Generic Case Review
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Generic Case Review www.drzaid.com
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Generic Case Review. www.drzaid.com. Chief Complaint. What questions do we want to ask this patient?. History of Present Illness. CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Differential Diagnosis Treatment. CC HPI PMHx MEDS - PowerPoint PPT Presentation
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Generic Case Review
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Chief Complaint
• What questions do we want to ask this patient?
• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Differential• Diagnosis• Treatment
History of Present Illness
• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Differential• Diagnosis• Treatment
Past Medical History
• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Differential• Diagnosis• Treatment
Medications
• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Differential• Diagnosis• Treatment
AllergiesNKDA
3rd year medical students that asktoo many questions
• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Differential• Diagnosis• Treatment
Social History
• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Differential• Diagnosis• Treatment
Family Medical HistoryMother- Father-
• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Differential• Diagnosis• Treatment
Review of systems
General: weight change, fever, chills, weakHead: headache, nasuea, vomittingRespiratory: SOB, wheeze, coughCardiac: HTN, murmurs, angina, palpitationsGI: appetite, n/v, incont., const/diarrheaGU: frequency, hesitancy, urgency, dysuria
hematuria, incont., stones, no dyspareunia, no discharge
MSK: muscle weakness, flank painNeuro: parasthesias, loss of sensationPsychiatric- Pt is not depressed
• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Differential• Diagnosis• Treatment
Physical ExamVS- BP- 140/87 T-98.2 R-16 P-82General- Pt is well nourished and AxOx3Heent- EOMI, PERRLA, no vision changesCV- RRR w/o murmurs or rubs, clicks or gallopsRESP- Clear to auscultation bilaterally, no wheezesAbdomen- Soft, NT, ND, no masses, BS, no bruitsGU- No discharge, bleeding, nodules or masses
Positive lloyd’s testMSK- No weakness, mild tenderness in R flank
TTA T11-L-1 EXT- No edema, negative moses, pulses b/l
• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Differential• Diagnosis• Treatment
Differential
• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Differential• Diagnosis• Treatment
What do we want to order?
• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Differential• Diagnosis• Treatment
Labs
• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Differential• Diagnosis• Treatment
CBC
1014 g/dl
40
300
Chemistry
140
4.2
100
24
8.0
1.1
100
Pregnancy TestNegative
• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Differential• Diagnosis• Treatment
• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Differential• Diagnosis• Treatment
Differential
• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Differential• Diagnosis• Treatment
Diagnosis
Thank you!
• Questions, comments, concerns?
