Case 1: Chest Pain: Ensure you check JVD ( HF, dire MI situations!

) , peripheral pulses
( rules out Aortic dissection) and carotid’s! ON PE check if both lungs have equal air to rule out
pneumothorax! Standard protocols include CXR, ECG, and CBC and Troponin and Cardiac CK.
ECHO CARDIOGRAM if MI

In case of an Aortic Dissection, do a TEE aka Transesophagela Echocardiogram as a

gold standard for that!!

GERD requires endoscopy

Acute MI - look at risk factors, and often will have hx of angina/exercise intolerance, and be
worked up early morning and have CP that radiates and casues pressure in chest

GERD - usually pain/ “heart burn” post eating at night with night time cough and regurgitation (
maybe pillows to sleep a la HF. Hx of antacid use and using them helps. Hx of coffee/
alcoholism

Order an endoscope if you suspect GERD and is resistant to antacid management

Cocaine Induced Angina - seen in patients with hx of cocaine usage. Always order a urine
toxicology in a patient if you suspect drugs!

Costochrondritis - pain on physical exam palpation/pleuritic pain, no hx of angina, and recent

cough or bouts of coughing that they feel tired and worn out from. It will hurt them to breathe
of laugh too much ( consider Rib fracture too!)

Regardless, do a EKG and Troponin

Pericarditis - pleuritic chest pain, XRAY clears this up. Also patient leans forward and has
pleuritic type chest pain! ECG will show diffuse ST elevations!

PE - hx of long sitting or being post surgery of hx of A fib. And now sudden CP and
tachycardia with no warning or hx and patient has massive SOB and pleuritic type pain. CXR
will be clear but do a D DIMER to rule it out, else do CT ANGIOGRAPHY TO CONFIRM IT AS
GOLD DIAGNOSIS!
Risk factors here is key!

Pneumothorax - on Physical exam will see uneven breathing between lungs. CXR to confirm is
not there. CXR should be standard ordering protocol for CP patients!

Aortic Dissection - sudden tearing chest pain that radiates to the back, often with no hx of
angina but hx of HTN with HIGH BP seen, and often uneven pulses in arms, and or
extremities!
..............................................................................
Case 2 Bleeding in da Urine! - Do a genital and rectal exam regardless ( BPH can can issues
with urination and needs a rectal exam to check! GROSS HEMATURIA is cancer until proven
otherwise and should be at top of yo differential, even with CVA tenderness temptress
bullshite!

Bladder Cancer /Transitional Cell Carcinoma - painless hematuria, smoker and painter!
Older age. and issues with voiding with polyuria and night time urination, dribbling and
incontinence in general! - work up with a Cystoscopy and UA and possibly CT of kidneys!

CVA tenderness is NOT seen in bladder cancer, sign of PYELO or Nephrolithiasis

instead!

Nephrolithiasis - while has hematuria gross, has sudden colicky flank pain as hall mark! Work
up with a Kidney CT. Pain migrates to groin!

BPH and or Prostate Cancer - this is a big differential as patients have obstructive
incontinence meaning they have urinary dribbling ( as with diabetics) due to blockage and not
hyperactivity of the depressor as with diabetics.

See hematuria, night time incontinence and the feeling that they never can empty
the full load of their bladder. See lots of post void residual volume!

Check with a post void residual volume, PSA and a rectal exam!

Hematuria here is usually microscopic and NOT USUALLY OVERT IN BLEEDING

( points to more nephrolithiasis kinda issue lol)

Glomeunephritis - does have hematuria and

often mild proteinuria, but has either HX of
diabetes or IgA nephropathy in kids. Also NO
CVA tenderness and hallmark is
HYPERTENSION/edema seen!

UTI - can cause hematuria but is not common in males. And Also usually has burning urination
and or frequency associated and risk factors and potentially fevers if in case of pyelonephritis
with CVA tenderness!

UA and UC needs to be done!

Regardless, workup needs a genital exam and or a rectal exam, Cystoscopy for transitional cell
carcinoma and and CT renal mass/stone and a UA for hematuria for bacturia, pyuria or check
for dysmorphic RBC/casts as signs of glomeular disease!

..............................................................................

Case 3 Back Pain - ALWAYS check reflexes, and do a through beck exam with ROM
( lean forward, side to side and then extend!) and ask for any inciting insident. ON PE,
check for paraspinal tenderness ( Muscular strain) or point tenderness for something like
TUMOR or anesthesia or for osteoarthritisthritis compression fracture.

ASK FOR URINARY/FECAL incontinence. If bladder don’t empty properly consider PSA
and prostate rectal exam too!

BACK PAIN MEANS YOU includes hip/leg exam ( aka Straight leg test) and
MOTOR DTRs. and babinsky sign for BAKC PAIN! and even GAIt for toe and heel
walking for back pain (can show you say Spinal stenosis)!! along with sensory
exam!

ALSO consider metastatic bone tumor of prostate cancer if they have point tenderness and
symptoms of BPH including urine incontinence at night ( and dribbling and post VOID high
volumes!)

Lumbar Muscle Strain - not hernia or stenosis just a strain aka tearing or pulling of the muscle
- nbd, just rest. SHOWS PARASPINAL TENDERNESS ( due to the muscles being
paraspinal being hurt and inflamed) BUT PAIN DOES NOT RADIATE DOWN UNLIKE IN
DISC HERNIATION!
Spinal Stenosis - SS bilateral and radiates down to legs that’s CHRONIC and not triggered in
fucking with better leaning forward. ( up hills, pushing shopping carts ect) and is
CHRONIC and not sudden unlike disc herniation!

Disc Herniation - often after a specific incident when patient lifts something heavy!
Better standing up straight and extending the spine and not bending at all. Pain radiates to
legs! and is helped by lying still and not fucking moving.

Osteoarthritic Fracture! - rest better, movement worse and point tenderness. Can also just
be “degenerative arthritis!)

Multiple Myeloma - CRAB symptoms (calcemia, renal, anemia and Benz jones proteins) and
older infixiduals with only symptom being back and bone pain.

Malingering - intentional faking? Maybe if they are all clear on physical exam and things just
don't add up?

WORK UP?
CXR fo sure and potentially MRI ( CXR aint everything!) and CBC and also prostate/rectal
exam to rule out metastatic bone cancer a la bone tumor and , and do a full gait, HIP/leg
exam, sensory and also DTRs, and also check for back tenderness. And also PSA and
check calcium? Protein Electrophoresis for fucking potentially multiple myeloma!
..............................................................................

Case 4 - Vehicular Accident with patient with RR of 22, and fuck! Post traumatic
accident, get a CT scan/ ( US if not hemostable) and CXR! and a septum culture and G
stain please! and CBC as well ( splenic infract/hemothorax sucks!)

Left chest pain, and worsening pain during inspiration! and LOWERED BREATH
SOUNDS in the left lung??! -> post accident? Think pneumothorax with pleruritic type
CP! Patient keeps trying to cough and it’s yellow gunky! + sharp pain in the LUQ
( THINK SPLEEN damage or lung pneumothorax!)

Also consider hemothorax as the cough brings up GUNK and also pneumonia if
patient has fever, unilateral CP and fever and a productive cough why not!

HX of infectious mononucleosis and cough and sore throat -> AND NOW CARE
ACCIDENT ==> SPLENIC LACERATION!

Pneumothorax - unilateral loss of brething post trauma, and HYPERESONANCE, shift of

trachea AWAY from injured side and even JVD as a result! Acute onset with pleuritic type pain
also seen! Get CP and SOB here too duh!

Hemothorax - presence of blood + pneumothorax, and has similar CP/SOB but also have
to worry about hemodynamic instability!
Pneumonia - fevers, productive cough, CP or feeling of sickness, HR increased, and even
crackles and pleuritic CP are all signs of pneumonia too! DULLNESS TO PRECUSSION
(opposite of hyper-resonance in pneumothorax), low grade fever and egophony. CXR will
elucidate a lobar infiltrate!

Rib Fracture - usually from falls with pleuritic chest pain that HURTS ON PALPATION and
during laughing/moving the chest wall!

Splenic Repture - history of Mono and LUQ pain. But would have massive hemodynamic
instability seen on CBC. And need to check for intracavity bleeding via bloody US or CT scan
duh!

ON PHYSICAL EXAM, check for signs of organomegaly!

Pleuritis - usual simple viral and is pain on inspiration and movement and is like
chostochondirtis a nbd but is a diagnosis of exclusion ! Exam is negative with the exception of
random CP a la rib fracture!

WORK UP: obvious CXR, US and CT ( pe and also for fucking splenic issues/intracavity
bleeding from hemothorax) and CBC and also septum stain and culture too sonny boi!)

And as patient was in a motor vehicle accident, consider mandating a Drug screen and urine
toxicology test!

..............................................................................
Case 5 - Pregnancy Test - Be happy to discuss options, but ensure you let patient know you
support them 100%. LAST MENSTRUAL PERIOD WAS ONLY SPOTTING? MAY BE FUCKING
JUST SPOTTING AND not a true menstural period as spotting happens in first trimester and is
NORMAL!

Always ask about menarche and any prior menstrual history and also ! Any history of
STDs, contraception and spotting between periods! and number of sexual partners, men
women or both as well ( ESPECIALLY IN STD CASES!) and even brest tenderness and hx
of last PAP smear!
Ask for any abdominal pain, post coital bleedings and weight changes and
appetite changes too! and fatigue too!

CHECK FOR ABUSE AND ASK IF THEY FEEL SAFE AT HOME!!! If they have a support
system and or an exit plan! Ask if they want to talk in private ect!

ƒor Pregnancy, check thyroid, and do a quick CV/Respiratory exam and then a abdominal
exam through and a SKIN EXAM to exam for skin pigmentation and pallor as that
changes in pregnancy!

BASE DIAGNOSTIC WORKUP - confirm pregnancy with a URINE HCG and a transvaginal
US to locate fetus, and then do a CBC with Diff, TSH and a fucking STD screen and also a
UA/UC and a RPR/VRLD for syphyllis, RUBELLA titers and HIV antibody test and a PAP
smear IF not done in past 3 years! and GHONORRHEA/CHLYMIDIA DNA TESTING!

TELL PATIENT TO STOP ALCOHOL AND DRUG USUAGE ASAP! and also excess caffeine
and excess exercise! Take prenatal vitamins and schedule patient for future visits!
“Unfortunately, natural methods of contraception such as pulling out before ejaculation are not
very effective. We will also need to perform a pelvic ultrasound to estimate the age of the fetus
and the expected date of delivery. If you are pregnant, we will check some more blood tests, a
Pap smear, and some vaginal cultures that we routinely perform in every pregnancy”

Differentials: JUST REMEMBER TO CHECK THROID GLAND ON PE DUFUS!

Normal Pregnancy - confirmed via fetus and positive uHCG! ( just console patients on
prenatal vitamins, avoid exercise and do necessary blood tests ( eg STD/syphyllis, CBC, Titers
for rubella and also UA/UC to rule out asymptomatic bacteria in the urine)

Look at breast engorgement, nausea vomitting and weight gain and weird
appetites for food a la PICA as all signs!

Any history of delayed periods or amenorrhea in a reproductive-age woman who

is sexually active should prompt the diagnosis of pregnancy unless otherwise
ruled out!!!


Ectopic Pregnancy - if hemp unstable or if in abdominal pain and or patient has strong HS of
surgery done or a congenital Bicornuate uterus issue! Keep in differential until fetus safely in
endometrial stripe is identified sonny pants!

Same with MOLAR pregnancy! - You’d see very high bHCG so at this point is patient’s plan,
this is STILL on differential until you do BCHG levels serially and or a fetus larger than normal
for gestational age!
Confirm with a transvaginal US

Remember the transvaginal US is great for lots of other stuff’s too!!

Case 6 - Kidd Diabetes! You are talking to Mum DOE!

Ask about Type, of diabetes, what meds/insulin dosages she uses, WHERE the
child injected and for compliance with it tooo!

ASK ABOUT how the child feels about this! How’s the family acting about iT!

ASK ABOUT RANGES OF HER LEVELS - both fasting ( up to 130) and post
prynadial (until 180)! and ask about HYPOGLYCMEIA EPISIDES TOO as that’s a
real FUCKING risk!! and if she has or has not have a emergency kit sonny boy!

And weight changes, diabetes type 1 means they lose weight as they can’t make
insulin and blood glucose goes up but actual usable energy goes down the
fucking DRAIN!!
 ASK about the 3Ps, poly dypsia, polyuria and weakness and fatigue!
ASK about tingling and numbness and the standard usual KIDS questions.
( development, birth history, LMP, excercise/playful activities of age, any issues at
school ect ect!)

Differentials include both type 1 and type 2 diabetus! and ofcourse obesity!

Work up via Insulin levels and C Peptide levels ( confirm not exogenous fucking diabetes)
and get a Hemoglobin A1C level and get electrolytes and glucose levels

IF YOU SEE ISLET CELL ANTIBODIES THAT SUPPORTS

DIAGNOSIS OF DIABETUS TYPE 1 SONNY PANTS!

UA, urine micro-albumin: To screen for diabetic nephropathy.

( Electrolytes via a CBC with differential and a CMP!!)

Hell even do a 24hr urine cortisol to rule out cushing issues and even an glucogonoma
( with uncontrolled diabetus!))
and if patient is taking
STEROIDS STOP AS IT THAT
ITSELF IS DIABETOGENIC YOU
DUMBASSS!

24-hour urine free cortisol:To rule

out coexisting Cushing’s
syndrome. 


..............................................................................
Case 7 - ARM PAIN - patient is 74yo Male that has arm close to body with left hand
holding it and it’s EXTERNALLY rotated and slightly abducted a la a dislocation or a
fracture fuck!

Patient fell onto outstretched arm. ON PE check for pain, location and pain with
movement and also PULSES ( as with any heart disease/aortic dissection R/O!)
After a fall, ask about LOC first! and then weakness and paralysis and or numbness and loss
of sensation in the arm ( rule out things like fucking COMPARTMENT SYNDROME!)

A fall in elderly means for social factors check out living situations and see who you like with
and the patient’s functional status!

If elderly may also ask for mood aka depression

IN YOUR CLOSURE MENTION POSSIBLE SOCIAL WORK ASSISTANCE, depression help or

moving to assisted living situations and or follow up tests! like DEXA scan!

( social work home
assessment can be
ordered!)



Differentials:

Arm Fracture (aka

humeral fracture)

Arm Dislocation ( Shoulder Joint dislocation) - especially if right arm is externally rotated and
abducted a la Subxulation of radial head seen in kids!

Osteoperosis is a common factor differential as the patient was elderly

POTENTIALLY ELDERLY ABUSE if son did not take him to the doctor due to lack of time!

WORK UP - Standard XRAY and MRI of the shoulder to better illustrate exactly the issue
and then also a DEXA scan to see the bone density as elderly are more prone to fractures
due to osteoporosis!

..............................................................................
Case 9: 25yo F post Assault! Urge patient to report it t the police! Assure it’s not her fault
and empathize the shit out of the encounter.

Key Questions need to ask:

HURT ANYWHERE
Are you okay?! Any body injury? Hemodynamics. Ask to tell story. Provide comfort
and assure patient it’s NOT her fault BUT NEED FULL DETAILS TO ENSURE BEST
CARE FOR HERE! Any bruising, bleeding or LOC or headaches?

Was assault sexual? Was there condom usage? Did they ejaculate. Type of intercourse.
As it’s sexual in nature, LMP is needed!

Vaginal Bleeding? Nausea? Abdominal pain? Current meds ( like OCPS or not?)

 Provide EMERGENCY CONTRACEPTION! and access to social worker for support

groups and or other resources. An assault is traumatic and I want you to know we
are on your side and available whenever you need us.

Physical exam Must Haves:

Full body exam! - Head inspection, neck palpation. Mouth inspection, chest
auscultation, palm auscultation, palpation and percussion ( patient said SOB => full
exam!), full abdominal exam, Neurologic exam = MENTAL STATUS as patient is
POST TRAUMA, check gross motor and cranial nerves too!

