USMLE World CS Cases.doc

30 yr. o/f complaining of abdominal pain vitalspulse9b/minb.p120/75 mm of hgtemp-101.3r.rate22/minmake a mental checklist of differential diagnosispelvic inflammatory diseasepelvic abscessendometriosisurinary tract infectionappendicitisrupture/torsion of ovarian cystacute cholecystitisrenal colicectopic pregnancyabortionacute gastroenteritisinflammatory bowel diseaseif the doctor asks you anything other than these just say no (or) say things that are normal in daily routine life.you are mrs. mary, age: 30yrshave abdominal pain since 12 hrsstarted slowly, progressively increasing7-b/10 in severityright below the umbilicusits a type of sharp painall over your lower abdomenbegan after eating a large mealmoving around makes it worseno alleviating factorsnot associated with vomiting but have nauseating feelingpassing urine more number of times and have burning urinationno bowel problemslast menstrual period was 3 weeks agono discharge from vagina/no bleeding from vaginahave fever since yesterday associated with chills and rigorshave one episode of urinary tract infections (uti) in the pastno allergiesonce hospitalized for evaluation of utihave multiple sexual partnersusing oral contraceptive pillsfamilies health is normalsmoking - noalcohol- norecreational drugs- nooccupation: working as a receptionistappetite and wt is normalno illicit drug intakeask this qt - doc is it an appendicitis?history taking (general proforma)asked about the location of painasked about the intensity of painasked about the quality of painasked about the origin and duration of painasked about the progression of painasked about any radiation of painasked about the aggravating factors.asked about the relieving factorsasked about any vomitingasked about feverasked about urinary problemsasked about bowel problems.asked about last menstrual periodasked about vaginal dischargeasked about vaginal bleedingpast historyasked about similar episodes in the pastasked about history of allergiesasked about past medical problems (high blood pressure, diabetes, kidney problems, urinary tractinfections)asked about previous hospitalizations (surgery)asked about family health.asked about appetite and changes in weightasked about smokingasked about alcoholasked about obg/gyn history (in detail)asked about sexual history (in detail including contraception)asked about medicationsasked about occupationexaminationexaminee washed handsauscultated abdomenpalpated abdomen superficiallypalpated abdomen deeplychecked rebound tendernesslooked for cva tendernessperformed psoas sign and obturator signexamined without gown not through the gowncounselingexplained the physical findings and diagnosisexplained further work up (blood tests, urinalysis, ultrasound, abdomen x ray)explained the importance of safe sexual practices and use of condoms.asked to perform rectal and vaginal examinationcommunication skillsknocked before entering the roomintroduced himself and greeted warmlyused my name to address mepaid attention to what i said and maintained good eye contactasked few open ended questionsasked non leading questionsasked one question at a timelistened to what ever i said with out interrupting me in betweenused lay mans languageused appropriate transition sentencesused appropriate draping techniquessummarized the history and explained physical findingsexpressed empathy, made appropriate reassurancesasked whether i have any concerns/ questions.d.d for this casepelvic inflammatory diseasepelvic abscessurinary tract infectionappendicitisrupture/torsion of ovarian cystinvestigationsrectal and vaginal examinationcbc with differential counturinalysispregnancy testabdomen x rayultrasound abdomencasein notes- i nuic.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 resent change in appetiteand weight. rest is unremarkable.pmh:uti one episode. hospitalized once for evaluation of possible pyelonephritis,ah:nkash:working as a receptionist. she never smoked nor had alcohol.sxh:multiple sexual partners, her partner doesnt use condoms, uses oral contraceptive pills. never beentested for stds.fh:both parents are alive and healthyob & gvn: lmp 3 weeks ago. no priors stds. no h/o vaginal dischargepe:vitals: pulse 98/min, b.p -120/75 mm of hg, r.r - 22/min, temp 101.3fgen:aaox3 (alert, awake and oriented to time place and person), in mild to moderate pain.heart: s, s, 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 isnegative. psoas and