Routine & Advanced Techniques HEENT
Head Inspect head for size and
shape
Inspect facial structure-
expression, nasolabial folds
Palpation Palpate bony structures of the
skull, face and jaw-
Tempromandibular joint
(TMJ)
Palpate temporal arteries
CN V (trigeminal) Assess sensory and motor
(light touch 3 branches and
strength masseter and
temporal muscles with teeth
clenched)
CN VII (Facial) Assess motor
Raise eyebrows, squeeze eyes
shut, wrinkle forehead, frown,
smile show teeth, puff out
cheeks
Eyes
Eyes Inspect external ocular
structures
Eyebrows, eyelashes, eyelid,
palpebral fissures
Conjunctiva
Sclera
Cornea
CNIII (Oculomotor) Inspect pupils
Direct and consensual light
reflex
Shape
Size
Accommodation
CN III (Oculomotor), IV Assess Extraoccular muscle
(Trochlear), VI (EOM)movement with 6
(Abducens) Cardinal Fields of gaze
CNII (Optic) Test Visual Acuity (functional
vision)-Snellen or Rosenbaum
chart and peripheral vision
(Confrontation test)
Inspection of intraocular
structures with
Opthalmoscope
Visualize Red Reflex, retinal
vessels, optic disc, retinal
background
Ears
CN VIII (Acoustic) Inspect external ears-shape,
symmetry, lesions
Assess functional hearing
Whisper Test
Palpate the external ear and
mastoid area
Inspect internal ear
structures with Otoscope
External ear canal
Tympanic membrane
Normal
Normocephalic, symmetric skull,
proportional to rest of body
Symmetric features, calm expression
No tenderness on palpation, smooth
and even movement of TMJ
Smooth and non-tender to palpation
Sensation present in 3 branches of CNV,
masseter and temporal muscles strong,
no fasciculation
Symmetric facial movements
Skin intact, lashes evenly distributed,
brows even and symmetric, palpebral
fissures symmetric, no drainage or
discharge,
Conjunctiva pink, sclera white
Cornea clear and transparent
PERRLA-pupils equal, round, reactive
to light and accommodation
Movement is smooth and symmetrical
Vision reported at 20/20 bilaterally,
peripheral vision is equal to examiner
Red reflex present, vessels non-
tortuous, clearly visible, uniformly
decreasing in size as they branch to
periphery, optic disc margins sharp
and distinct creamy yellow-light pink in
color, uniform color of retina, no
nicking or hemorrhages
Ears equal bilaterally, symmetrical top
of pinna aligned with outer canthus of
eye, no lesions
Hearing intact
No lumps, masses or tenderness
External canal may or may not have
cerumen present, no drainage, no
edema or erythema
TM pearly gray, translucent, cone of
Common Abnormal
Microcephaly
Coarse facial hair (in women),
asymmetry, edema, abnormal facial
movements
Tender to palpation
Creptius of TMJ, pain with TMJ
movement, limited movement, clicks
or catches of TMJ
Tenderness to palpation, edema or
hardness of arteries
Sensation not identified in any of the
3 branches, fasciculation noted
Dropping of facial features or lack of
movement
Exopthalmous, Ptosis, lid lag,
flakiness of lashes, loss of hair,
incomplete closure of the eyelid,
drainage or discharge
Red conjunctiva
Yellow sclera (icteric)
Cloudy cornea, white opaque ring on
cornea
Unequal pupils, nonreactive to light
Nystagmus with lateral gaze
Hesitancy, squinting, peripheral
vision unequal to examiner
Red Reflex decreased or irregular,
dark shadows-cataracts, blurred
disc margins, papilledema, irregular
disc size between the two eyes,
hyperemic disc, tortuous vessels,
localized pale fundus, hemorrhages,
Smaller or larger in size, misaligned,
low set ears, lesions present
Does not repeat whispered
words,hearing loss, garbled speech
Masses palpated, tenderness to
palpation
Edema, erythema, discharge,
cerumen impaction, TM cloudy,
erythematous, bulging, retracted,
perforated, foreign body present
 light visualized at 5 or 7
Nose
Nose Inspect nose Skin smooth and intact, symmetric and
midline, nostrils symmetric, no
drainage, no lesions
Palpate nose Nose non-tender, no masses
Test for patency of nares Nares patent bilaterally
Inspect internal nasal cavity Nasal septum midline, turbinates deep
with Otoscope pink in color, mucosa smooth with no
Nasal mucosa crusting or drainage
Turbinates
Nasal septum
Palpate paranasal sinus Non-tender
Mouth
Mouth Inspect lips Lips moist, pink, smooth and
Teeth and gums symmetric
Tongue Teeth in good repair, white in color,
Buccal mucosa aligned, no caries or broken teeth
Tongue- pink, moist with ruggae
surface, symmetric and glistening.
Buccal mucosa-smooth, pink, intact, no
lesions, slight odor to breath
CN X (Vagus) Inspect the palate, uvula, Hard palate-smooth, pale and
CN IX posterior pharynx, tonsils immovable
(Glossopharyngeal) Soft palate-smooth and pink
Uvula midline-rises symmetrically with
“ahh” (CN X)
**Test gag reflex (CNIX)-will not be
doing in lab
Posterior wall of pharynx-pink and
smooth, tonsils may be absent or
present (grade if present)
CN XII (Hypoglossal) Assess movement of tongue Movement smooth and symmetrical
from side to side
Neck Inspect neck Neck centered, trachea midline, no
visible masses
Palpate neck-lymph nodes Lymph nodes may be palpable and if so
should be soft, mobile, non-tender and
equal bilaterally
May not be palpable
Palpate trachea Midline and non-tender
Palpate the Thyroid gland for May not be palpable, should move
enlargement, masses or freely with swallowing, non-tender
tenderness
Lesions, erythema, asymmetry of
nose, discharge present
Tenderness to palpation, masses
palpated
Narrowed nares passageway
Nasal septum deviated, mucosa
erythematous, pale, cobblestone in
appearance, discharge present,
crusting
Tenderness to palpation
Lips cracked, dry, asymmetric
Teeth with poor dentition, cracked
or discolored, maligned, caries
present
Tongue-smooth, dry, asymmetrical,
edematous, atrophy, hairy
appearance
Ulcers of buccal mucosa, white
patches, dry mucosa, acetone breath
odor
Nodules on the palate
Uvula deviation, split uvula
Exudate or mucoid film posterior
pharynx, erythema
Edematous erythematous tonsils
with or without exudate
Gag reflex absent
Asymmetrical movement
Mass visible, goiter, visibly enlarged
lymph nodes trachea visually
deviated, tics or tremors present
Enlarged, tender, firm nodes
Tender to palpation, deviated
Enlarged, nodule palpated, tender to
palpation, bruit on auscultation of
enlarged thyroid
 Palpate muscle strength in Muscles smooth and non-tender, Tenderness to palpation, unilateral
both sternocleidomastoid strength equal bilaterally or bilateral muscle weakness,
(SCM) and trapezius muscles muscle spasms, edema

Routine & Advanced Techniques

Normal Common Abnormal
Respiratory
Apprehension, restlessness, nasal
General Appearance,
Relaxed appearance and posture, flaring, intercostal retractions,
Inspection posture and breathing
breathing effortless accessory muscle use, “tripod
effort
position”,
Rate 12-20 breaths/min, smooth Respiratory rate less than 12 and
Respirations-rate, pattern
effort, even respiratory depth, rise greater than 20 bpm, retractions,
and chest expansion
and fall symmetrical frequent sighing

Inspect nails, lips and skin Nail beds pink, skin tone consistent
Cyanosis or pallor
color with ethnic background, lips pink

Ribs slope approx. 45dgrees, thorax Asymmetry

Inspect the posterior thorax
symmetric Barrel chest
for shape & symmetry
AP:transverse diameter 1:2

Palpate posterior thorax

Palpation wall for masses, bulges or No masses, bulges or tenderness Mass palpated, tender to palpation
tenderness
Palpate for thorax
Expansion symmetrical bilaterally Unequal chest expansion
expansion
Palpate posterior thorax
Unequal vibrations felt on side to
for tactile fremitus-“ninety- Vibrations felt equally bilaterally
side comparison, Absent vibrations
nine”
Percuss (Greek key pattern)
Percussion posterior and lateral Resonance heard throughout Hyperresonance, flat or dull tones
thorax for tone
Percuss posterior thorax
Excursion should be equal
for diagphragmatic Decreased excursion
bilaterally
excursion
Auscultation of posterior Adventitious sounds-wheezes,
Auscultation Clear sounds bilaterally
and lateral thorax crackles, rhonchi
Auscultation of anterior
Adventitious sounds-wheezes,
thorax (will not be doing as Clear sounds bilaterally
crackles, rhonchi
part of the lab)
Auscultation of voice
sounds
Egophony-eee tones muffled
Egophony-“eeee” Eee tone changes to an aaaa tone
Bronchophony-sounds muffled
Bronchophony-“Ninety- Clear sounds
Whispered Pectoriloquy-whispered
Nine” or “1-2-3” Loud and clear
sounds are muffled
Whispered Pectoriloquy-“1-
2-3”
Abdomen exam sequence

Have patient lying flat, bladder empty.

Drape abdomen for exam to allow for privacy.

Inspect abdomen (rounded or flat, non-distended) Identify location of liver, spleen,

gallbladder, appendix, ascending, transverse and descending colon and bladder.

Auscultation of bowel sounds in all 4 quadrants (bowel sounds present in all quadrants)

Auscultate aorta, renal arteries with bell (no bruit noted)

Percuss abdomen in all 4 quadrants (describe as tympanic or dull over organs)

Percuss liver margin at right MCL (liver border below ribs at MCL)

Percuss liver size (estimate liver span Right MCL)

Percuss Spleen Left MAL 10th ICS (dullness over spleen)

Percuss for CVA tenderness

Light Palpation of abdomen- palpate all 4 quadrants (abdomen soft, non-tender, no mass,
guarding or rigidity)

Deep Palpation Abdomen- liver, spleen and kidneys (liver border palpable, spleen not
palpable, kidneys not palpable. No tenderness, no masses)

Palpate aorta pulse (aorta palpable, smooth, approx. 2.5 cm in size slightly left of midline)
Head
Found
 Gag reflex intact
 Palpated jaw: no clicks, full ROM
 Palpated scalp: no masses, normal hair distribution
 Right temporal artery: no bruit
 Left temporal artery: no bruit
 Head is normocephalic, atraumatic
 Scattered pustules on face and facial hair on upper lip
Ears
Found
 Right TM intact and pearly gray, positive light reflex
 Left TM intact and pearly gray, positive light reflex
 Rinne test on left side: normal
 Rinne test on right side: normal
 Whispered words heard on right
Missed
 Weber test: normal
 Whispered words heard on left
Neck
Found
 Oral mucosa moist without ulcerations or lesions, uvula midline
 No supraclavicular lymphadenopathy
 No axillary lymphadenopathy
 Right carotid artery: no bruit
 Left carotid artery: no bruit
 Left carotid pulse: 2+, no thrill
 Thyroid smooth without nodules, no goiter
Missed
 Right carotid pulse: 2+, no thrill
 Acanthosis nigricans noted on neck
Nose
Found
 Nasal mucosa moist and pink, septum midline on right
 Nasal mucosa moist and pink, septum midline on left
 No maxillary sinus tenderness
 No frontal sinus tenderness
Eyes
Found
 Vision 20/40 right eye
 Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema
 Right eye pupils equal, round, reactive to light
 Vision 20/20 left eye
 Left eye pupils equal, round, reactive to light
 Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema
 Left fundus with sharp disc margins, no hemorrhages
 Mild retinopathic changes on right
 Upper eyelids: conjunctiva moist, pink, no lesions, white sclera
 Lower eyelids: conjunctiva moist, pink, no lesions, white sclera
 EOMs intact bilaterally
 Normal convergence, no nystagmus

Interview
Found
 Asked about corrective lenses
 Asked about swollen lymph nodes
 Asked about problems with nose
 Asked about mouth/throat problems
 Asked about problems hearing
 Asked about eye problems
 Asked about ear problems
  Asked about blurry vision
 Asked about recent changes in vision
 Asked about thyroid problems
 Asked about change in hearing
Missed
 Asked about current headache
Documenting HEENT:
Ears
ears bilaterally symmetrical top of pinna aligned with outer canthus of eye, no lesions no lumps , masess or tenderness, external canal has no
cerumen present, no drainage, no edema or erythema, pearly grey, translucent, positive light reflex hearing intact, whispered words bilaterally
Rhine AC>BC Weber midline
Model Note: Normal canals, pearly grey, positive light reflex. Whispered words heard bilaterally. Rinne AC>BC. Weber midline.
Head
Head is normocephalic, atraumatic, symmetrical facial structure and facial movements, calm expression scalp had normal hair distribution, with
no masses upon palpatation coarse scattered hair on upper lip and chin scattered comodones and pustules along chin and cheeks movement of
TMJ temporal areas smooth and non-tender to palpation Gag reflex intact "Headaches when studying"
Model Note: Normocephalic, atraumatic. Normal hair distribution. Coarse, scattered hair on upper lip and chin. Scattered comodones and
pustules.
Eyes
skin intact, lashes evenly distributed, brows even and symmetric, palpebral fissures symmetric no drainage or discharge conjunctiva pink, scelra
white, cornea clear and transparent no ptosis or edema PERRLA, no nystagmus EOMs intact bilaterally red reflex present, vessels non-tourtuous,
clearly visible, uniformity decreasing in size as they branch to periphery, optic disc margins sharp and distinct creamy yellow-light pink in color,
no nicking cotton wool patches noted in right eye with fundal exam left fundus with sharp disc margins, no hemorrhages mild retinopathic
changes on the right Snellen vision exam: 20/20 vision in left eye, decrease vision in right eye 20/40 Peripheral vision -fields intact by
confrontation "vision has decreased past few years"
Model Note: Equal hair distribution on lashes and eyebrows, lids without lesions. No ptosis or edema. PERRLA, no nystagmus. Sclera white,
conjunctive pink and moist without discharge. EOM's intact, Snellen vision exam: right 20/40, left 20/20. Cotton wool patches noted in right eye
with fundal exam. Left fundal exam disc margins sharp. Peripheral vision - fields intact by confrontation.
General
Patient A&O x3 no s/s of distress, obese, pleasant, calm and cooperative, appropriate to situation
Model Note: Obese, pleasant, no acute distress, clean, dressed appropriate for age.
Mouth
oral mucosa moist , pink , smooth, intact, no lesions, uvula midline, no dental caries TMJ with no audible clicking, joint smooth movement
Model Note: Oral mucosa moist without ulcerations or lesions, uvula midline. No dental caries. TMJ with no audible clicking, joint movement
smooth.
Neck
neck centered, Trachea midline no visible masses, no lymphadenopathy, non tender to palpation thyroid smooth with out nodules, no goiter
Model Note: Acanthosis nigricans noted on neck. Trachea midline. No lymphadenopathy, neck supple, thyroid smooth without nodules, no goiter.
Nose
Nasal mucosa moist, pink, smooth and intact, septum symmetric and midline, nostrils symmetric, no drainage, no lesions no maxillary sinus
tenderness, no frontal sinus tenderness "problems with nose when around cats"
Model Note: Nasal mucosa moist and pink, septum midline. No sinus tenderness.
 DOCUMENTATION EXERCISE PART 1
Subjective:
CC: Sore Throat, Runny Nose, And Nasal Congestion
ID Insurance Co:
S.Q. 33year-old-female United Healthcare
HPI:
S.Q. is a 33-year-old female who presents to the clinic on 9/26/13 with 6 days of a sore throat accompanied by a runny
nose and nasal congestion. The symptoms started 6 days ago and have gotten progressively worse. In that time she has
noted, “thick, yellow-green nasal drainage, that runs down the back of her throat”, along with pressure in cheeks and
forehead, with pain 6/10. She has also c/o a headache with pain 6/10, as well as pain in the ears and “ears feeling full”
and a mild non-productive cough. Hurts worse in the head and cheeks when she leans forward, and talking and eating
make throat sorer. Tried OTC PSE with no relief. Only thing that helps alleviate some of the pressure and pain
temporarily are steamy showers. She states she has “no desire to eat and decrease appetite” due to the pain in throat
and achiness. She is 5’6” and 140lb. States her last menstrual period was 6/13/13 (2mths ago).
S.Q. has prior history of Hay Fever, and sinus infections, but otherwise no history of sore throats. She denies vision
changes, blurred vision, and eye discharge. She states she is “has no fevers and night sweats, but is warm and sweaty at
times.” She states she has no lymph node or cervical tenderness. She denies having difficulty moving with her neck. States
no recent dental, head trauma, or exposure to ototoxic medications.
PMH:
Childhood Illnesses:
Reports to having Chicken pox when she was younger.
Adult Illnesses:
1. Hay Fever
2. Sinus Infections
Prior Surgery/Hospitalizations/Blood Transfusions:
Besides 2 Caesarian Births, no prior surgery
No history of blood transfusions
Immunization:
Have had all childhood immunizations
Flu Vaccine -received January 2013
Tetanus Shot-received November 2013
Says she is “up to date, on all other vaccines”
Medications:
Orthotricyclin 1 pill by mouth each day (Birth-control 28 day pill)
Takes no vitamins, supplements
Allergies:
Latex- causes hives, hand swelling, and no history of anaphylaxis
No known medication or food allergies
Psychiatric history/emotional status:
Patient states she is “Stressed from all responsibilities and non-stop activities, never have a free day”
Denies any psychiatric history, feels “good most of the time, never have mood swings, or feel suicidal, I love my life.”
Family History:
The patient’s parents are alive, both of who live and work on a Strawberry farm. Father is a 66-year-old male with history
of HTN and high cholesterol. Mother is a 62-year-old female with history of Rheumatoid arthritis that causes swelling in
the hands. The patient has one brother living at age 30 with no prior medical history or no pertinent medical history, just
being a “partier”. She has no history of anyone in her family having a similar presentation to her current illness.
Social History:
The Patient was born in Plant-City, Florida, where she currently resides out in the country. She school through the 12th
grade and received her high school diploma. After her high school graduation she started work at an auto production
plant, where she currently works. On the weekends she helps her parents on their strawberry farm, where she packages
and ships the fruit. Every Sunday and Wednesday she attends church and is very involved in church activities and
volunteering out in the community with the church.
She was married at age 18. She and her husband have been together for 15 years. She has two children, all of whom live
at home and attend school. She denies any economic hardship and states her and her husband “live comfortably”.
She is currently sexually active, with only her husband, but is on birth control. She has no prior history of sexually
transmitted disease. She currently does not smoke, but smoked when she was younger for 7 years (16-23yr) about 2 a
day; and hasn’t had one in 10years. She reports she drinks 2-3 times a week and goes through about a bottle of wine
every 2-3 days. She reports no illicit drug use whatsoever.
The patient does not get regular exercise other than working out on the farm and running her kids around. She does not
watch her diet as closely as she thinks she should, she states she “loves good ole southern comfort country cooking,
and puts butter on everything”. Last Pap smear and mammogram were done a year ago, performs self-breast exam
about every 6mths.

REVIEW OF SYSTEMS:
General
Weight as per HPI, no Fever or chills.
In the last 6 days has had fatigue, and decrease of energy. Occasional night sweats,
Diet
Normally appetite good eats a “southern diet with lots of butter, bacon, fried chicken and greens”
Past 6 days had a decrease in appetite
Skin, Hair, Nails
No rash, eruptions, itching, or pigment changes
Head and Neck
Headache 6/10, no dizziness, no h/o head injuries, no loss of consciousness
Eyes
She does not wear glasses; she has no blurred vision, eye pain, redness, tearing, diplopia, visual changes, trauma, eye diseases,
or flashing lights
Ears
No hearing loss, vertigo, or tinnitus
C/o ear pain, discharge, and fullness started 6 days ago
Nose
C/o Congestion, and postnasal drip started 6 days ago
No epistaxis
Throat and Mouth
No bleeding gums, ulcers, mouth dryness, or tooth problems
C/o Hoarseness, and sore throat, started 6days ago
Lymph
No tenderness, or enlargement
Respiratory
C/o Non- productive cough
Denies shortness of breath, dyspnea on exertion, occasional night sweats, no known exposure to TB
Cardiovascular
No chest pain, palpitations, edema, or claudication
Gastrointestinal
No dysphagia, heartburn, dyspepsia, nausea, vomiting, no constipation, has BM every 2days, no abdominal pain, no blood in
stool or black tarry stool.
Genitourinary
No dysuria, flank pain, urgency, or frequency, No nocturia, hematuria, or dribbling
Endocrine
Denies Heat/cold intolerance, weight change, polydipsia, polyuria, or hair changes, No increased in glove, or shoe size
Female
LMP: 6/13/13, age at menarche unknown, gravity, parity, menses (onset, regularity, duration, symptoms) not stated, sexual life 1
partner her husband, normally sex 1-a-week, currently on birth control
Breasts
No Pain, tenderness, lumps, or discharge
Hematology
No easy bruising, bleeding, or history of blood clots. No prior blood transfusion
Musculoskeletal
No Joint pain, stiffness, heat or swelling
Neurologic
No lightheadedness, vertigo, syncope, seizures, fainting, numbness, decline in memory, or loss of coordination
C/o HA 6/10 and head fullness, weak past 6 days with onset of symptoms
Mental Status
A&O x4
No trouble with concentration, sleeping, socialization, mood changes, or suicidal thoughts
Objective:
VS: Temperature 98.6F (oral), Heart rate 80bpm, Respiratory Rate 20rpm, Blood Pressure (left arm, regular adult cuff) 110/75
O2 Sat: 96% RA
General: Well-developed adult Caucasian female appearing her stated age, in no respiratory distress sitting on exam table.
She is alert and cooperative with the exam.
HEENT:
Head: Head is normocephalic without scalp or facial tenderness
Eyes: Visual field is full by confrontation, bilaterally. Extra ocular movements intact and full; no nystagmus. Lids and globes
are symmetric. No ptosis. Eyebrows full; no edema or lesions evident. Conjunctivae pink. Sclera white without injection or
jaundice. No discharge. Cornea clear; corneal reflex intact bilaterally. PERRLA. Red reflex in eyes bilaterally, disc well
defined and cream colored bilaterally No hemorrhages or exudates seen.
Ears: Normal auditory canals, Aurilcels in alignment, lobes without masses, lesions, or tenderness. Tympanic membranes
are pearly grey, intact, and light reflex visualized bilaterally. Conversational hearing appropriate. Able to hear whispered
voice.
Nose: Septum midline, patent bilaterally septum midline. Thick purulent discharge present. Tender, turbinate, and
edematous. Nasal mucosa edematous, with erythema, right airway partly occluded, Postnasal drip present. Epistaxis to the
right nare
Sinuses: Edema present over frontal and maxillary sinuses, Sinuses tender to palpitation to frontal and maxillary sinus, no
transluminous frontal sinuses
Throat: erythema present with thick mucous and bumps, High Uvula in post exterior, gag reflex intact, hoarseness present.
Neck: Trachea midline, the thyroid was not palpable. No jugular venous distention (JVD) or carotid artery prominence, no
nodules, tenderness, or bruits, full ROM of the neck without discomfort, no lymphadononapathy
Mouth: Buccal mucosa pink and moist without lesions. Gingiva pink and firm. Tongue midline with no tremors,
fasciculation, or lesions.
Lungs: Thoracic expansion symmetric. Resonance present Breath sounds were remarkable for wheezing and stridor.
Heart: Heart sounds normal, regular rate and rhythm, S1 and S2 heard without murmur
Abd: Non-distended, no tenderness to palpitation. Bowel sounds present. No masses were palpable. No splenomegaly.

A: URI
Bacterial sinusitis

Differentials: Allergic rhinitis

Vasomotor rhinitis
Rhinitis medicamentosa
Endocrine induced rhinitis
Hypothyroidism
Pregnancy
 DOCUMENTATION OF HISTORY AND PHYSICAL EXAM

Patient Name (Initials only) :_ES__ Date examined ___2/12/09

Preceptor Name: Dr. G

CHIEF COMPLAINT:
Dizziness and weakness in right leg

HISTORY OF PRESENT ILLNESS (chronology and progression, pertinent positive and negatives)
Patient, an 82 year old Caucasian male, was in his usual state of health until 2 weeks ago, when he experienced sudden onset
slurred speech, dizziness, weakness in his right leg which precipitated a fall in his home. These complaints began after his daily exercise.
Dizziness and weakness continued unabated until 4 days ago, when his wife brought him in for a check-up. He was subsequently admitted
for testing to rule out stroke. He reports that his dizziness has improved since admission, and is currently 3- 4 out of 10. He has no history
of such symptoms. Patient attributes his symptoms to a stroke, but is concerned that they may be due to amyotrophic lateral sclerosis.
Medical history is significant for hypertension, diabetes, high cholesterol. Additional complaints include rhinitis (a side effect of
medication for benign prostatic hypertrophy), depression, and longstanding hearing loss.

PAST MEDICAL HISTORY

Childhood and adult illness (HTN, TB, Ca, CAD, Bleeding Disorders, Sickle Cell)
Diabetes, hypertension (controlled), and a 10 year history of hearing loss.

Previous Hospitalizations/Surgery/Trauma/Fractures
None reported

Medications (Prescribed/OTC/Vitamins/Supplements/Herbal)
(Write generic names)
“Lots”
Aspirin (81 mg daily)
Tamusolin
Benzocaine
Hypertension medications
Cholesterol medications (unable to specify which)
One-A-Day vitamins

Medication Allergies/Adverse Reactions

Rhinitis, lacrimation from Tamusolin

Immunizations _Up to date Flu ____ Pneumonia ____Tdap _____Zoster

FAMILY HISTORY (HTN, TB, Cancer CAD, Bleeding Disorders, Sickle Cell, diabetes, anemia, asthma, consanguinity)
Father: hypertension (died at 58 of trauma)
Mother: diabetes; died at 75 of heart disease
Maternal cousin with amyotrophic lateral sclerosis

SOCIAL HISTORY
Living Arrangement (s/m/w/d/partner)
Lives with wife of 45 years, daughter (age 36), daughter (age 40) and son-in-law. One son (age 41) who lives nearby. Wife and children
reported in good health.

Residence (house, apt., shelter, homeless; safety measures)

House; no identified hazards

Sexual history( if appropriate) Occupation

N/A Retired family practioner

Environmental Exposures Travel History

No significant exposures identified No significant history identified

Tobacco, Alcohol and Other Drug Use

Denies tobacco, EtOH, other use

Diet and Exercise

Reports a balanced diet and daily exercise.

Education (highest level attained)

MD

REVIEW OF SYSTEMS-Please use lay language when talking to patients – you can document in medical terms. Describe all positive
and pertinent negative findings.

Constitutional (fever, chills, night sweats, weight change ,fatigue, malaise nutrition, deformities, grooming)
15-20 lb weight loss in the past 2 weeks. Loss of appetite. Otherwise, no pertinent history

Eyes (vision, pain, discharge, photophobia)

Vision fluctuates from acute to blurry. Increased watering attributed to Tamulosin. No other reported symptoms.

Ears/Nose/Throat (hearing, tinnitus, dizziness pain, discharge, smell, , hoarseness, nose bleeds smell, hearing, discharges, lesions,
hoarseness)
Rhinitis, attributed to Tamulosin. No other reported symptoms.

Mouth / Dental (tooth decay, gum disease, last visit to dentist, speech problems, sinus drainage, taste, snoring)
Broken dentures; otherwise, no reported symptoms.

Breast (lumps, nipple discharge, family history of breast cancer, self breast exam)
No reported symptoms

Cardiovascular (Palpitation, angina, heart attack, chest pain, shortness of breath, PND, orthopnea, claudication, syncope, hypertension,
cyanosis, varicosities, edema)
Recent history of syncope described above. No other reported symptoms

Respiratory (asthma, dyspnea, cough/sputum, hemoptysis, TB skin test status)

No reported symptoms

Gastrointestinal (dysphagia, anorexia, nausea, vomiting, hematemesis, diarrhea, constipation, melena, rectal bleeding, change in bowel
habits, hemorrhoids, jaundice, abdominal pain, food intolerance)
No reported symptoms

Genito-Urinary (dysuria, hematuria, frequency, polyuria, urgency, hesitancy, incontinence, renal stones, nocturia, infection, frequency, dysuria,
retention, incontinence)
No reported symptoms

Male Reproductive –( penile discharge, STD history, testicular pain or mass, infertility, impotence, libido)
No reported symptoms

Female Reproductive – menarche, last period, age of menopause, postmenopausal symptoms, postmenopausal bleeding, abnormal periods, ,
STD history, last Pap test, OB-Hx, discharge, odor, infertility, libido, method of contraception
Not applicable.

Musculoskeletal (joint pain( mono or poly articular), edema, heat, redness, stiffness, deformity, muscle pain, tenderness, fatigue(e.g. with
arthritis), atrophy?)
No reported symptoms

Neurological (headache, syncope, vertigo, seizures, loss of vision, diplopia, parasthesias paralysis, weakness in any limbs, tremor, ataxia, memory
loss)
Weakness in right lower limb, syncope, vertigo, vision fluctuation. Reports that his wife complains he asks the same question multiple
times in a short period of time; did not associate this with present illness. No other reported symptoms.

Skin (itching, rash, lump and bumps, hair and/or nail change, de/pigmentation)
No reported symptoms.

Endocrine: (excessive thirst, sweating, dizziness, palpitations, weight change)

15-20 lb weight loss, attributed to decreased appetite. No other reported symptoms

Hematologic/Lymphatic: (bruising, cyanosis, rashes, lesions, enlargement of lymph nodes, petechiae, purpura)
No reported symptoms.

Psychiatric: (stress, insomnia, previous psychiatric illness, depression, anxiety, hallucinations, memory loss)
Depression attributed to current condition and prolonged hospital stay. No other reported symptoms.

PHYSICAL EXAMINATION (Please describe your findings)

Vital Signs:
Ht.___________ Wt.___________ BMI__________
Temp_________ Pulse________BP___/____
RR________Pain________
General Appearance: (habitus, level of consciousness, distress)

1. Head (Hair, scalp and cranium)

Bald head with slight dryness on scalp. Otherwise, normal exam.

2. Eyes
Lids and conjunctivae (discharge, icterus, ptosis, edema) No significant findings.
Pupils and irises (reaction to light and accommodation, size, symmetry, extraocular movements, visual fields, visual acuity) Vision
corrected to normal with bifocal lenses. No significant deficit evident.

Optic discs and posterior segments (size, Cup to disc ratio, appearance, vessel changes, exudates, hemorrhages) No significant findings.

3. Ears/Nose/Throat
External ears, nose (scars, lesions, masses, foreign body) No significant findings.
Otoscopic exam (external auditory canals, tympanic membranes/mobility) No significant findings.
Hearing (whispered voice, Rinne and Webber test) Significant amount of cerumen; no other significant findings.
Nose (Nasal Mucosa, septum, turbinates) No significant findings.

4. Mouth / Dental
Inspection of lips, teeth and gums Missing several teeth; dentures were broken. No other significant findings.
Oropharynx (oral mucosa, tonsils, tongue, palate, salivary glands, posterior pharynx) No significant findings.

5. Neck
Overall appearance (masses, symmetry, tracheal position, crepitus)
Thyroid (enlargement, tenderness, mass)
Lymph nodes

Respiratory
Inspection/respiratory effort and rhythm (shape, intercostal retractions, use of accessory muscles,)
Palpation of chest (chest movements, tactile fremitus, tenderness)
Percussion of the chest (dullness, hyperresonance)
Auscultation of lungs (breath sounds, adventitious sounds, rubs)

6. Cardiovascular
Neck Veins
Palpation of the heart (PMI location, size, thrills)
Auscultation: (normal sounds, abnormal sounds, murmurs)
Examination of:
Carotid arteries (pulses, bruits, amplitude)
Abdominal Aorta (size, bruits)
Femoral arteries (pulse, amplitude, bruits)
Pedal Pulses (pulse, amplitude)
Extremities (edema, varicosities)

7. Gastrointestinal
Inspection/auscultation of abdomen (masses, appearance of abdominal wall)
Palpation/percussion of liver, spleen, and general abdomen (enlargement, irregularities, ascites, masses)
Examination for presence/absence of hernia (inguinal, femoral, ventral)
Examination of anus, perineum, rectum (including patency, sphincter tone, hemorrhoids, rectal masses when indicated)

Obtain stool sample for occult blood (when indicated)

8. Lymphatic (Palpation of Nodes in 2 or more areas)
Neck Axillae Groin Other

9. Skin and Subcutaneous Tissue

Inspection (rashes, lesions, ulcers)
Palpation (induration, subcutaneous nodules, tightening)

10. Back, Extremities, Musculoskeletal

Gait
Inspection/palpation of digits, nails (clubbing, cyanosis, inflammation, petechiae, ischemia, infections, nodes)

Examination of the Joints, Bones, and Muscles in 1 or more of the six areas below:
a. Head and Neck
b. Left Upper Extremity
c. Right Upper Extremity
d. Spine, ribs, and pelvis/hips
e. Right Lower Extremity
f. Left Lower Extremity
Include for each area:
Inspection/palpation Range of Motion Stability Muscle Strength & Tone

11. Neurological
Level of consciousness, higher functions and speech
Test of cranial nerves with notation of deficits
Motor system including deep tendon reflexes, strength, tone, & cerebral function
Sensation (touch, pain, vibration, proprioception & Babinski)
Cerebellar signs
Gait
Abnormal movements (tremors, choreoathetoid, dystonia, tics)

12. Psychiatric:
Description of insight and judgment. Insight and judgment were appropriate to situation.
Assessment of mental status (including orientation to time, place, person, recent and remote memory, mood and affect,depression,
anxiety, agitation) Detailed exam not conducted, but reported depression.

List 3 main problems identified in this patient

1. _Dizziness_________________________

2. _Weakness________________________

3. _Slurred speech____________________

__________________________

List 3 differential diagnoses for Problem #1 (above)

1. Stroke
2. Side effects from Tamulosin
3. Polypharmacy

Signature Student Name (printed)

Comments from Preceptor:

Differential Diagnosis Paper #2
Case Information
Chief Complaint/Reason for Visit
“Joint pain for the past 2 years”
History of Present Illness (HPI)
Mrs. C is 50 year old woman that is in the clinic today with complaint about joint pain for the past 2 years. Reports pain is in
her hands and wrists on both sides. She describes the pain as a “dull aching” pain and “stiffness.” States pain is worse in the
morning and usually improves throughout the morning within about 2-3 hours. She states that on particularly bad days, she uses
OTC NSAIDs with moderate relief. She does also state she has noticed a decrease in her energy level recently but feels it may
be due to her age. No history of recent infections or sick contacts. Does not feel anything makes the pain better or worse.
Past Medical History
Medications: Atacand 8 mg po Bid
Allergies: Codeine -Vomiting and hallucinations
Surgeries: None
Hospitalizations: None
Major/Chronic Illnesses: Hypertension since age 45
Gynecologic: Menses monthly, 5 day duration, menarche-age 15
Immunizations-Up to date on immunizations-Had influenza vaccine in fall
Family Medical History
Mother-Deceased Age 80 – HTN, DM
Father-Alive (81) – Arthritis, Degenerative joint disease, HTN
Social History
Occupation: Retail-owns her own business
Education Level: College graduate
Tobacco: Denies tobacco use
ETOH: Denies ETOH intake
Recreational Drugs: Denies
Diet: Eats a balanced diet
Exercise: Walks her dog every morning and evening for 30 minutes
Sexual History: Sexually active-married to spouse for 29 years
Cultural Background: Caucasian
Review of Systems (ROS)
Constitutional: Feels generally well, Denies fever, chills. Positive for increasing fatigue over the past 2 years
LYMPHATIC:
Denies enlargement or tenderness to lymph nodes
RESP:
No shortness of breath or cough
CV:
Denies palpitations or chest pain
GI:
Diet without change
MUSCULOSKELETAL:
Positive for joint stiffness in her hands and wrists bilaterally, improves after 2-3 hours in the morning, positive for joint
swelling intermittently to her fingers, denies redness or warmth to her joints,
NEUROLOGICAL:
He denies dizziness or gait disturbances.
IMMUNOLOGICAL:
Denies frequent cold or infections
INTEGUMENTARY:
Denies rashes or eruptions
PSYCHIATRIC:
Denies any anxiety, depression or suicidal ideations.
Case Study for Differential Diagnosis Paper #1
Chief Complaint/Reason for Visit
“I have a cough for the past 3 days.”
History of Present Illness (HPI)
M.B. is a 15 year old female that presents to the office today as a returning patient with concerns about a cough.
She is accompanied by her father. M. B. states the cough started 3 days ago and is intermittent in nature.
Describes as a dry cough, does not produce any sputum. She does state similar symptoms in the past year
intermittently, but she did not seek treatment. She does state associated tightness feeling in her chest when she is
coughing. She states the cough is sometimes worse at night. She does not recall any aggravating factors, but she
did start training for swim team a couple days ago. She has tried OTC Mucinex per her father, but does not feel
any relief. Denies any ill contacts.
Past Medical History
Medications: Veramyst 1 spray each nostril daily (taking since age 13)
Mucinex (OTC) for the past 3 days
Allergies: Aspirin-rash
Surgeries: Tonsillectomy at age 5
Hospitalizations: none other than for tonsillectomy age 5
Major/Chronic Illnesses: Hayfever
Gynecologic: Menses monthly, 5 day duration, menarche-age 14
Immunizations-Up to date on all immunizations
Family Medical History
Mother-Alive (41) - high cholesterol
Father-Alive (43) - no health problems, smoker
Social History
Occupation: Student
Education Level: High School Sophomore
Tobacco: Denies tobacco use
ETOH: Denies ETOH intake
Recreational Drugs: States she tried marijuana one time only
Diet: Eats a balanced diet
Exercise: Joined the swim team recently for exercise and socialization
Sexual History: States she has never been sexually active. Completed the Gardasil vaccine series at age 13
Cultural Background: Caucasian- Irish descent
Review of Systems (ROS)
Constitutional:
Feels generally well, Denies fever, chills
HEENT:
Denies headaches, dizziness or syncope
Denies changes in her vision
Denies hearing loss or ear pain
Positive for nasal stuffiness-intermittently-currently uses the nasal spray with good results
Denies sore throat, changes in voice
LYMPHATIC:
Denies enlargement or tenderness to lymph nodes
RESP:
Cough-intermittent, non-productive for the past 3 days. