the episodes are 4-5/10 in severity,
l All over the chest,
l Its a type of tightness and squeezing in quality.
l No radiation
l No aggravating and alleviating factors
l Not associated with vomiting and sweating
l Have hyperventilation, diaphoresis, dizziness and its a kind of fear of dieing and sense
of terror
l 5 episodes of similar problems in the past each lasts around 20 mts
l You also have headache during the episodes.
l You are not able to predict them and you are worried to go out because they are
coming most of the times when you go out.
l No allergies.
l Hospitalized 2 times previously for evaluation and you didn't find out what exactly is
the problem
l No Urinary or bowel problems
l Family's health - mother had hypochondriac disorder
l You don’t have any family conflicts and other problems
l Obg/gyn - normal
l Smoking - 1 pack per day for 8 yrs
l Normal sleep
l Alcohol - no
l Occupation - Working as a Red Cross member
l Appetite and wt is normal
l Diet - normal.
l Tried antacids but didn't give any relief
l No illicit drug intake (cocaine) and other drugs
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case19 Scenario Print
45 Yr. O/M complaining of Rt lower abdominal pain
Vitals
l Pulse--100/min
l Temp--98.7
l R.Rate--20/min
l B.P--130/80 mm of Hg.
Make a mental check list for Rt Lower Quadrant abdominal pain in a male pt
l Appendicitis
l Meckel's diverticulitis
l Perforated viscus
l Intestinal obstruction
l Yersinia enterocolitica
l Pancreatitis
l Urolithiasis
l Even acute cholecystitis
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case19 SP Print
If the doctor asks you anything other than these just say 'no' (or) say things that
are normal in daily routine life.
l You are Mr. Evan, age: 45yrs
l Have abdominal pain since 2 hrs,
l Started suddenly, progressively increasing,
l 8-9/10 in severity,
l Right behind the umbilicus
l It’s a type of sharp pain.
l Going to RT side of my lower abdomen
l Began after eating a large meal
l Moving around makes it worse
l No alleviating factors
l Associated with 2 episode of vomiting and sweating
l Vomit contains yesterday food, no blood
l No Urinary or bowel problems ,last defecation was 20 hrs back
l No fever,
l No similar problems in the past,
l No allergies.
l Had peptic ulcer in the past and was treated 10 yrs ago
l Never hospitalized
l Family's health normal
l Smoking – 1 pack per day for 20yrs
l Alcohol- 3 beers daily since 15 yrs
l Occupation: Working as a bus driver
l Appetite and wt is normal
l No illicit drug intake (cocaine)
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case20 Scenario Print
55-year-old male with bilateral leg pain
Vitals:
Pulse: 78/min
Temp: 98.0 F (36.7 C)
RR: 16/min
BP: 140/80 mmHg
Make a mental check list of DD for bilateral leg pain:
l Thromboangiitis obliterans
l Atherosclerotic vascular disease
l Lumbar spinal stenosis
l Diabetic polyneuropathy
l Radiculopathy due to spinal disease
l Medications, such as statins
l Trauma
l Deep vein thrombosis (rarely bilateral)
Unilateral pain:
l Cellulites/myofascitis
l Deep vein thrombosis
l Rupture of Bakers cyst
l Osteomyelitis
l Bleeding into the leg (if the patient is on warfarin/coumadin)
l Radiculopathy
l Pathological fracture of the bone
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case20 SP Print
SP's Notes
*If the doctor asks you anything other than these, just say 'no,' or say things that
are normal in daily routine life.
l You are Mr. David, age: 50 years
l Have pain in both legs for past two months
l Started insidiously, progressively increasing
l 5-6/10 in severity
l Mainly over the calf muscles
l It is a type of throbbing pain
l No radiation
l Aggravating factors - walking, running, prolonged standing
l Alleviating factors - rest and sitting
l No rest pain, no fever, no trauma, no swelling, no back pain, no weakness
l No sensory changes such as tingling or numbness in legs
l No similar problems in the past
l No sexual problems - sexually active with wife
l Medical problems - have diabetes for past three years, but diet controlled, no high
blood pressure; also have high cholesterol and takes simvastatin
l No recent hospitalization; no prolonged bed rest
l Father died because of stroke at 65; no family history of blood clots
l Occupation - Working as a postal worker and having hard time at the end of the day
l Smoking - two packs per day for 20 years
l Alcohol - Occasionally
l No allergies
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case21 Scenario Print
40-year-old male with vomiting of blood
Vitals:
PR: 88/min
Temp: 98.0 F (36.7 C)
RR: 20/min
BP: 110/80 mmHg
Make a mental checklist of DD for hematemesis:
l Peptic ulcer decease
l Gastric erosions
l Esophageal varices
l Mallory-Weiss tear
l Esophagitis
l Duodenitis
l Malignancy (esophageal and gastric)
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case21 SP Print
*If the doctor asks you anything other than these, just say 'no,' or say things that
are normal in daily routine life.
l 40-year-old, Mr. Ross
l Had two episodes of vomitings for the last two hours
l You take one baby aspirin daily for prevention of heart attack
l Vomit contains one tablespoon of blood each time
l Have abdominal pain of 4-5 in severity, no radiation, and nauseating feeling since
yesterday
l Your stools are black for the past month
l Have had heart burn for the last two years, usually relieved by antacids
l Appetite and weight are normal
l No similar problems in the past
l Never hospitalized
l Working as a mail man (postal worker)
l Smoking one pack per day for the past 25 years
l Drinks four to five beers every day for the past 25 years
l No family history of bleeding problems. Father died at the age of 60 with heart attack.
l No allergies
l Except aspirin, for past five days for headache, no other medications
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case22 Scenario Print
55 Yr. O/M Complaining of Chest Pain
Vitals
l Pulse--78/min
l Temp--98.7
l R.Rate--20/min
l B.P--130/80 mm of Hg.
Make a mental check list for Chest pain
l Myocardial Infarction
l Unstable Angina
l Pulmonary Embolism
l Costochondritis
l Pleuritis
l Pericarditis
l Aortic Dissection
l G.E.R.D
l Esophageal perforation
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case22 SP Print
If the doctor asks you anything other than these just say 'no' (or) say things that
are normal in daily routine life.
l You are Mr. Adam, age: 55yrs
l Have chest pain since 2 hrs
l Started suddenly, progressively increasing
l 8-9/10 in severity
l Right behind the sternum
l Its a type of tightness and squeezing in quality.
l No radiation
l Walking and moving around makes it worse
l No alleviating factors
l Associated with 1 episode of vomiting and sweating
l Have mild shortness of breath
l No Fever
l No Cough
l No similar problems in the past,
l No Allergies.
l Had high blood pressure for 20 yrs taking Atenolol 50 mg.
l Had diabetes since 5 yrs but its under control
l Never hospitalized
l No Urinary or bowel problems
l Families’ health: father died because of heart attack
l Mother had stroke
l Smoking – 1 pack per day for 30yrs
l Alcohol - 1 glass of wine / day since 15 yrs
l Occupation-- Working as a librarian
l Appetite and weight is normal
l Diet -- eats lot of junk and fatty food.
l Tested for cholesterol 1yr ago and it was 280.
l No illicit drug intake [cocaine]
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case23 Scenario Print
70 Yr. O/M complaining of Frequent Falls
Vitals
l Pulse--78/min
l Temp--98.7
l R.Rate--20/min
l B.P--130/80 mm of Hg.
Make a mental checklist of differential diagnosis for falls
l Cerebellar disease [Alcoholic/Tumor]
l Parkinson’s disease [Idiopathic/drug induced]
l Diabetic neuropathy [Sensory ataxia]
l Brain tumors
l Hyperthyroidism
l Fractured hip
l Seizure
l Vertigo
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case23 SP Print
If the doctor asks you anything other than these just say 'no' (or) say things that
are normal in daily routine life.
l You are Mr. Adam, age: 70yrs
l Have been falling frequently for past two months.
l Started like twice a week to now twice a day increasing,
l Have problem in maintaining balance when you try to stand
l No major injury until now, but are concerned if you will have any fracture
l You get once in a while some palpitations too and then once you loose your
consciousness
l Have problem in holding things your hands keep on shaking and this increases
especially when you try to reach for an object.
l Your friend says that your speech has changed and you have noticed that too.
l You have lost a lot of weight in last two months,
l You have headache on and off. But it is mostly in the mornings.
l You are not sexually active, your wife passed away five years back
l Your son does not live in the same city
l You do not have any problem with calculation and memory, but have difficulty in
reading.
l Have diabetes since 10 yrs but under strict control.
l No difficulty in urination, bowel and sleep
l No smoking,
l Alcohol--2 beers a day for 3o yrs
l You have been taking phencyclidine for past 15 yr. and have stopped just 5 months
back.
l Retired from job.
l Do not have any body to talk to.
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case24 Scenario Print
35 Yr. O/M Complaining of Cough and Chest Pain
Vitals
l Pulse--94/min
l Temp --101.7
l R.Rate --24/min
l B.P--130/80 mm of Hg.
Make a mental check list for Cough and Chest pain
l Pneumonia
l Pleuritic pain
l Pleural effusion
l Pulmonary edema
l Tuberculosis
l Pulmonary embolism
l Ca. Bronchus
l Infective endocarditis
l GERD
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case24 SP Print
If the doctor asks you anything other than these just say 'no' (or) say things that
are normal in daily routine life.
l You are Mr. Littman, age: 32yrs
l Have chest pain since 2 days and cough from 2 days
l Started in the morning with malaise
l 5-6/10 in severity
l On the left side of chest
l It’s a type of sharp, shooting, electric pain.
l All over your left chest.
l Moving around, deep breath makes it worse & relieved by expiration
l Fever with chills twice fever remains between the episodes of the chills
l Cough is present with expectoration. It is 2 – 5 teaspoon in amount, yellow in color,
fowl smelling and there is no blood in the expectoration/sputum
l Sweating present: Mild shortness of breath with exertion present (pt keeps on asking…
will I survive, is this Pneumonia, Can I attend volunteer services, what will happen to
my other commitments)
l No bowel problems
l Allergies to Penicillin and aspirin.
l Once hospitalized for evaluation of angina, has toothache since 15 days and it was
removed 7 days back.
l Have single sexual partner
l Families’ health – all are well. A friend suffered from pneumonia few days back in
office.
l Smoking –yes, 1pack for 20 yr.
l Alcohol- two shots every weekend when he goes for playing pool with his friends
l Occupation: Working as a Senior Investment Advisor with Morgan Stanley
l Appetite reduced and wt is decreased
l No illicit drug intake
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case25 Scenario Print
60-year-old male complaining of lower abdominal pain
Vitals:
PR: 98/min
BP: 130/85 mmHg
T: 101 F (38.3 C)
RR: 22/min
Make a mental checklist of Differential Diagnosis:
l Diverticulitis
l Renal colic
l Appendicitis
l Ischemic colitis
l Infectious colitis
l Leaking aneurysm
l Intestinal obstruction from strangulated or incarcerated hernia
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case25 SP Print
*If the doctor asks you anything other than these, just say 'no, ' or say things that
are normal in daily routine life.
l You are Mr. David, age: 65 years
l Have abdominal pain for the past 24 hours; it started slowly, progressively increasing;
now it is 5-6/10 in severity. The pain is mainly over the left side of your lower
abdomen.
l It is a type of crampy pain
l No radiation
l No aggravating factors
l No alleviating factors
l Has feeling of nausea and had vomited once, but no blood in the vomit
l Had diarrhea 2-3 times yesterday with one episode of bleeding, but no prior black
stools. The diarrhea and vomiting started after the abdominal pain.
l No urinary problems
l Have slight fever since yesterday, but no chills
l Went outside for dinner with the family yesterday, but none of them are sick
l No recent travel
l Appetite is decreased
l Lost 10 pounds of weight in last 3 months
l Never had this type of pain before
l Ten years ago, you had a kidney stone, but that pain is not this severe. That stone
passed spontaneously.
l You were hospitalized only once for that kidney stone. Never had any surgeries.
l Smoking – No
l Alcohol - 1 beer daily for past 15 years
l Family history – Father died from colon cancer when he was age 63
l You take only hydrochlorothiazide for high blood pressure. No other medications and no
recent antibiotic use.
l No known drug allergies
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case26 Scenario Print
35-year-old male complains of fatigue
Vitals:
l PR: 82/min
l BP: 120/80 mmHg
l RR: 16/min
l Temp: 96.8 F (36.0 C)
Mental Checklist of DD:
l Depression
l Anemia
l Hypo or Hyperthyroidism
l HIV or AIDS
l Malingering
l Hypochondriasis
l Post Traumatic Stress Disorder
l Chronic fatigue syndrome
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case26 SP Print
If the doctor asks you anything other than these just say 'no' (or) say things that
are normal in daily routine life.
l You are Edward, age 35 years
l Feeling very weak and low for past 2 months
l Getting tired very soon
l Not able to sleep properly
l Having nightmares almost every night
l Had a traumatic event of getting robbed 2 months back
l No shortness of breath
l Feeling anxious all the time
l No associated palpitations or sweating or tremor of hands
l Restricted my daily activities to minimal
l Not able to concentrate on work
l Feeling emotionally distant and lonely
l No change in appetite or weight
l No fever
l Did not notice any swelling in neck
l Has been having constipation for the past 3-4 months but no black stools; bladder
habits are normal
l Smokes 1 pack/day, for past 10 years; Not an alcoholic
l Occupation is florist
l No stress at home or at work
l Not using any medications
l Never hospitalized
l Single sexual partner
l No illicit drug use
l All family members are healthy
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case27 Scenario Print
65-year-old female complaining of loss of hearing
Vitals:
PR: 80/min
BP: 130/86 mmHg
T: 98.0 F (36.7 C)
RR: 16/min
Make a mental check list of DD for loss of hearing:
Conducting hearing loss:
l Cerumen impaction
l Otitis media with effusion
l Tympanic membrane perforation
l Otosclerosis
l Foreign body in ear canal
l Cholesteatoma
l Tympanosclerosis
l Tumor of the ear canal or middle ear
Sensorineural hearing loss:
· Presbycusis (hearing loss with aging)
· Ototoxicity
· Noise-induced loss
· Meniere ’s disease
· Diabetes
· Acoustic neuroma
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case27 SP Print
*If the doctor asks you anything other than these, just say 'no, ' or say things that
are normal in daily routine life.
l You are a 65-year-old woman
l You have noticed decreased hearing in your left ear
l Noticed it for the past 3 months
l Progressively increasing
l Especially prominent when somebody with a shrill voice speaks to you
l Nothing makes it better or worse
l You have not had any earache, but you have an ear infection history 10 years back,
which resolved with antibiotics
l No pus or discharge from the ear
l You have no sensation of ringing in your ear
l You don’t feel that the room is spinning around you
l You don’t have any dizziness or feeling of imbalance
l You have been working in an industry where iron and steel is recycled and frequently
expose you to loud noises
l There has been no weakness with any of your facial muscles
l You don’t have any other neurological problems, like loss of sensation, numbness,
tingling any where in the body
l You take hydrochlorothiazide for high blood pressure. You were admitted in the hospital
for severe urinary tract infections, for which you were treated with antibiotics. You
don’t know the names.
l No family history of hearing loss
l Never had any syphilis, or other medical problems except high blood pressure and two
episodes of urinary tract infection
l You are feeling okay with your life, but are frustrated with the hearing problem
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case28 Scenario Print
A 53-year-old male with right knee pain and swelling
Vitals:
PR: 80/min, regular
BP: 130/60 mmHg
RR: 18/min
T: 101.0 F (38.3 C)
Mental Checklist of DD:
· Osteoarthritis
· Septic arthritis
· Pseudogout and gout
· Reactive arthritis
· Traumatic knee injury
· Lyme disease
· Monoarticular rheumatoid arthritis
· Psoriatic arthritis
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case28 SP Print
*If the doctor asks you anything other than these, just say 'no,' or say things that
are normal in daily routine life.
· You are Mr. Scott, age 53 years
· Actually, you have pain in both the right and left knees for the past year, and you are
thinking that is due to your heavy weight; but, for the past 2 days, you are having
severe right knee pain. You are having difficulty in walking because of pain.
· The pain is all around the right knee joint, constant pain, throbbing in nature, no
radiation to anywhere, and it is 7 out of 10 in severity. You tried ibuprofen, but it did
not relieve your pain
· There are no aggravating and relieving factors for pain, and you do not know what
might have precipitated it
· You have 10-15 minutes of morning stiffness in your joints everyday
· There is no history of trauma to your knee joint
· You feel warm, but no fever, chills, nausea, or vomitings. You did not take
your temperature.
