Comprehensive Patient Case Review: Key Questions and Clinical Findings
This detailed case review examines essential questions for patient assessment including Chief Complaint (CC), History of Present Illness (HPI), and Past Medical History (PMHx). It includes a structured approach to documenting medications (MEDS), allergies, social and family history (SocHx, FMHx), and a Review of Systems (ROS). A thorough physical examination is presented, leading to differential diagnosis considerations. Laboratory tests and visual findings are analyzed to support the diagnosis and treatment plan. Essential for 3rd-year medical students in honing their clinical inquiry skills.
Comprehensive Patient Case Review: Key Questions and Clinical Findings
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Presentation Transcript
Generic Case Review www.drzaid.com
History of Present Illness • 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 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 Allergies NKDA 3rd year medical students that ask too 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 History Mother- Father-
Review of systems General:weight change, fever, chills, weak Head:headache, nasuea, vomitting Respiratory:SOB, wheeze, cough Cardiac:HTN, murmurs, angina, palpitations GI:appetite, n/v, incont., const/diarrhea GU:frequency, hesitancy, urgency, dysuria hematuria, incont., stones, no dyspareunia, no discharge MSK:muscle weakness, flank pain Neuro:parasthesias, loss of sensation Psychiatric- Pt is not depressed • 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 Physical Exam VS- BP- 140/87 T-98.2 R-16 P-82 General- Pt is well nourished and AxOx3 Heent- EOMI, PERRLA, no vision changes CV- RRR w/o murmurs or rubs, clicks or gallops RESP- Clear to auscultation bilaterally, no wheezes Abdomen- Soft, NT, ND, no masses, BS, no bruits GU- No discharge, bleeding, nodules or masses Positive lloyd’s test MSK- No weakness, mild tenderness in R flank TTA T11-L-1 EXT- No edema, negative moses, pulses b/l
Differential • 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 What do we want to order?
CC • HPI • PMHx • MEDS • Allergies • SocHx • FMHx • ROS • Physical Exam • Differential • LABS • Radiological • Differential • Diagnosis • Treatment Labs
CBC • CC • HPI • PMHx • MEDS • Allergies • SocHx • FMHx • ROS • Physical Exam • Differential • LABS • Radiological • Differential • Diagnosis • Treatment 14 g/dl 10 300 40 Chemistry 8.0 140 100 100 4.2 24 1.1 Pregnancy Test Negative
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
CC • HPI • PMHx • MEDS • Allergies • SocHx • FMHx • ROS • Physical Exam • Differential • LABS • Radiological • Differential • Diagnosis • Treatment Diagnosis
Thank you! • Questions, comments, concerns?
