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Comprehensive Case Presentation of a [Age]-Year-Old Patient by Medical Student [Name]

This document outlines a detailed clinical case presentation focused on a [age]-year-old patient, as part of the medical student's training. It includes critical components such as the chief complaint, history of present illness, past medical and surgical history, medications and allergies, social and family history, and a review of systems. Essential physical examination findings and differential diagnoses are also discussed. The case aims to enhance the understanding of patient management and the underlying disease processes, preparing future healthcare providers for real-world clinical scenarios.

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Comprehensive Case Presentation of a [Age]-Year-Old Patient by Medical Student [Name]

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  1. A -Year-Old with Medical Student Presentation Name of Student Date and time

  2. Chief Complaint and History of Present Illness • Concise statement of chief complaint • Quality/Location/radiation/severity • Chronology – onset, timing, duration, frequency, changes over time • Aggravating/alleviating factors • Associated symptoms • Pertinent risk factors • Attributions (what does patient think is causing the problem?)

  3. Past History • Past Medical History: • diagnoses • complications/sequelae/progression • current management and status • Surgical History • Reason if appropriate

  4. Medications and Allergies • Current Medications • Dosages, OTC meds., alternative therapies • Immunizations • Hormone replacement, aspirin, calcium • Devices • Nutritional supplements • Allergies: Note specific reactions

  5. Social History • Tobacco, alcohol, drug, and caffeine • Exercise/diet • Travel /exposures • HIV risk factors • Occupation and current living situation • Seat belts use, smoke alarms, helmet use, and gun safety • Social cultural/ethnic background • Screening examinations

  6. Family History • Cancer • Hypertension • Heart disease • Diabetes • Other relevant diseases • Illness similar to present illness

  7. Reproductive/Sexual History • Sexually active • Contraception; STD prevention and STD • Menarche (age) • Menses • Menopause (age) • Pregnancies; abortions: spontaneous; full-term, premature, living (Para Gravida format)

  8. Review of Systems • General: Fever; sweats; weight change; energy level • Skin: Rashes; pruritus; lumps or lesions • HEENT: • Headache; trauma, vision; glasses; diplopia; inflammation; pain; hearing; tinnitus; vertigo; pain, epistaxis; obstruction; drainage; dental care; dentures; sores; sore throat • Breasts: Lumps; discharge; pain; swelling • Respiratory: Dyspnea; pleuritic pain; cough; sputum; wheezing; asthma; hemoptysis; cyanosis; snoring; apnea; TB exposure; PPD

  9. Review of Systems • Cardiovascular: Chest pain; dyspnea-various types, orthopnea; edema; palpitations; claudication • Gastrointestinal: Appetite; dysphagia/odynophagia; heartburn; nausea/vomiting/diarrhea; constipation; change in bowel habits; hemorrhoids; jaundice; hematemesis/melena/hematochezia • Genitourinary: Dysuria; nocturia; hematuria; frequency; urgency; hesitancy; incontinence; discharge • Musculoskeletal: Joint/back pain; swelling; stiffness; deformity; muscle aches

  10. Review of Systems • Neurological: Dizziness; syncope; loss of coordination; weakness; memory changes; seizures; paresthesias • Psychiatric: Depression; sleep disturbance; anorexia; anhedonia; suicidal/homicidal ideation; anxiety; eating disorders; hallucination; delusions; behavioral changes • Hematologic: Anemia; easy bruising; heavy bleeding • Endocrine: Polyuria; polydipsia; heat/cold intolerance • Functional Status (optional): Activities of Daily Living: bathing; ambulating; toileting; transfer; eating; dressing

  11. Physical Examination Vital signs and General Appearance • Blood pressure (standing/lying if indicated) • Temperature • Pulse • Respiratory Rate • Oximetry on _____ • Height and weight (if appropriate)

  12. Physical Examination • Head / Face /Ears / Nose / Mouth /Neck

  13. Physical Examination • Chest

  14. Physical Examination • Abdomen

  15. Physical Examination • Neuromuscular

  16. Physical Examination • Rectal and Genitalia

  17. Physical Examination • Osteopathic structural examination

  18. Differential Diagnosis • What is the differential diagnosis of this patient’s problem based on symptoms and signs?

  19. Differential Diagnosis 19

  20. What Testing is Indicated?

  21. Test Results

  22. Discussion of Disease Process

  23. Discussion of Management

  24. References

  25. Questions

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