Mini-CPX 6

Part 2: Approaching the Physical Exam

Further history obtained from the patient:

Past medical history:

Medical illnesses: Seasonal allergies, for which the patient takes Zyrtec (she has been on this medication for over 5 years); she’s had seasonal allergies since childhood. No other major ongoing chronic medical problems. No history of hospitalizations or surgeries.

Health maintenance: she regularly sees her primary care doctor for routine health visits, including annual pap smears. She is up to date on her vaccines, including her influenza vaccine this year. She has not had her cholesterol checked recently (in the past year), but the times it has been checked in the past, it has been normal.

Diet: reports eating a “typical American diet,” without any dietary restrictions.

Family history:

Mother: type 1 DM requiring injectable insulin since her early 20s.

Father: HTN and hypercholesterolemia since his mid-50s, and is on medications for both.

Maternal aunt has rheumatoid arthritis.

No other chronic illnesses in the family, as far as the patient is aware.

Medications:

Zyrtec 10 mg once dailyOrtho Tri-Cyclen, once daily

Allergies: NKDA

Social history:

Occupation: librarian at the local public library

Living situation: married, lives with husband and 2 children (5 year-old girl and 7 year-old boy), both healthy.

Sexual history: sexually active with husband, who has been her only partner since they were married (>10 years ago); has always used condoms with all past partners, including her husband; no history of sexually transmitted diseases in the patient or her husband.

Substance use: Does not smoke (never has). Alcohol use: consumes 1-3 drinks (beer or wine) at the most, per week—usually only on weekends (not daily). Denies recreational drug use now or in the past.

Travel: no recent travel to foreign countries.

Sick contacts: no one around her has been sick lately (other than minor colds), including no known tuberculosis (TB) exposures. No exposure to hospitals, nursing homes, homeless shelters, or incarceration facilities.

Denies major life stressors, other than this illness.

Review of symptoms:

General: reports weight gain—approximately 20 pounds over the past 6 months; denies changes in diet over that period of time. Distribution of weight gain seems equal throughout her body. Also reports feeling “cold” all the time, compared to her husband, who often complains about how warm she keeps the temperature in the house (this symptom started several months ago and has progressively worsened). Denies fevers, night sweats, problems sleeping, excessive thirst, or appetite changes—appetite has been normal.

HEENT: Mild chronic rhinorrhea, nasal congestion, clear nasal discharge, and occasional sneezing (no worse than usual), attributed to her seasonal allergies; denies headaches, sore throat, eye pain or discharge, ear pain or discharge, or unusual gum bleeding.

Respiratory: shortness of breath with exercise/exertion, mild to moderate in intensity—enough to discourage her from finishing a task; noted this symptom primarily over the past 2 to 3 weeks, and it has progressively worsened over that period of time. Denies cough or difficulty breathing when lying down or when sleeping at night.

CV: reports dizziness upon standing sometimes, but not always (doesn’t notice it as much if she’s well hydrated)—noted this symptoms more frequently over the past several weeks; denies chest pain, chest pressure, heart palpitations, syncope, or lower extremity swelling.

GI: reports constipation, which she describes as difficulty passing stool more than in the past, and it sometimes hurts when a stool is very large in size; she has bowel movements about once every 2 to 3 days, but sometimes she goes close to a week before passing a BM. Stools are non-bloody and are brown in color (no “black” or “tarry” appearance). Denies abdominal pain other than times when she’s very constipated; denies nausea, vomiting, diarrhea, or heartburn.

Skin: reports dry skin recently (over the past few months), attributed to being indoors in the dry heat during the winter; she’s tried applying moisturizing lotion for this, but it doesn’t seem to help much. Denies rashes or unusual skin lesions, yellowing of the skin, itching, easy bleeding with scratches, easy bruising, or swelling.

GU: reports her menstrual periods have become heavier than in the past, requiring her to use at least 4 to 5 large pads a day, for the duration of her period; but her period still lasts the same number of days it has in the past (~5 to 7, every 28 days). Denies vaginal bleeding between menses, vaginal discharge, lesions or rashes in her genital area, pain with sexual intercourse, dysuria, urinary frequency or urgency, or loss of interest in sexual activity.

MSK: Denies joint pain or swelling; denies muscle aches or pain.

Psych: reports doing her hobbies less than prior to when her symptoms began (e.g., running, gardening). Denies depressed or anxious mood, irritability, loss of interest in social activities or things that normally bring her pleasure, loss of interest in sex, loss of self esteem, feelings of hopelessness, feelings of guilt, difficulty concentrating, or thoughts of suicide.

Instructions:

Based on the information given in this patient’s HPI and chart, use the template below (starting on page 5) to create a list of PE maneuvers you would perform on this patient.

For each PE maneuver on your list, indicate the specific reason you would perform this maneuver in the right column, in terms of how it is relevant to your revised differential diagnosis for this patient. You must include this information for every PE maneuver, to receive credit.

Note:

It is important that you avoid including unnecessary PE maneuvers that are no longer needed based on what you know so far, focusing your exam content using your revised differential diagnosis after reading the full history. QUALITY is much more important than QUANTITY, in this regard. That said, do not short cut areas of the exam, if more exploration is needed.

The number of rows included in this template in no way indicates the number of PE maneuvers expected to be included in any part of this assignment—they are simply here to provide a structure for creating your planned PE, however long or short you make it.

Physical Exam Maneuvers Organize this list according to organ system.

Reason(s) why this PE maneuver is relevant to the exam for this patient

Add additional rows, if needed.