· There is no history of febrile (flu-like) illness or diarrhea in the recent months
· You do not have pain or swelling in other joints
· There is no history of rash anywhere in your body (even in the past)
· You do not have any other complaints
· You never traveled to any where for the past 5-6 years
· No history of tick bites or insect bites
· Three years back, you had pain and swelling in the right and left wrists and fingers
and subsided with ibuprofen
· You do not have any problems with your bowel movements or urination
· You are a retired librarian
· Not sexually active for the last couple of years, because you do not feel like having
sex
· No illicit drug use
· Family history - mother has a history of pseudogout and father is hypertensive
· Using Tylenol (acetaminophen) occasionally for knee pain for the past year
· You have no known drug allergies
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case29 Scenario Print
A 50-year-old man with blurred vision
Vitals:
BP: 150/90 mmHg
Temp: 98.0 F (36.7 C)
Pulse: 70/min
RR: 16/min
Make a mental checklist of DD for blurry vision:
· Diabetes mellitus
· Cataract
· Hypertensive retinopathy
· Glaucoma
· Macular degeneration
· Brain lesions
· Hyperviscosity syndromes (polycythemia)
· Illegal drugs
· Temporal arteritis (usually starts unilateral)
· Trauma or infections to the eye (if unilateral)
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case29 SP Print
*If the doctor asks you anything other than these, just say 'no,' or say things that
are normal in daily routine life.
l You are a 50-year-old man
l You have come to the doctor due to the chief problem of blurred vision in both eyes
l You have not seen a doctor for the past 10 years
l You have had blurred vision since approximately 2 months, on and off
l You do not have any eye discharge, halos around light, and you don’t have any eye
pain
l You do not have nausea, vomiting, headache, weakness in the arms and legs
l You do not have any history of seizures, loss of consciousness, complete loss of vision,
eye problems
l You have been experiencing excessive thirst of late
l You have been eating more than you usually do over the past few months
l You have lost about 10 pounds over the past few months
l Your mother has diabetes, and she uses pills for the problem
l You do not know if you have any medical problems, because you have not seen any
doctor for the past few years
l You are a postal worker
l You do not drink alcohol, except a couple of beers on weekends
l You smoke 1 pack/day
l You do not use any recreational drugs
l You are sexually active with your wife only; no problem with sex
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case30 Scenario Print
32-year-old Michelle with multiple bruises
Vitals:
PR: 90/min
BP: 120/80 mmHg
RR: 16/min
Temp: 99.4 F (37.4 C)
Mental Checklist of DD:
· Accident
· Physical assault
· Spousal abuse
· Bleeding disorders
· Collagen vascular disorders
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case30 SP Print
*If the doctor asks you anything other than these, just say 'no,' or say things that
are normal in daily routine life.
l You are a 30-year-old woman
l You have a bruise on the right arm between your shoulder and your elbow
l You are accompanied by your husband
l When the doctor asks you how you sustained the injury, you tell him that, "My husband
told me that I fell down the stairs."
l On further questioning by the doctor, you say that you have been hit by your husband
l You have been married for 7 years
l Your husband is a truck driver
l Your husband hits you whenever he has his rage episodes - usually once a week
l You have 2 children, a boy (age 6) and a girl (age 5). He does not hit them. He loves
them, but they are afraid to go near him when he has his rage episodes.
l Your husband is an alcoholic, and he almost always has a bottle of bourbon by his side
l Both your parents are living in the same town as you are and neither of them is aware
of the abuse that you are subject to
l You feel that your husband loves you
l You love your husband, but you are always on the edge when he is around
l You feel that it is very difficult for you to leave him
l You have never reported the matter to any agency
l You do not feel safe at home, especially when he is around
l You have felt at least on two occasions that he might kill you
l You do not have an emergency plan to leave home if the need arises
l You do not wish the matter to be reported to the authorities
l You have a satisfying sexual relationship with him, and you are monogamous
l You do not smoke, drink, or use recreational drugs
l There is a shotgun at your house. You think your husband might use it.
l When the doctor persuades you that you need not endure such a relationship in which
you are always in mortal fear, you say that you are going to think about reporting it to
the social welfare agencies
l If you have been persuaded enough by the doctor, take his phone number and tell him
that you are going to call him if the need arises.
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case31 Scenario Print
A 20-year-old Elisa with burning urination
Vitals:
PR: 82/min
BP: 110/80 mmHg
RR: 16/min
Temp: 101.0 F (38.3 C)
Mental Checklist of DD:
l Cystitis
l Pyelonephritis
l Urethritis
l Vulvovaginitis
l Pelvic inflammatory disease
l Noninflammatory dysuria (trauma, irritant, allergy)
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case31 SP Print
*If the doctor asks you anything other than these, just say 'no,' or say things that
are normal in daily routine life.
l You are Elisa, age 20 years
l Having burning urination for the past 4 days
l Associated with fever, around 101 F
l Having chills and rigors
l No nausea and vomiting
l Noticed a tinge of blood in urine
l Frequency of urination increased up to 10 times/day; you are also having frequent urge
to go to bathroom
l Having mild, dull constant pain in the suprapubic area
l No back pain
l Having some greenish vaginal discharge for couple of days, but no vaginal bleeding
l You had a similar episode one year ago, and it was diagnosed as chlamydia infection of
the cervix and was treated with doxycycline as an outpatient
l No other medical problems
l You recently changed your sexual partner; no pain during sexual intercourse
l Using oral contraceptive pills for contraception; never used condom as contraception
l Last menstrual period was 14 days ago
l Not a smoker
l Occasionally drinks a glass of wine
l Not using any other medications
l Occupation is a college student
l No known drug allergies
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case32 Scenario Print
A 50-year-old male with difficulty swallowing
Vitals:
BP: 130/90 mmHg
PR: 85/min
Temp: 98 F (36.7 C)
RR: 16/min
Make a mental checklist of DD:
Oropharyngeal dysphagia:
· Neuromuscular (CVA, Parkinsonism, multiple sclerosis)
· Mechanical obstruction (Zenker diverticulum, thyromegaly)
· Skeletal muscle disorders (myasthenia gravis, muscular dystrophies, polymyositis)
· Miscellaneous (medications, radiation)
Esophageal dysphagia:
· Mechanical obstruction [carcinoma esophagus, benign strictures, webs and rings
(Schatzki)]
· Achalasia cardia ( achalasia, scleroderma)
· Gastroesophageal reflux disease
· Miscellaneous (diabetes, alcoholism)
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case32 SP Print
*If the doctor asks you anything other than these, just say 'no,' or say things that
are normal in daily routine life.
l You are Mr. Peter, age 50
l Have difficulty in swallowing for past 3 months
l Started with difficulty with solids
l Progressing slowly
l Started having difficulty in swallowing liquids recently
l The food gets stuck behind the sternum; no problem with chewing and transferring into
esophagus
l Used to push food with a gulp of water; not able to do that anymore
l History of regurgitation of food hours after intake
l Heart burn present in lower part of chest for past 2-3 years; Taking plenty of antacids
l Recent loss of weight. Nearly 10 pounds.
l Recent loss of appetite
l Never took any corrosive liquids accidentally or intentionally
l No history of nausea or vomiting
l No difficulty in breathing
l No weakness in arms or legs
l Other than heartburn, no other medical problems
l No previous hospitalizations
l Occupation: used to work as stock broker
l Smokes – 1 pack/day for past 30 years
l Alcohol – occasional glass of wine
l Family history – no history of cancer or neurological diseases in the family
l Other than antacids, not taking any other medications
Ask this question after the encounter, ‘Doc, do I have cancer?’
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case33 Scenario Print
30 Yr. O/M came to HIV drug refill
Vitals
l Pulse-78/min
l B.P-120/75 mm of Hg
l Temp-98.8F
l R.rate-22/min
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case33 SP Print
If the doctor asks you anything other than these just say 'no' (or) say things that
are normal in daily routine life.
l You are Mr. Nathan, age: 30yrs
l You came for taking refill for Zidovudine.
l You have been taking it for past six months
l Taking 250 mg five times a day. Taking medications regularly.
l No problems with taking medications (no muscle weakness etc…)
l Not taking any other medications
l It was diagnosed 1year back. ELISA testing further confirmed by Western blot.
l No Cough
l No fever, No history of night sweats, no headache, vomiting, no eye problems
l No problems with swallowing
l No swelling anywhere in the body
l No history of diarrhea
l Vaccinations for Pneumonia taken last year
l Appetite is reduced
l Weight has reduced
l No depression, you are fine
l No white plaques in oral cavity
l No complaints of reddish papules over skin
l Using only bottled water
l No plans to travel in near future outside United States
l No history of any ulcer/ discharge on genitalia.
l No Allergies.
l No history of tingling, numbness in extremity and pain in abdomen
l Have multiple sexual partners. All are males.
l Using condoms.
l Attitude towards life is positive. Have informed his sexual partners about his HIV
status.
l There is no one-take care of you, all your friends and family members abandoned you.
l Families’ health is normal
l Smoking – No
l Alcohol- No
l Occupation: Working as a truck driver
l No illicit drug intake
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l Not participating in any study
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case34 Scenario Print
16-year-old female with amenorrhea
Vitals:
PR: 76/min
BP: 120/70 mmHg
RR: 16/min
Temp: 98.0 F (36.7 C)
Mental checklist of DD:
· Primary amenorrhea
· Secondary amenorrhea
· Pregnancy
· Anorexia nervosa
· Hyperprolactinemia
· Thyroid dysfunction
· Polycystic ovarian syndrome
· Stress
· Post pill amenorrhea
· Hypothalamic pituitary ovarian axis problems
Note: Both hypothyroidism and hyperthyroidism can present with amenorrhea.
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case34 SP Print
*If the doctor asks you anything other than these, just say 'no,' or say things that
are normal in daily routine life.
· You are Helen, 16-years-old
· Did not have periods for past 2 months
· Last period 2 months back
· Menarche - 3 years back
· Had regular periods since then
· 28-30 days cycle lasting 3-4 days
· Moderate bleeding
· Never had any abnormal vaginal discharge
· Periods were regular and normal until 2 months back
· Never become pregnant
· No nipple discharge; once in a while, mild headaches are there
· Lost weight of 10 pounds over last 6 months; unintentional
· Appetite is good
· You have final exams and lot of stress going on
· Single sexual partner, using condoms as contraception (sometimes you miss during
safe periods)
· You are also having anxiety, but no palpitations, bowel problems, and thyroid
problems (no hair loss, no voice change, no change in texture of skin)
· No other medical problems
· Never had pelvic inflammatory disease; no procedures done on your uterus
· Not a smoker
· Not an alcoholic
· No illicit drug use
· No allergies
· You do not take any other medications
Please ask this question somewhere in the case, ‘Doc, am I pregnant?’
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case35 Scenario Print
35-year-old female with acute right lumbar and lower abdominal pain
Vitals
PR: 100/min
BP: 110/70 mmHg
Temp: 38.3 C (101 F)
RR: 16/min
Mental Checklist of DD:
l Renal colic
l Ovarian torsion
l Urinary tract infection and pyelonephritis
l Pelvic inflammatory disease
l Mittelschmerz
l Appendicitis
l Threatened abortion
l Ectopic pregnancy
l Dysmenorrhea
l Endometriosis
l Fibroids
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case35 SP Print
*If the doctor asks you anything other than these, just say 'no,' or say things that
are normal in daily routine life.
l You are Joanna, age 35 years
l Have lumbar and lower abdominal pain for the past day
l Started suddenly over the right lumbar area and then progressed towards the pelvic
area and lower back
l Progressing since then and it is of 7-8/10 in severity
l Sharp pain
l Not comfortable in any position
l No relieving factors
l Having burning urination for the past 2-3 days
l Passing slightly discolored urine
l Having fever with chills for the past day
l Also feeling nauseous, but did not vomit
l No vaginal discharge or bleeding
l Last menstrual period (LMP) was 20 days back; your menstrual cycles have become
heavy these days, but no intermenstrual bleeding
l You don’t think you are pregnant; have 2 healthy children
l Bowel movements regular
l Had 2 episodes of urinary tract infections in the past 2 years, do not remember the
medications that you used. Also, has a history of pelvic inflammatory disease 2 years
ago.
l Was treated as outpatient; never hospitalized in the past
l Never had kidney stones
l Single sexual partner; no problems with sexual intercourse
l Using condoms
l Smokes 1 packet per day for the past 8 years
l Occasionally drinks alcohol
l No allergies
l Not taking any other medication
l No illicit drug intake
Ask this question at the end of session, ‘The pain is really hurting me, Doc. Please
relieve my pain, Doc.’
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case36 Scenario Print
70-year-old male with insomnia
Vitals:
PR: 88/min
BP: 130/90 mmHg
RR: 16/min
Temp: 98 F (36.7 C)
Mental Checklist of DD:
· Depression
· Post-traumatic stress disorder
· Anxiety disorder
· Chronic pain syndromes
· Drug induced
· Age related sleep changes
· Thyroid problems
· Sleep apnea
· Restless leg syndrome
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case36 SP Print
*If the doctor asks you anything other than these, just say 'no,' or say things that
are normal in daily routine life.
l You are David, age 72 years
l Onset of insomnia: for past 2 months
l Duration of sleep: 2-3 hours a night
l Has difficulty falling asleep
l Also has difficulty staying asleep
l No nightmares
l No recent traumatic event
l Snores a lot at night; you do not know anything about a breathing problem; you feel
tired in the morning and get some headaches as well
l Having chronic epigastric pain for the past 2 months, but it is very mild (1-2 on a 10
scale), and it is constant all the time and there are no aggravating and relieving factors
and no radiation
l Live alone, since the death of your wife (2 years); your son lives 5 miles away from
you. Feeling emotionally lonely.
l Do not have any feelings of guilt
l Good family support
l Appetite decreased for past 3 months
l Slight loss of weight, 2-3 pounds
l Occasionally feeling anxious
l Not having any associated symptoms, like palpitations or sweating or dizziness
l Decreased the regular daily activities to minimal
l Bowel and bladder habits normal
l No problems of hypo/hyperthyroidism
l No recent hair loss
l No tremor in the hands
l No change in the voice
l Not taking any caffeinated drinks before bed
l Smoker – 30 years – 2 packs/day
l Occasionally drinks beer
l No family history of cancer
l Admitted 3 months back in the hospital for unstable angina; takes aspirin, metoprolol,
and sublingual nitroglycerine; previous doctor also gave lorazepam, as needed, for
anxiety during your hospital stay.
l Taking the medicines regularly
l No recent change in medications
Ask this question, ‘Doc, do I have any problem for not getting enough sleep?’
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case37 Scenario Print
65-year-old male patient with difficulty urinating
Vitals:
PR: 92/min, regular
BP: 130/80 mmHg
RR: 16/min
Temp: 99 F (37.2 C)
Mental Checklist of DD:
l Benign prostatic hyperplasia
l Carcinoma of prostate
l Stone in the urinary tract (obstructive)
l Strictures of urethra
l Carcinoma bladder
l Sphincter dysfunction
l Infection
l Neurological dysfunction, like spinal cord trauma and diabetes
l Drug induced (anticholinergics)
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case37 SP Print
*If the doctor asks you anything other than these, just say 'no,' or say things that
are normal in daily routine life.
l You are Dawson, 65-years-old
l Having difficulty in passing urine for the past 2 months
l Having difficulty in initiating urination
l The flow is intermittent
l Have to strain to pass urine
l Need to go to bathroom often
l Getting up more frequently in the nights (5-6 times)
l You feel like your bladder is not emptied properly
l Never noted much urgency
l Slight burning sensation
l Noticed some blood in urine only one time
l Do not have any pain
l No fever
l No change in bowel movements
l Appetite is decreased recently and lost 10 pounds of weight from the past year
l Did not notice any weakness in legs
l No history of sexually transmitted diseases or urinary tract infections in the past
l No history of trauma
l Has history of diabetes mellitus and taking glyburide, and it is under control for the
past 10 years
l Is not taking any prescriptive drugs
l Taking over-the-counter drugs, like Tylenol, occasionally, and vitamins
l Never hospitalized before
l No illicit drug use
l Not a smoker
l Drinks beer at least 2 cans per day
l Family health - Father died of prostate cancer when he was 75
Ask this question, ‘Doc, do I have prostate cancer?’
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case38 Scenario Print
45-year-old female complains of breathlessness and anxiety
Vitals:
PR: 94/min, regular
BP: 130/80 mmHg
RR: 22/min
Temp: 97 F (36.1 C)
Mental Checklist of DD:
l Anxiety secondary to medical condition, e.g., hyperthyroidism, arrhythmias,
pheochromocytoma
l Substance abuse
l Panic disorder
l Generalized anxiety disorder
l Adjustment disorder with anxious mood
l Acute stress disorder or post traumatic stress disorder
l Hypochondriasis
l Malingering
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case38 SP Print
*If the doctor asks you anything other than these, just say 'no,' or say things that
are normal in daily routine life.
l You are Mrs. Elizabeth, 35-years-old
l Having difficulty breathing occasionally for the past 3 months
l Associated with palpitations, sweating
l Comes about 2-3 times per week
l Lasts for about 30 minutes
l Occurs at any time, usually when I go out
l Crowded places aggravate the symptoms
l Slow breathing and relaxation leads to relief
l Not associated with chest pain
l I get a feeling as if I am going to die
l As a result of these attacks, I stopped outdoor activities
l You also worry too much about your kids' future even though they are doing well; you
have a loving husband, but always doubt that he may leave you.
l Some times you get diarrhea and some times you get constipation; difficult to predict
l Did not notice any trembling hands
l Did not notice any swelling or mass in the neck
l Visited emergency department repeatedly, but no diagnosis reached
l No other medical problems
l Occupation à housewife
l Do not smoke
l Alcohol à Occasional glass of wine
l Do not drink too much caffeine; just as usual
l No illicit drug use recently; you have used marijuana when you were in college
l No stress at home
l Family support is good
l Mother has a history of generalized anxiety disorder
l Not taking any medications
l Allergic to penicillin (rash)
Ask this question, ‘Doc, do I have anxiety like my mom?’
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case39 Scenario Print
53-year-old male with a long history of epigastric pain
Vitals:
PR: 84/min
BP: 120/70 mmHg
RR: 16/min
Temp: 97 F (36.1 C)
Mental Checklist of DD:
l Peptic ulcer
l Gastritis
l Esophagitis (GERD)
l Carcinoma of esophagus, stomach, and pancreas
l Chronic pancreatitis
l Cholecystitis
l Hepatitis
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case39 SP Print
*If the doctor asks you anything other than these, just say 'no,' or say things that
are normal in daily routine life.
l You are Donald, 53-years-old
l Have chronic epigastric pain for past 2 years
l Occurs on and off for a period of a few months
l Sharp localized pain
l 5-7 in a scale of 10 in intensity
l Food intake brings on the pain and also aggravates it; some times you woke up with
heartburn in the middle of the night.
l Antacids used to relieve the pain
l Occasionally, the pain radiates to the back
l Twice I had vomitings with streaks of blood; this happened 2 weeks ago
l Appetite decreased slightly, and you feel that your stomach is always full
l No restriction on spicy foods
l Lost weight - about 14 pounds in last 6 months
l Has been feeling abdominal bloating recently
l Never had jaundice before
l No change in bowel habits; occasionally notice black stools
l Not a smoker
l Drinks alcohol; 1-2 beers a day, for past 20 years
l No other medical problems; never been hospitalized
l Mother died from pancreatic cancer when she was at 60
l Has been taking ibuprofen for knee pain; you have knee pain secondary to
degenerative joint disease
l No illicit drug use
Ask this question, ‘Doc, why am I having this pain for such a long time? Is it not
curable? Please relieve my pain, Doc.’
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case40 Scenario Print
45-year-old male complaining of bloody vomiting
Vitals:
PR: 90/min, regular
BP: 100/60 mmHg
RR: 18/min
T: 98.0 F (36.7 C)
Mental Checklist of DD:
· Gastric ulcer
· Duodenal ulcer
· Esophageal and gastric varices
· Mallory-Weiss tears
· Gastritis
· Erosive esophagitis
· GI malignancy
· Vascular ectasia
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case40 SP Print
*If the doctor asks you anything other than these, just say 'no,' or say things that
are normal in daily routine life.
History of presenting illness:
· You are Mr. George, age 55 years
· Your main complaint is bloody vomiting. The first episode was 2 hours ago while you
were working at your office, and the second episode was 30 minutes ago. Then, you
got scared and came to the emergency room. You have never had this problem
before.
· The vomiting was associated with epigastric pain (above the umbilicus). Both the
vomiting and abdominal pain occurred almost simultaneously.
· You did not have any prior episodes of retching or coughing before the bloody
vomitus. The first vomit, itself, was a bloody vomiting. It was bright red in color. The
quantity was around a cupful.
· The epigastric pain was 6-8/10 in severity, burning in quality, and radiating to back.
Actually, you have had on-and-off heartburn over the past 2 years, but you never
consulted the doctor for that. You often take antacids and eat some crackers, usually
relieving your pain; but, recently, it has been getting worse.
· Drinking caffeinated beverages and alcohol aggravates your pain.
· You are feeling slightly dizzy since vomiting occurred.
· You have also noticed black-colored (dark tarry) stools once in a while; otherwise,
your bowel habits are normal and you do not have constipation or diarrhea.
· No problem with your urination; no blood in the urine.
· You did not notice any fever.
· Your appetite is good; you did not lose any weight.
Other medical problems:
· Your other medical problems include high blood pressure and chronic tension
headaches.
· You do not have any other medical problems, except high blood pressure and tension
headaches.
· You have never been admitted in the hospital and have never had any surgeries.
Social history:
· You are working as a marketing manager in a sales company. You have a little bit of
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stress at work.
· You smoke around 2 packs per day for the past 25 years. You have never tried
quitting.
· You also drink alcohol, around 2-3 beers per week for the last 10 years.
Family history:
· There is no family history of liver disease or bleeding disorders.
· All your family members are healthy.
Medications:
· You use ibuprofen as needed for tension headaches.
· Also, you take hydrochlorothiazide for high blood pressure.
· You do not take any other medications, including recreational drugs.
Allergies:
· You have no known drug allergies.
Ask this question, ‘Doc, will I die from bleeding? Is it a cancer?’
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case41 Scenario Print
60-year-old male complains of dizziness
Vitals:
PR: 80/min
BP: 140/90 mmHg
RR: 16/min
Temp: 97.0F(36.1)
Mental Checklist of DD:
· TIA or stroke
· Drug induced
· Coronary artery disease
· Autonomic dysfunction
· Postural hypotension
· Congestive heart failure
· Arrhythmias
· Hypoglycemia
l Intracranial pathology
l Ear problems
l Anemia
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case41 SP Print
SP’s Notes
*If the doctor asks you anything other than these, just say 'no,' or say things that
are normal in daily routine life.
· You are Robert, 60-years-old
· Having dizziness for past 4 days
· Occurs occasionally
· Lasts for 2-5 minutes
· More on getting up from sitting position
· Lying down will help reduce the dizziness
· Sometimes associated with palpitations or sweating
· No chest pain
· Never lost consciousness during these episodes
· This time noticed weakness in right lower leg and lasted for 10 minutes and resolved
spontaneously; no headache, nausea, or vomiting
· No change in bowel or bladder habits
Other medical problems:
· You have diabetes for 15 years and take glyburide twice daily; you check blood sugar
twice daily, and it is in the range of 120-160 mg/dL.
· You have high BP from the past 10 years. One week back, medication for BP control
was changed from atenolol to terazosin (alfa blocker).
· So far, no heart problems and never had any strokes.
Social history:
· Smoker for 30 years, 2 packs/day
· Not an alcoholic
· Exercise regularly
· Occupation - clerk in food store
· Lives with wife; she is healthy
Medications:
· Only terazosin and glyburide
· Taking medication regularly, as prescribed
Allergies:
· You have no known drug allergies
Ask this question, ‘ Doc, did I have stroke?’
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case42 Scenario Print
30-year-old male with new onset of seizure
Vitals:
PR: 82/min, regular
BP: 120/80 mmHg
RR: 18/min
T: 99.0 F (37.2 C)
Mental Checklist of DD:
· Seizures (secondary to head trauma, infections, drugs, metabolic disorders)
· Hypoglycemia
· Syncope
· Migraine
· Stroke
· Space occupying lesions
· Alcohol or drug withdrawal
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case42 SP Print
*If the doctor asks you anything other than these, just say 'no,' or say things that
are normal in daily routine life.
l You are Keith, age 30 years
l Had an episode of seizure a few hours ago; the episode lasted around 3 minutes, but
you were unconscious probably about 20 minutes. You felt a little nauseous before the
onset of seizures, and then you don’t know what happened, but your co -workers told
you that you had jerky movements for a couple of movements.
l Did not pass urine or feces during the episode
l You bit your tongue during the episode
l You have been noticing some weakness in the right hand for the past 3 months
l Once in a while, you get very mild headaches, but these days your headache is
constant and more in severity
l Having mild fever, cold and flu-like symptoms for the past couple of days
l No history of ear discharge or sinusitis
l No pain in the neck
l No history of head trauma
Other medical problems:
l You have type-1 diabetes and have been on insulin for the past few years. You do
not think this is an episode of hypoglycemia, because you know how that looks like.
l No other medical problems
Social history:
l Occasionally drinks alcohol. Last drink was 2 days ago.
l No smoking history
l Never used any illicit drugs
l Occupation - Clerk in postal department
Family history:
· There is no family history of seizures
Medications:
· Insulin NPH type 10 units in AM and 8 units at PM. Usually checks blood sugar 2 times
a day.
Allergies:
· No known drug allergies
Ask this question, ‘Doc, do I have a brain tumor?’
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case43 Scenario Print
A 23-year-old male with rectal bleeding
Vitals:
PR: 90/min, regular
BP: 110/60 mmHg
RR: 18/min
T: 101.0 F (38.3 C)
Differential diagnosis of lower GI bleed in an young patient:
· Anal fistula/fissure
· Inflammatory bowel disease
· Infectious colitis
· Neoplasm
· Vascular ectasia
· Gonococcal proctitis
· Hemorrhoids
Differential diagnosis of lower GI bleed in an elderly patient:
· Diverticulosis
· Angiodysplasia
· Malignancy/polyp
· Ischemic colitis
· Inflammatory bowel disease
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case43 SP Print
*If the doctor asks you anything other than these, just say 'no,' or say things that
are normal in daily routine life.
· You are Steve, age 23 years
· Having bleeding per rectum for past 3 days
· Started mildly with blood streaks in stools for past one month; progressed over 3
days to frank blood in stools; never had black stools.
· Associated with mild (2-3/10), crampy lower abdomen pain
· Suffered from chronic constipation for past 5 years. Have to strain a lot while
defecating. Also, you use to have severe pain sometimes when defecating, but the
bowel movements increased in frequency to 3 times a day recently.
· No nausea or vomiting
· Having mild fever (100 F) without chills for the past 4-5 days
· No recent change in weight or appetite
· No similar episodes in the past. Never admitted in the hospital before.
· Do not eat much vegetables or fruits
· You are working at local restaurant. No illicit drug use.
· Multiple female sexual partners; no homosexual activity; does not always use
condoms.
· Not a smoker; not an alcoholic.
· Father died from colon cancer at the age of 65
· Not using any medications chronically
· You have no known drug allergies

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