Differentials:
Rape Pregnancy
STD
Emotional Trauma/Rib FRACTURE ( SOB with right sided CP alleviated by resting!
and Tenderness to palpation on chest wall!

Pneumothroax/Hemothorax - is SOB and pleuritic CP and coughing up blood or

goop. Regardless, CXR way to be! Hear hyper resonance not dullness to
precession and maybe even looking JVD!

Tests to Order:
PELVIC EXAM! and swabs of samples for STDs and used as evidence in
case if patient WANTS to file charges!
As patient as CP and hurts to breathe/on palpation, definitely XR
UHCG!

STD Tests ( DNA for chlymida and Ghonorrhea), and cervical swab culture!

HIV antibody test, VDRL and HBV antigen !

US/CT if knife wound

Rape KIT evidence Collection! - regardless if patient WANTS to pursue further or

not!
..............................................................................
Case 10: 35yo F with pain in right calf! WHEN DOING PULSES DO FEMORAL,
POPLITEAL AND DORSALIS PEDIS AS pulses are core issue that may be affected!

Key Questions need to ask:

Any hx of Surgery? Long periods of sitting/recent long drives and flights? Any Afib? Any
past hx of DVT?

ARE YOU ON OCPS, those fuckers can casue increased clotting! Or pregnant
( ask about LMP!)

Redness and or Warmth present?

Any recent falls to the area ( cellulitis nidus) or any PUS in general with iT!

ANY SOB? Pain breathing? CP? Are the vitals racing? ( CT ANGIO SONNY BOI!)\

Physical exam Must Haves:

Leg tests/Hip tests (straight leg raise, abduction, adduction ect)

Motor strength and reflexes and sensation in the legs!

PULSES of the extremities! BOTH FUCKING popliteal, DP and femoral!
 Physically feeling the leg
AND THEN GAIT, GAIT IS IMPORTANT in
leg case like diabetes ( fall risk post neuropathy) and back
pain!!! (

Lung exam!

Cardio Exam

Differentials:
DVT
Cellulitis - patient had recent fall, this can cause nidus for infection and lead to
cellulitis!
Osteomyelitis

Fracture of the femur!

Tests to Order:
Xray of legs and also Xray of lungs

Dopplr Ultrasound and a D Dimer too!

MRI? for cellulitis/Osteo!?

Wound and Blood Cultures and CBC with differentual!

IF Results show a clot, we will start blood thinners! As they have chance to travel to your
lungs!

..............................................................................

Case 11 Voice Hoarseness 62YO M!

Key Questions to Ask -

How are you feeling? Sick? Fevers? Weakness, COLD? Sore Throat?

History of GERD?/Heart burn after eating? Pillows at night?

Any smoking HX ( can be fucking Throat Cancer!) what about alcohol usage? Chewing
tobacco hx?

Thyroid History? Any meds for thyroid? SYMPTOMS OF THRYOID

Have you had a productive cough/coughed up blood?

Generalized weakness, malaise, weight loss? Night sweats?

Nausea Vomitting/Constipation Diarrhea Incontinence, Headaches, Fevers, Weight loss

and CP and palpitations?

TROUBLE SWALLOWING FOODS/LIQUIDS!

ANY VOICE OVERUSE ( DUH!) eg public speaker post fucking huge campaign lol!

Physical Exam Must Haves

Thyroid palpation, swallow and look or nodes

Look in mouth, eyes ( conjunctiva) and ears for signs of Viral + LOOK FOR NODES!
Abdominal Exam/Cadio Exam/ Pulm Exam

Differentials
Laryngitis/Viral Infection - Recent flu hx and low grade fever and malaise!

Cigarette smoking and long use of alcohol and GERD help as can viral infrection!

Laryngeal Cancer OR FUCKING POLYP- hx of weight loss, fever, and malaise and
horseless of voice and low grade fevers and history of alcohol use and cigarette use!

GERD - prior hx or taking meds or taking meds HELPS them

 LONG STANDING GERD - can lead to laryngitis irritation and inflamation!

HYPO Thyroiditis/Thyroid Carcinoma/Grave’s Disease? -> pretty sure disqualified

by PE but can be growing

Atrial Myxoma, Mitral Stenosis long standing or Prolapsed Mitral Valve ect!

Tests 2 Order
CBC with DIff, and ESR lol! ( ESR increased in infectious and malignant casues)
Laryngoscopy ( rule out cancer)

CT of the chest and neck, best for finding cancer, that is not as easy with
laryngoscopy!
H.Pylori Testing

Thyroid Studies

US of the neck?

Cardiac echo as that can also impinge and casue hoarseness as with the thyroid issue (
eg long standing mitral stenosis and or a cardiac myxoma lol!

..............................................................................

Case 12 - Neck Pain babe! 67 YO Female

Key Questions 2 Ask

Physical Exam Must Haves - ask patient to move neck and feel for pain. Carotid auscultation.
Hyper extend and flex the neck. Ask to swallow food. Any issues swallowing food? Any
hoarseness in your breath?

Any recent strenuous neck activity? Any specific stressor preluding the pain?

As there are nerves in the area, any numbness or tingling in the arms! Sensory or issues
with motor in the arms ( could be a brachial plexus injury) and also PULSES!

PLEASE REMEMBER TO SCAN THE WHOLE FUCKING ARM for sensation to pinprick

AS THE NECK INJURY CAN CAUSE ISSUES NOT WITH JUST NERVES BUT ALSO
PULSES NEVER FUCKING FORGET THE PULSES LOL!

AS POTENTIALLY CANCER - ask for fevers, weight loss, night seats and fatigue!

Differentials-
Muscle Sprain - rapid rotation of neck preceded pain as with a disc herniation

Disc Herniation => PINCHED NERVE! - numbness in arm and huts to move head.

Cervical Fracture - not as likely as NO point tenderness

Neck cancer/metastatic cancer breast and lung cancers & can casue cord compression

Thyroid issue?

Osteoarthritis - degenerative disc disease to make a fracture?

Tests 2 Order
Neck US? maybe for a laryngoscopy hoarse voice thing

 CBC and DIff, and RULE Out a bony met of multiple myeloma ( Calcium, BUN.CR
and anemia!) - also seen in back pain!

Neck XRAY ( C spine)

MRI for spinal nerve chehings!
As potentially a fracture in elderly woman, consider a DEXA scan if didn’t have one
already and mammograms and such!

NERVE CONDUCTION STUDIES IF THERE IS LOS OF SENSATION a la sensory loss a la disc

herniation or in the case of diabetic nephropathy so there’s that yes!

..............................................................................

Case 13 - 48 Yo F of Abdominal Pain FUCK! - pain’s for 2 weeks post eating fatty meals and
laos fucking hx of heart burn, antacids, help and hx of NSAID use and also fucking N/V and
also after eating fatty greasy foods lol!


Questions to ask: FUCK!!

One sided of multisided?

Pain started in one location or did it radiate anywhere. and move down now? How much does
it hurt is is continous?

Hx of pain after eating fatty greasy meals? - fat malabsorption? Blood in poop a la mesenteric
ischemia and or fuckinh

How’s constipation and diarrhea? Pain started suddenly or any hx of similar symptoms in
past? Eat anything fishy in past? ANY surgeries in the past ( eliminate SBO as a potential casue
lol). history of easy casues of pancreatitis a la alcoholism and or biliary stone hx! Any childern/
fat/female fourty? Any hx of biliary cholic? Any atherosclerotic/PAD hx

HX of NASID use for gastritis bebe! That is looking key! as is alcohol use!

Physical Exam Must Haves - Murphy’s sign ( breath in during palpation of the liver), pain on
breathing in!, Any rebound or guarding. LISTEN to bowel sounds, precise, palpate the whole 9
years! As atherosclerosis is in Differential check pulses and fucking carotid!

Differentials:
Appendicitis

SBO( passing gas/nausea/vomitting) - again not for 2 fucking weeks lol

Pancreatitis/Pancreatic cancer - see leaning forward and pain on inspiration!