obturator signs are -d/d:investigations:pelvic inflammatory diseaserectal and pelvic examinationpelvic abscesscbc with differentialurinary tract infectionurinalysis including c/sappendicitispregnancy testrupture or torsion of ovarian cystultrasound abdomencases. iii.iii”27 yr. o/f complaining of rashvitalspulse78/minb.p120/75 mm of hgtemp-98.3 fr.rate22/minmake a mental checklist of differential diagnosisinfectionsinsect borne diseasesslephoto dermatitisdrug inducedoccupational exposurerheumatoid arthritisother autoimmune diseasesif the doctor asks you anything other than these, just say no, (or) say things that are normal in daily routine life. you are a 27y/o female c/o rash since 7 days on face and neck. it is a flat rash appeared after gardening for 3 hrs. remained same as a flat rash but is increasing in size day by day increases on exposure to sun no relieving factors no new areas were involved no itching/burning no redness of eyes no tenderness/no numbness you also have joint pains since 4 days, early morning stiffness have fever since 2 days no breathing problems/no chest pain none of the family members or close contacts has similar problems no h/o travel no history of similar past episodes allergic to penicillin past h/o joint stiffness several times, subsides on its own never hospitalized no urinary and g.i problems familymother has rheumatism obg/gynhas never been pregnant, last menstrual period was 2 weeks ago. sexually active with boyfriend, using condoms regularly no smoking, no alcohol no recreational drugs. took aspirin for headache 7 days ago occupationworks in chemical manufacturing companyhistory taking (general proforma)asked about the location of rashasked about whether the rash was initially flat or raised/blisteredasked whether the rash changed to any characterasked about any new areas involvedasked about the progression of the rashasked about the aggravating factors.asked about the relieving factorsasked about any precipitating factorsasked about itching and burning over the rashasked about any pain or numbness over the rashasked about any breathing problems/chest painasked about redness of eyesasked about any joint pains.asked about feverasked about any one else in close contact have similar rashasked about recent travelasked about any animal contactasked about history of insect bites and h/o outdoor activities in the recent pastpasthistoryasked about similar episodes in the pastasked about history of allergiesasked about past medical problems (high blood pressure, diabetes, joint problems)asked about previous hospitalizationsasked about urinary and bowel problemsasked about family healthasked about smokingasked about alcoholasked about sexual historyasked about obg/gynasked about occupation and stresses in lifeasked about illicit drug intake and other drugsexaminationexaminee washed handslooked inside mouth for oral ulcersexamined 3 jointslistened my heartauscultated all over the lungsexamined without gown not through the gownexamined face and neck for rashcounselingexplained the physical findings and diagnosisexplained further work up (blood tests)communication skillsknocked before entering the roomintroduced himself and greeted warmlyused my name to address mepaid attention to what i said and maintained good eye contact.asked few open ended questionsasked non leading questionsasked one question at a timelistened to what ever i said with out interrupting me in betweenused lay mans languageused appropriate transition sentencesused appropriate draping techniquessummarized the history and explained physical findingsexpressed empathy, made appropriate reassurancesasked whether i have any concerns/ questions.d.d for this caseslerheumatoid arthritisphoto dermatitisdrug inducedoccupational exposureinfectioninvestigationscbc with differential count, esranti nuclear antibodies assay/anti ds dmarheumatic factor assaybiopsy of the rashskin tests for allergencasi.is. iii.iii” vitals 65-year-old female complaining of arm and leg weaknesspr: 78/min bp: 160/90 mmhg temp: 98.3 f (36.7 c) rr: 16/minmake a mental checklist of differential diagnosis:stroketransient ischemic attack (tia)hypoglycemiasubarachnoid hemorrhagesubdural hematomaintracranial massguillain barre syndromecomplex migraineconversion disorderif 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; s-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 chestpain 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 anyspells or weakness like this before.you have been diagnosed with high blood pressure 25 years ago, and you take atenolol 50 mg oncedaily.you have had a heart attack (mi) 6 years ago after which you have undergone a bypass surgery. youtake 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 ofcigarettes 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 heartattack. 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?”case3 checklisthistory taking including ros:asked about the onset of weaknessasked if the weakness was progressiveasked how you felt most of the days before the weaknessasked about the sensory changesasked about any numbness on one side of faceasked about history of speech problems; history of difficulty swallowingasked about history of loss of consciousnessasked about any jerky movements/seizure activityasked about the associated factors, like visual changes such as blurriness/double visionasked about any palpitations and chest painasked about nausea/vomitingasked about history of feverasked about any incontinence/bowel or bladder dysfunctionasked about a history of frequent falls/spellsasked about any history of recent head traumaasked about the home situationpast medical history:asked about similar symptoms in the pastasked about past/other medical problems (hypertension, diabetes mellitus, hypercholesterolemia,myocardial infarction, strokes, and migraine headaches)enquired about previous hospitalizations (surgery)allergies:asked about any allergiesfh:asked about any family history of strokes, heart attacks, or aneurysmssh:asked about smokingasked about alcohol intakeasked about living situationmedications:asked about my medicationsexamination:checked cranial nerves ii to xiitested muscle power bilaterally and laterallychecked deep tendon reflexes in both upper/lower extremitieschecked for sensory modalities proximally and distally and bilaterallychecked cerebellar function testschecked coordination and gaitdid the rombergs testlistened for carotid bruitchecked for neck stiffnessauscultated heartcounseling:told me the probable diagnosistold me the probable tests that i needed to undergoadvised to admit into the hospital for further evaluationcommunication skills:knocked before entering the doorgreeted me warmlymade eye contactintroduced himself by nameaddressed me by my namewas sympathetic and empathetic towards meused open-ended questionsused closed-ended questions in a nonjudgmental wayhad an understanding attitude towards my anxietydid not give false reassurances to my questionsd.d for this case:evolving stroketransient ischemic attacksubarachnoid hemorrhagework up:periodic monitoring of vitals/neuro checkcbc with differentialsbasic metabolic panel (na, k, cl, co2, bun, and cr.)ct scan of the head without contrastdoppler of the carotidsecg and tee (trans esophageal echocardiogram)cases pt notes- i nuicc: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. 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. rombergs and gait unable to perform, because of severe weakness and unable to stand. no neck stiffness noted. heart: si, s2 normal; no murmurs, gallops, or rubs. no carotid bruit.d/d:evolving stroketransient ischemic attacks or reversible ischemic neurological deficitsubarachnoid hemorrhageinvestigation:cbc with differentialbasic metabolic panel (na, k, co2, cl, bun, cr, ca, glucose)12 lead ecgct head without contrastcarotid dopplertransesophageal echocardiogramcase4 scenario29 yr. o/f known sickle cell anemia pt c/o chest pain vitalsp.r: 98/min. b.p: 120/75 mm of hg . temp: 101.3fr.r: 22/minmake a mental checklist of differential diagnosischest syndrome due to sickle cell anemiapneumoniacostochondritispericarditispulmonary thromboembolismsalmonella osteomyelitispanic attackscase4sp. i -imtif the doctor asks you anything other than these just say no (or) say things that are normal in daily routine life.you are mrs. mary, age: 29yrshave chest pain since 12 hrs, started slowly, progressively increasing, 7-8/10 in severity. located inmidline of the chest. its a type of sharp pain. no radiation.moving around makes it worse, respiration worsens; otc (over-the-counter tylenol) pain killers reducethe pain.have mild shortness of breath.not associated with nausea or vomiting.no urine problems. no bowel problems.last menstrual period was 2 weeks agohave fever since 3 days associated with chills and rigors, have cough associated with sputum which isgreen in colorno pain in the