Ovarian Torsion - LABD pain and needs a US of the pelvic ASAP!

Diverticulitis

GERD! - FUCK YOU THOUGHT YOU CAN IGNORE GERD LOL! ( antacids make it better)

GASTRIC ULCER - pain with types of food! and gets better when you eat and or with stoppage
of food a la the duodenal ulcer hehe!

Hepatitis

Cholecystitis - worse with fatty foods, post eating, and nausea and vomotting and femalefat,
forty!

Gastritis - aka food poisoning

Ectopic Pregnancy - pain not on and off for 2 weeks

Biliary Cholic

Cholangitis

Cholelithiasis

Mesenteric Ischemia - bloody poop + abdominal pain and hx of atherosclerotic disease

In this casue murphy sign sign was + with nausea and vomitting making cholecystitis first big
gess, peptic ulcer disease the second big guess and fucking gastritis for pain on palpation and
history of NSAID use the their big thing.

Also can lead a differential for fucking SBO considering 2 C section babies lol!

Diagnostic Tests: CT scan, Amylase/Lipase, CBC with Diff, Electrolytes, CXR, Pelvic US, and
fucking Pylori testing and endoscopy! Digital rectal exam and occults blood test too! - rule
out colon cancer!

You can determine between gastritis and PUD

US of the abdomen for easy cholecystitis rule out! and upper endoscopy and H.pylori
testing waaaaat?
..............................................................................

Case 14 - Headaches Galore - ASK in relation to period as period migrants are a fucking
thing!!!

Questions 2 Ask - duration, frequency and quality of the headache. Is it behind the eyes or up
in your head? Any pressure in the eyes? Any prior history of these sets of episodes? How long
do they last? Last for 40 minutes a la cluster headaches or a few hours a la migranes? Any
correlation to menstual cycle or taking OCPS? Does it wake you up from night time!

ANY AURA or photophobia/sound phobia

As headache, any nausea morning time? What is weight of girl, could be pseudotumor cerebri
(do a fucking LP!

Any numbeness/parathesia across any part of the body?

ANY FAMILY HISTORY OF MIGRANES!

Any drug or alcohol usage??

SAME TIME EVERY DAY? AURA ( culuster vs migrane!) vs Any major stressors in life a la
tension headache? ANY RECENT FALLS ( a la subdural hematoma/suarachnoid hemmorage
aka worst headache of life and or any LOS/drowsyness)!

DO A FUCKING MENTAL STATUS EXAM! - hematoma/hemmorage is on the differential!

Physical Exam to Do -
ANY NUCHAL RIGIDITY as meningitis is on the docket
Feel head and neck, palpate everything
MOTOR strength and neuro exam ( carnival nerves!) and DTRs!
Fundoscopic Exam! - check for retinal hemmorages/presure as with a diabetic
retinopathy patient!
Differentials
Tension

Culster

Migrane

Pseudotumor Cerebri

Brain Tumor - can’t rule this out without imaging

Subarachnoid Hemmorage

Sinusitis/Meningitis! - if patient had recent infection and or signs of rhinorhea,

conjunctivitis and or just all around sick face!

Depression is also on differential son! - Especially if patient exhibits exaggerated mood

and stuff!

Diagnostic Tests -
LP - rule out posedotumor cerebra

CT Scan of the head rule out an acute bleed, MRI better for ruling out masses!
EEG NO AS THERE WAS NI LOSS OF CONCIOUSNESS or a SIEZURE YOU DOLT!
MRI

CBC/ Diff

If jaw pain, headaches in temporal region, and old lady consider temporary arteritis and
get a fucking ESR ready!

..............................................................................

Case 15… 36YO F No period in 3 Months

Questions 2 Ask - Pregnancy, PCOS and Pituitary issues and Thyroids!

When was last LMP? Was it normal or spotty ( may be first trimester pregnancy)? How were
periods before this last one? Any hx of irregular periods in the past (rule out primary
amenorrhea!!)

Are you taking OCPS? If so how complaint? How much sex are you having and with whom?
ALWAYS USING CONTRACEPTIVES? Are you sexually active ( regardless order a pregnancy
test!)?

Any thyroid issues? Are you a fucking runner or supper skinny?

How’s your mood been, depression? How’s the diet and exercise been?

Any thyroid issues in the past?

Any hx with prolactinoma or galactorrhea? What about issues in vision ( bitemprola

hemiopsnia)

Any hirsuitism? Any deepening of the voice or male pattern baldness? -> CONCERN for
fucking PCOS? Any new diabetes?

HEAVY FLOW ( a la fibroids, polyps ect!)? Heavy Pain a la endometriosis? and fibroids?
( fibroids also casue incontinence too)!

Any cold/heat intolerance, fatigue? Constipation? - Concern for fucking Hypothyroid

Breast fullness and or tenderness and any skin changes of pregnancy?

Any pain in lower abdomen ( ectopic pregnancy/molar pregnancy rule OUT!)

PREMATURE OVARIAN FAILURE- vaginal dryness? Hot flashes, with loss or gain, urinary
frequency and incontinence with premature ovarian falure? Menopause in relatives was it
early?

NIPPLE DISCHARGE - can be protectinoma or early pregnancy !

Physical Exam Maneuvers

Check peripheral vision, NEURO in general and DTRS as neuro is involved!

Check thyroid

Pelvic exam (order as a diagnostic)

Breast fullness and or tenderness and any skin chang es of pregnancy? ==>
BREAST AND PELVIC EXAMS NEED TO BE DONE AFTERWARDS

Differentials
Pregnancy

PCOS/Diabetus

Prolactinoma

Hypothyroid and prolactin increase = Roughly 70% of women with secondary

amenorrhea and galactorrhea will have hyperprolactinemia.

Depression

Asherman Syndrome/ a la hx of multiple surgeries in the past!

Diagnostic Tests 2 Run

 UHCG

MRI scan of pituitary

Thyroid function tests aka TSH, electrolytes and CBC

Glucose Levels! ( concern for PCOS!)

FSH/LH and testosterone levels

Hysteroscopy for fibroids/polyps and washermen’s syndrome or to rid a baby lol!

..............................................................................

Case 16! - Pain During Sexy times of a 28 YO F! - Remember Sex is involved! Has had pain for few months and whitish D/C with a fishy odor
and no barrier contraceptive just OCPS, raped in college, but 10 yers since she has normal sex drive and feels safe at home so unlikely to be
vaginismus and denies hot flashes vaginal dryness and trouble sleeping /menopause like symptoms to rule out premature ovarian failure/
early menopause!
Questions 2 ASK -
Rule out STD and vaginal discharge (smelly?) sonny boi! that causes new onset pelvic pain on
sex as can fibroids and mental trauma vagismus

Period and sex Questions - LMP, any issues in past ( heavy bleeding ASK ABOUT NUMBER
OF TAMPONS, spotting between, pain in past?), date of start? History of irregular periods a la
PCOS! Was there always pain on sex or is this recent? Any abdominal pain outside of sex?
During periods?

ANY VAGINAL DISCHARGE? ODOR OR PRUITIS?

ASK of prior hx of STDs and what their sex drive also is!!

LAST PAP SMEAR and any hx in past of being irregular! and any OCPS and how much sex?
Do you practice safe sex? With whom and how frequently? Noticed any discharge outside of
sex? ==> CULD BE STD like cervicitis and or PID from unfaithful partner!


Mood and Psych History - any recent major life events? Any traumatic events?
Depression? Ask what her sex drive is and if she feels safe at home, as abuse may now
be on our mind!

Pregnancy History - ever been pregnant before ( GXPX?) and if so any complications of the
pregnancy ( eg botched C section ct)

Any issues with incontinence or constpiations ( checking or fibroids) and heavy bleeding during
periods??

Physical Exam Maneuvers

Abd, CV, pulm, leg STRs, minimal really

Differentials:
Endometriosis

STDs aka CERVICITIS ( as sex woithout Barrier method -> spread Ghonorrhea/Chlymida -
> causing cervicitis and fucking painful sex sonny boi

Bacterial Vaginitis aka Vulvovaginitis - fishy odor like clear/whitish discharge! and pruitis!
Fibroids/polyps
Vagismus

PID scarring from past ghonnrhea - also cause of infertility too!

Atrophic vaginitis - usually menopause somen but need to r/o -> ask about drones, and
lack of lubrication during sex! Also hot flashes, trouble sleeping

Diagnostic Tests 2 RUN:

Pelvic Exam, and transvaginal ultrasound to rule out masses!, Pregnancy Test, wet mount,
KOH/Whiff test, Ghonorrhea/Chlymida DNA test, HIV antibody test,Pap Smear if not in last 3
years!Hysteroscopy, Exploatory Laproatomy last case

..............................................................................

Case 17 Will be Nao Skipped a bit sonny pants!

...........................................................c...................

Case 18 - 5 DAY OLD kid

with Yellow skin and EYES
- fucking jaundice

Remember Kernicterus
is NOT what jaundice is!
Lol!

Questions 2 Ask


Vaccinations up to date?

Is child alert, awak, playful and active? Does he cry well +?

Eating, pooping, peeying/ breast milked? and number of diapers and poops? BELLY full?
ANY SEZURES/shaking, fevers? Any recent contacts with sick people? GBS during
birth?
ANY NOTICIBLE DRYNESS IN HIS MOUTH - important for dehydration!!!!!!!!!!!!!!!!!!!!!!!!
BIRTH HISTORY and trauma? HOW MANY WEEKS WAS HE DELIVERED AT?

Smoking/alcohol/drug usage during pregnancy?

How was he before the last few days?

Has it gotten worse? When did you first notice it?

HOW OFTEN ARE YOU FEEDING HIM ( EVERY 2-3 HOURS IS BEST!)

Started Breast Milk? IS HE SUCKING WELL? How is he being fed? What areas is it mostly
visible?
How is is weight doing?

Number of wet diapers and poops?

Is he feeding well? ( breast milk jaundice is totally a thank!) and is there vomitting?
Is his belly distended and full?
Any recent Upper Respiratory infection and or dry mouth or
shaking/seizures and fevers or breathing fast!!
Sometimes kids with poor UDP transferase => leads to more jaundice!

Nausea/Vomitting/Constipation/Diarrhea/Incontinence/Fevers/Headaches, CP and SOB?

Weight loss or gain?

Any joint pains? Fevers/ Cold like symptoms

Obvious PMH/Surgical history? FAMILY HX OF ISSUES WITH BIRTH JAUNDICE?

ASK ABOUT Groub B strep and or culture of bacteria during pregnancy? ANY DISEASES
herpes/ect during pregnancy?

Physical Exam - none as this is a phone call, ask patient to come in for CBC!

Differentials
- Physiologic Jaundice of Newborn
- Hemolytic Disease of the NewBorn ABO/RH incompatibilities as
mum and dad have different bloods (B+ and A+, and baby may
have hemolysis)!?- ASK ABOUT MUM’s RH and Blood type and
Dad’s (bad if mum’s second baby and her RH- and baby is also
RH- and FUFUFUFUCK!)
- Neonatal Sepsis - maternal infection hx of GBS! ( sepsis/
meningitis ect in neuborn!)
Diagnostic Tests - ask them to come in asap, call ambulance if needed!
Need to CBC/diff and CMP with liver function tests!
TOTAL And indirect bilirubin tests! ASAP as this is the deciding factor in needing to treat
baby with phototherapy or fucking not!
DIRECT COOMBS test for hemolysis asap!
CRP?

TORCH INFANTS: These

infants may exhibit other findings that
may help reach the correct diagnosis,
such as small size for gestational age,
rash, microcephaly, cataracts,
microphthalmia, and/or
hepatosplenomegaly. 



AKA POOR BREAST FEEDS -> JAUNDICE FUCK! ( but as this kid is feeding well likely fucking
physiologic jaundice and nbd!)

BREAST MILK JUANDICE IS LATE TERM ( and happens after the first week of life!)
BILIARY ATREISA is too soon for a 5 day old lol!

ONE LAST TIME FOR POSTERITY: Check indirect and direct bilirubin and also a
COOMBS test for infection and other causes of hemolysis babe!

CRP and CBC with diff to monitor for signs of infection!

Serology for CMV, toxoplasmosis, and rubella; RPR for syphilis; and urine culture for
CMV: In suspected intrauterine (TORCH) infections. 


..............................................................................

Case 19 GO GO GOPE MUM of 7MONTH Child for a Fever!

What 2 Ask -
Birth Hx/Trauma?

How have the past few months been?

When did it start? How high were fevers?

Vaccination history?

Any sick contacts? SIBLINGS OR DOES HE GO DO DAY CARE

Is he playing? Feeding well? Sleeping well? Peeing and pooping

well? ( how often eating, what food, and how often diapers in wet
and also pooping)

Is the inside of his mouth dry?

Does he have a runny noise and is he coughing? Eyes watery?

ANY LYMPH NODES??! DONT FORGET IT!
Any siezures? Constpiation/Diarrhea? Nausea/Vomitting?

 MPH of family/heriditary diseases?

How has his growth been otherwise? -> ANY ISSUE IN GROWTH
DELAYS?

N/V/C/D/I/ and also headache. fever, weight loss, and CP and SOB!
(LYMPH NODES) ONE MORE TIME!! Great for kids infections lol!

What medications did you give them? - hopefully not aspirin lol!

Bronchiolitis!!!!

Differentials
Viral Infection - fevers and kids are under warranty!

Ear Infection/AKA OTITIS MEDIA SONNY? - ask if they are pulling

their hair and or ears! AND IF THERE IS ANY FUCKING EAR
DISCHARGE LOL!
PNEUMONIA - considering kid has fucking cough, fever, rhinoshea
ect! can make case for pneumonia and need CXR to rule it out!
Bronchiolitis - ask about belly breathing and flaring of nostrils a la
asthma or more likely in his age group bronchiolotis!
Septic Infection

Things 2 HAVE to do on Physical Exam - none here

Diagnostic Procedures
CBC/Diff

Repiratory Viral Pannel too babes!

BLOOD CULTURES ( as potential sepsis equation and even meningitis
equation!) ==> ESPECUALLY IF THE FUCKER IS LETHARGIC AND
NOT MENTALLY WITH IT, that’s fooking important to know!
XRAY ro confirm no pneumonia!

Urinalysis? FOR FUCK WHAT?

Pneumonatic Insufulation too for dtaht ear infection!

Can even do LP and CT of the head down the line but NOT NOW man!!

..............................................................................

Case 20 - Eric Glenn a 26 Year Old Male with COUGH! LOOK FIRST
FOR DYSPNEA LOL!


Is it morning cough a la post infectious post nasal drip type cough!

Any recent infection/URI - could be most infectious cough

DO you have a sore throat? Rhinorrhea? Watery eyes or conjunctivitis?

Are you coughing up any Phlegm? if so any blood or what color?

Has it gotten worse? Duration? anything helps? ( eg antacids)

Night time only a la Asthma? Any hx of asthma?

What medications are you taking, hopefully not an ACE inhibitor lol!

Any recent sick contacts?

Pain with breathing? Location and quality of that pain!

DOES IT FEEL BETTER SLEEPING ON ONE SIDE VS ANOTHER - fuck

could be PNEUMONIA post viral infection (tot’s possible) and ask
about PPD!!!
Night sweats/Exposure to TB is involved when we’re dealing with cough
and if there is blood in the cough!

Any drugs alcohol tobacco? ( in older patient concern for GERD grows)

Physical Exam Manuevers - HEENT -, look inside mouth and ears, nose
and throat! Neck palpate for nodes/nodes - important with
promiscuityusity and you now need to keep HIV in your mind lol!

CV and Pulm - full exams!

Differentials
URI!

Asthma/Allergic

Pneumonia

GERD

Post Infectious Casue ( if morning time cough only after post nasal drip!)
and if its a chronic fucking cough lol!

Influenza if cough and then joint pains and stuff like that!

NOTE AS
PATIENT
IN PMH
talked
about

ghonorrhea in the past, consider looking more into SEX - with whom,
how often and consider teaching about safe sex! AS PATIENT has
frequent sex, get HIV TESTING

Diagnostic Tests
CXR! ensure no pneumonia, also septum G
stain and culture!!!!
CBC with diff and blood cultures

HIV antibody testing as HIV can have

innocuous results!
PPD as now TB is on the list just as HIV is
with promiscuisity! ( if need be at a later
time and if cough continues!!!)

PFTs with Methacholine chilling - Asthma check?

H.Pylori Testing

..............................................................................

Case 21 a 52 YO F comes to office complaining of yellow eyes and skin

for the past 2 fucking months with itchiness and pain that comes and
goes!! ( two months = NEEDS A FUCKING cancer rule out)

Questions 2 Ask!
IV drug abuse/or blood transfusion! history of Hep? Vaccinated at all? Any
recent vacation a la hepatitis A sonny pants ( though that never lasts 2
months!)?

Alcohol usage? CAGE questions! No to case but that’s a LOT of wine!

Any pain? Where? In right quadrant? - if painful right quadrant, bark up

ascending cholangitis and obstructive jaundice!

History of gallstones, biliary cholic or cholecystitis in the past?

When did the pain start? Frequency and radiation? Severity of the pain?

Any fevers? Nausea and Vomitting ( both expected!)

Any family hx of pancreatic cancer and any fevers/wieght loss? weakness

ALSO REMEMBER COLON CNACER LOVES TO MET to the fucking

liver, so colonoscopy is a RELEVENT QUESTIONING LINE!
CHANGE IN STOOL COLOR AND URINE! - remember that fucking
biliary issues casue change in stool color!

REMEMBER TYNENOL IS BAD FOR THE LIVER, have them stop

taking Tylenol and fucking stop drinkinging until more tests come
back!!!!

Physical Exam
Look into eyes, Neck nodes and shite, CV standard Abdomen full exam
including MURPHY sign you big DOLT!)

Examine extremities and look for edema in legs and ascites in the
stomach!. LOOK FOR JVD and hepatojugular reflex! (if + means
fucking heart disease),

Differentials:
EXTRAHEPATIC BILIARY OBSTRICTION IN GENERAL! : Obstructive
Jaundice with Choledocolithiasis/ascending cholangitis and Painless
Jaundice of Pancreatic Cancer ( too dark!?)

Viral Hepatitis - due to recent travel to mexico and jaundice and sclera
icterus and RUQ tenderness and history of blood transfusion ( could be
type B or something!)!

Alcoholic Fatty Liver Disease! - frequent clcoholic use and frequent

tynenol use at the same time!
Cirrosis/Liver Cancer- no weight loss. As liver would be tiny and also
would have FINDINGS OF FUCKING CIRRHOSIS - ascities, palmar
eretheyma, tangelesticas/spider veins! - THUS IN SUCH A PATIENT
CIRROSIS HAS BEEN RULED OUT YOU DOLT!

Diagnostic tests:

AST/ALT levels! - final and ALK phosphatase levels as that’s MUCH

more specific to a gallbladder/biliary tree obstruction pathology than
anything else loL!

Direct and Indirect bilirubin - final!

COOMBs test please!

Ultrasound of RUQ abdominal US!! and potentially ERCP to treat

AFTERWARDS, no point in ordering it NAO, ! - diagnostic AND
there’reutic and best case if ultrasound is no good! STONE is down
AFTER the gallbladder fuck fuck fuck!
CT scan if ERCP finds nothing ( though that would mean pancreatic
cancer NOT in head of pancreas but tails )!

..............................................................................

YOU NEED TO CHECK FOR ORGANOMEGALY IN THE ABDOMINAL EXAM AND RULE
OUT FUCKING CIRROSIS YOU BIG FUCKING PRICK! same with ascites and fucking skin
for spider nevi/tanglesticas and palmar erethma!

……………………………………………

Case 22 - Dizzies, at 53 YO - ALWASY check orthostatic for dizziness

and syncope episodes as well as now EYES, muscles and
nyastagmus, and PEERLA! ( cranial nerves as head involve!)

How long have you been dizzy for? What exactly do you mean? Light
headed? Does the room spin? Any hearing loss? Any tinnitus? DOES
THE ROOM SPIN SUDDENLY WHEN YOU MOVE YoUR HEAD!?

When did these episodes happen? On a hot day, getting fucking shot or at
heightened emotional moment?

Which ears have hearing loss? Any fullness/pressure or discharge

( can be infection causing dizzyness and fucking hearing loss lol)

Any history of episodes before?

Had any falls or history of falls in last few days?? any loss of
consciousness? Hx of seizures in past? Any issues with vision?

Any headaches, nausea of vomitting?

ANY DIARRHEA? — WHHAATA? ?

Physical exam findings- BPPV NEEDDS NYSTAGMUS CHECK SON!

and do a full fundoycopic exam of the eye for papliedema as in
diabetic patients lol! inspect ears with otoscope and externally, cerebellar
function testing, nose to finger tip test! and DTRs, Test facial nerves and
vision ( H in space!) too as brain tumor is ON the mix! Check cognition too
( Person/place/time?!)

AS BALANCE MAY BE AN ISSUE, NEED TO SEE PATIENT’s full gait so

have patient walk!
Make-sure you do a Rime and Webber test!
Epley/dixhall pike maneuver to check for nystagmus!! Maneuver

Differentials: Meninere’s Disease ( dizziness but also with hearing loss

you fuck!) , BPPV ( lasts for 20-30 minutes? and has NO hearing loss
unlike this patient !), otosclerosis, acoustic neuroma, Brain Tumor!

OH AND THE ONE YOU MISSED - dehydration hypotension! - Risk

increased from diarrhea ( diarrhea not just recent illness, but an actual
cause of dehydration and electrolyte abnormalities

Diagnostic 2 DO list -! CT scan with contrast!,MRI, tympanometry, CBC/

diff, and the DIX hall pike Manuver to rule out BPPV, Meininere’s disease is
a diagnosis of elusion and rule out the fucking cancer too!

And as with recent hx of diarrhea, get electrolytes too sonny boi!

..............................................................................

Case 23- 33yo F with Left Knee Pain

Questions 2 Ask:
When start, how much does it hurt? Is it only one knee. Did pain maigrate?

Any hx of gout or pseudogout in past? ( PSEUDOGOUT IN older adults)

Any fevers?

Any recent falls?

Alleviating factors, radiation? Severity and location of pain. When did it

start?

Any history of STDS/Ghonorrhea? => sex life, unprotected sex, possible

partners unfaithful.

Any recent infections viral or otherwise!

Septic arthritis - prior joint damage or IV drug usage or recent oral

surgery?

ANY RASHES and photosensitivity? and hx of abortions - FUCKING

LUPUS?? IS OON THE FUCKKING DOCKET!
History of tick bites, never forget limes either!!

Any other symptoms ->>> apparently other joint pain you fuck face
and wrists and fingers painful and stiff and now morning stiffness for
an hour!

=> RHEUMATOID ARTHRITIS is now a differential!

ARE YOU ABLE TO WALK ON THE KNEE!> CRUCIAL POINT and check
gait if possible!

DO NOT REPEAT PAINFUL MAUNEVRS AND EXPALIN ALL

MANUEVERS TO TEH FOOKING PATIENT!!

Differentials: Septic Arthritis, Gout/Pseudogout/ Ghonorrhea Arthritis

Diagnostic Procedure- Joint aspiration, CBC with DIff and blood cultures,
MRI of the left knee, ( probably XRAY only!)

..............................................................................

Take aways: Gout is usually monoarticular, and this patient has both
monoarticular knee swelling and pain
ALSOCHOL NEEDS TO BE ASKED ABOUT GOUT SUSPICION!
AND also RA like bilateral morning stiffness and hand joint
symmetrical bilateral inflammation and pain!

RA also has systemic symptoms of low fevers, anorexia/wieght loss

and fucking joint tenderness and stiffness

FOR JOINT PAIN, need to rule out fucking SLE (rash, photosensitivity, hx
of abortions lol)

And also rule out LYME’s disease!

TESTS 2 ORDER

Joint aspiration of knee with G stain and culture,/Blood cultures

XrAY both left knee and the hands ( helps confirm RA!) that’s going on
concurently!

CBC/Diff

Anti DNA antibodies for SLE and ANTI neutrophil antibodies too!
RF and Anti CPP antibodies for RA

Counsel patient on safe sex as it was found she had Ghonorrhe in the
past and still does NOT use protection or barrier entry!

PELVIC exam needed again? WHYYY? - to rule out

decimated honorrhea that’s fucking why!!!

..............................................................................

• CASE 24 - HEEL PAIN! 31 yo MAle with Heel pain!

Questions 2 Ask
Physical Exam Have toos: GAIT, leg test, pulses of the legs, and full
movement of the ankle joint.

Any recent trauma/excertion to the area?

Social - what is your job? How often a day do you walk?

Any fevers? Or other symptoms?

Does the pain relief with rest? and worsens with use?

Does pain radiate? Is pain only in ONE LOCATION or does it radiate

and is it sharp and pinpoint or the entire lower heel?
any fevers>

What medications are you taking? Do you run a lot on these legs?

Ensure [PMH asks about past joint/rheumatologic issues a la RA

On Physical Exam - heel pain, so check nerves as it may be

neuropathic withs esation/achiles reflex, bone pain with fucking
fracture OR fckung
ankle joint motor strength snd movement

Babinsky as you might as well!

GAIT TEST! —> WNL GAIT,

Gait test? YEP

Differentials

Plantar Facitis - rest and new Dr.Sholl’s rest!

Stress Fracture - show up on LEG xRAY or a MRI!

Achilies Tendonitis - would show pain above Achilles tendon and the
reflex would be fucked up!

DiagnosBonescan to rule out a stress fracture or MRI

CBC and DIFF

Plantar Facitis - pain worst first few steps out of bed and WORSE in
morning and radiates to the arch of the foot, no radiation, and rest and
ice seems to help a bit!

Walking barefoot makes pain much worse!

Pain is intermittent and 2 weeks long!

Achilies Tenditinitis - is another good differential -> training for a marathon

babe! That should be enuff! and pain with toe dorsiflexion, which needs
to stress the awhiles tendon!

The pain with dorsiflexion is ALSO seen in the fucking Plantar

Facitis RUMP
..............................................................................

..............................................................................

25- Mum of 18month old child has a fever?

Cough or shortness of breath>?

What to ask: how long has she had teh fever, gotten worse? When was
last doctor’s visit? Birth history? Vaccinations? - mumps and rubella will
fuck you over!
Has she been playing normally? Lethargic? oFussy or normally playful?

Any sick contacts? At home? AT daycare if she goes? Any siblings

recently sick or anyone else at home?

Any ear discharge, pulling at ears? Any crying when peeing? Has her
number of wet diapers gone down? Any constpiation/ or bloody stools?
Vomiting?

How much is she eating? and what is she eating POOPINg, PEEING? I
AND O veryimpoatnt in a small child!
Inside of her mouth look dry? Does she complain of a sore throat or a
strawberry red tongue or a sandpaper like rash?

Any rhinorrhea?

WHat’s ger PMH like? any diseases ect? Allergies?

What medications have you given her?

Any siezures ?
ANY LYMPH NODES!
ANY RSHES!
Stuff to do on physical exam: look into mouth, pharynx, ears (TMs),
discharge or not, and look for conjunctival pallor and conjuncitivitus. Look
into nose for rainorrhea.

Differentials……………………………………………………………………
Acute otitis media - pulling at ears, and recent hx of URI and cold, with
fever and pulling at ear and not playful as usual!

Scarlet fever withs ore throat, and maculopapular rash and hopefully
scarlet tongue,

UTI - why not! If back pain and costobertebral angle tenderness maybe
even consider pyelo as an option!

URI, Pneumonia UNLIKELY TO BE FUKCING RIBELLA as vaccinations

are up to date! == all equally unlikely as no pain on urination or lack of
diapers/

AND DONT FORGET MENINGITIS - kid was not playing well, and fever
and issues sleeping and had a maculopapular facial rash — consider
meningococcal meningitis !

Diagnostic Procedures -

THROAT CULTURE!

CBC and Blood cultures, (FOOKIN MENINGITIS) UA and urine culture

UA, Respiratory Viral pannel,

WBC with DIFF, Pneumonatic insufflation of tympanic membrane

..............................................................................

IN TEH REAL CASE: Kid pulling ears, double swallowing and had URI last
week. ==> and a rash on the face and chest!? Rash started on face and
spread to her belly a la mumps measles and rubella and also scarlet fever!

SCARLET FEVER< OTITIS MEDIA AND FUCKING MENINGITIS WERE

CHOSEN BY THE BOOK!
..............................................................................

Pearls : URI recently is a important precursor to getting a Otitis media.

ESPECIALLY if they are pulling at their ears ( no discharge or not!)

(cough and runny nose = indications of a URI = makes otitis media

more likely, as currently no cough, runny nose ect, just ear pulling

Can’t rule out meningitis! A SCARLET fever rash can also be fucking
meningococcal type rash and be careful as the also has fevers and a
change in the lethargy of the kid!

ANd for meningitis blood cultures are good, better answer would be LP
and CSF analysis!

Throat culture for Scarlet fever and septum analysis culture but no cough
so no pneumonia risk

Pneumatic insufflation for the acute otitis media bullshite lol!

..............................................................................

Case 26! - Remember! - for a Chronic cough case, shortness of breath is

big fucking easy win right there! Cough => amount of spetum, when you
get the cough, smoker or not, pack years,

TB and Lunch cancer are on the card as can simple URI and fucking
Pneumoni aalso be included! As can GERD and fucking post URI cough
too!


But blood tinged = TB ( with prior exposure as in nursing home working

or jail or fucking IV drub abuser), and also has night sweates, fevers and
anorexia/weight loss unintentionally!

LUNG CANCER ALSO HAS SAME PROPERTIES As fucking TB so can't

exclude that especially with patient’s extensive smoking history haha!

And ofcourse typical pneumonia too lol! Just fucking increased

septum production of whitish and sometimes blood tinged septum
and fucking need need to do a septum culture rehardess!

PNEUMONIA has abrupt onset fevers, chest pain, chills and

pleuritic chets pain and dyspnea and increased tactile fremitus
on PHYSICAL EXAM

Diagnostic Tests: CXR PA and lateral both! and Septum culture and
also PFTs and also fucking counsel patient on sitting smoking and
stay off smoking lol! and for TB a PPD test! CBCt and blood cultures
too

Eventually CT of the chest to fully rule out cancer and even

bronchospcoy for a direct TB sample if need be!
……………………………………………………………………

..............................................................................
Case 27 - 61 YO Male p/w fatigue for past 6 months and loss of interest,
sleep and energegy and concentration. It’s affecting day to day life. He
also reports past 4 months of GI discomfort, epigastric pain that radiates
to the back. Does not get better with food or by not having food. Denies
any bloody diarrhea.

FM hx of breast cancer, past surgical hx of appendectomy at 16 and Mood

is depressed! Drinks 2x bees daily and several on weekend ( CAGE!).

Questions to ask - about hs hypothyroism and also about mood,

alcoholism ect and past hx of pancreatitis?and hx of smoking and alcohol
usage increases risk of gastric cancers!


LAST colonoscopY??

Has he had nausea and vomitting? No C/P, no CP.SOB. no fevers, or

headaches and no nodes?

Physical Exam Must Haves:

Differentials: Rule Out gastric and colon Cancer, pancreatitis cancer,

hypothyroidism AND APPARENTLY PEPTIC ULCER DIEASEAS with the
weight loss and pain radiation to back and unless it fully reptured,
would not get bloody stool or maybe get occult bloody stool

Diagnostic Procedures - CT scan of abdomen for pancreatic cancer as

PAIN radiates to back and has been there for fucking MONTHS and
fucking pancreatitis lol!!!, rectal exam ( occult stool), ask about last
colonoscopy ( unneeded if no rectal bleeding)!, lipase and amylase, and
also upper endoscopy? , TSH levels, and HEMOCCCULt stop

Remember that pancreatic cancer does not just have to be painless

jaundice and may be tail pancreatic cancer with weight loss, fatigue
and pain that radiates to back, THOUGH ALL OF THEESE THINGS
CAN ALSO BE CHRNIC PANCRATITIS!!! due to extensive hx of fucking
alcoholism!


And never discount depression lol!

SMOKING and alcoholism both contribute to pancreatic cancer, though

smoking wins out in such a case!

……………………………………………………………………

Also a maniftestion of fucking DEAK issues withc eliac disease in a middle

aged woman with weight loss and diarrhea and no blood an just all-round
mailiase! (……………………………………………………………………

FUCK YOU, may have a duodenal ulcer -> weight loss but this patient
denies any relief in relation to food, that key factor that precludes a
diagnosis of peptic ulcer diease!

Hypothyroids is another one but without any thyroid issues and no other
supporting issues a la fucking constpiation, cold intolerance, and dry skin
does not seem likely! Just fatigue may be initial sign so a TSH test is
OKAY to perform!)

WHEN GI PAIN and talking about pooping, always do a rectal exam and
na occult stool test!

..............................................................................

CASE 28 - HTN follow up! - IMPOTANCE MEASN NEURO IS FUCING

INVOLVED and HTN means carotids, and fuking heart exam and
extremities pulses involved due to CAD risks and PAD risk too!
Ask about SEX DRIVE, morning erections, relationship with partner, and also ask about
fucking alcohol usage as that may also hinder an erectioN!


Basically here in HTN, you need two protocols -> Heart disease pathway includes
HTN, HLD, and Diabetes questions, questions on diet and excerice and ANGINA/PAD/
CAD and also check carotids, and extremities pulses ( PAD)

As impotence also check thyroid! and Cirrhosis is a possibility with HEAVY alcohol
usage but liver would be TINY and they would have palmar erethema, spider
veins, and hair loss and impotance!

IMPOTENCE can be of PAD variety and neural variety just as much it can be from
drug induce impotence! and needs to have a neuro pathway too! -> eg babinski reflex
and fucking DTRS and also extremities

Finally the impotence may just be good old hypogonadism of aging ( seen here maybe
due to this guys old age, and also receding hair line ect!)

Depression can also casue it but this dude’s mood is FINE!

ENSURE YOU INCLUDE SOCIAL HX in THE fucking HPI!

Diagnostic Tests - CBC with diff, TSH ( thyroid can’t be ruled out!), FSH/LH and
testosterone levels, and a gential exam work up and hell even prostate exam aka
rectal! ( this is also a casue for erectile dysfunction loL!)

Finally remember that this was originally a HTN case, tell

patient that their BP is good, but could be better and
lowered and to eat a healthier diet and exercise for
atleast 20 minutes 3x a week!

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Case 29 - 20 YO F with insomnia -> consider anxiety, GAD, panic attacks
depression, thyroid issues and poor sleep hygiene!

She drinks coffee all the time, has unintentional weight loss, increased BM
( thyroid), palpitations and sweating ( CHECK FOR TREMORS FOR A
THYROID EXAM), has a tachycardia, and feels sleepy during day and
irritable and only gets 4 hours of sleep after sleeping at 2:00-6:00 after
going to bed at night at 12:00 each day

Loop in thyroid physical exam: tremors, palpitations and sweating. as well

as Grave’s otholoapathy is needed. Check for thin skin, and ask about heat
intolerance!

Important point to learn: ANXIETY IS TOTALLY A DIAGNOSIS :)

So she had diagnosis of anxiety potentially hypothyroidism and also

fucking sleep hygiene insomnia !

( TV before bed, sleeping really late and

several cups of caffeine = should all do it!)
( and bonus palpitations with coffee seen)!

Work Up: CBC Diff, TSH and T4 and also

fucking sleep study for potential OSA!
Other types of insomnia to consider - insomnia due to adjustment disorder
or insomnia due to depression ( this patient had hx of depression but has a
currently happy mood!)

Sleep Study, TSH and T4/T3 levels are all helpful as is an CBC test!
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Case 30 - Phone call with mum with 2 yo kid with strange fucking
rbetahing!

Differentials include fucking CROUP, foreign body aspriation and ofcoruse

epiglottis and bronchiolitis ( SOB, or using belly muscles to breathe?!)

Ask as a baby, follow the baby protocol: last doc visit, birth history(vaginal
or C section!), growth and development? Any issues so far or major
hospitalizations? Are all his vaccinations up to date?

What was he doing when the weird nosies of breathing started? Can you
think of anything that it may be?

Is there a barking cough? Any drooling or cyanosis !

Are the noises on inspiration ( a la croup and aspiration and
epiglotitis) or expiration a la bronchiolitis( is he using belly muscles to
fucking bretahe!!)

Is he at home most time? or at day care? Any sick contacts around him?
Any fevers? any coughing? Any productive cough

RULE OUT CATASTROPHIC EPIGLOTITIS - Full vaccinations? Finger tips

and or face blue? Trouble breathing for him? —> ED IMMEDIATELY!
Eating? What and how often?
Sleeping?
Playing - lethargic or not?

PMH, PSH, FH? and SOcial Hx - just growth and development and at
home or not and diet and pooping number of diapers hx with mum!


Finalized Differentials include ==>

CROUP
Foreign Body Aspiration
Epiglotitis - not likely but still keep it. Need to fo a XRAY to rule it out even
if no cyanosis or fucking drooling seen as per epiglottis!

REMEMBER TO ILICIT IF It’s just noisy breathing or the baby is

BREATHING FAST and having difficulty a la CROUP or even an aspiration
or bronchilitis! infection

Epiglotitis - hoarseness of breath,

drooling, cyanosis of the hands and
feet. REMEMBER TO FUCKING RULE
THIS OUT but still can be on
differentiall!

Oh and rule out anaphylaxis as reason for SOB (that does not have
stridor just muffled breathing!)
Diagnostic Procedures-

CHEST XRAY works ( PA and lateral) and XRAY of the neck AP and PA
lateral!) , CBC with DIff and RSV antigen and also bronchoscopy ( as not
issues with larynx rather with the breathing nd so bronchoscopy is more
approriate), laryngysocopy is for visualizing the vocal cords!
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..............................................................................
Case 31 GOPE! HEUEHUE! - 20yo F with Abd pain, LMP 5 weeks ago,
and frequency is every 4 weeks with 7 days, this time today was supposed
to be the next one lol, brown spotting on her period now and unpretected
sex ( STD 6 Months prior!, no condoms on OCPS), and now with RLQ pain
and loose stool this morning, nausea, vomitting slight fever and fucking no
blood in stool. Already has one kid, and needs to be counseled on safer
sex ( condoms) and also

As ectopic is on the platter, ask about prior hx of abortions and or

miscarriages!

APPENDICITIS is on your differential but pain never migrated or

radiated.

CHECK PSOAS SIGN ( lift leg, and obturator sign, flex knee and
internally rotate at hip to really screw in some pain), and see if
pain at Mc.Burney’s Point, check for abdominal guarding, fever and
all that shite!

+ Had nausea and vomitting as well!

PID in general - had hx of 6Months ago STD! RING RING RING That is
fucking NOOOOT GOOD at all loL! and now having lower abdominal pelvic
pain characteristic of fucking PID!

Ectopic Pregnancy - this was week of period, had brown spotting and
fucking abdominal pain, fever and RLQ pain! 6 Pack years of smoking -
Counsel on that - to quit. Counsel on safer sex practices.

THIS ALSO WILL HAVE spotting and rebound tenderness so hooray!

Patient Counseling and Shite!

HIV test? Ask her permission to do one! ( As lots of partners in last 1 year),
and also also test for STDS via vaginal swab if needed!

CBC with DIFF to check for anemia

Urine BHCG

ABD CT Scan, pelvic CT scan

Cervcial Cultures - PID is on the line and past hx of STDS!

US of the abdomen and pelvic
Pelvic Exam and Rectal Exam as well fucking bitch!

Reptured Ovarian Cyst! is also on the fucking LIST!

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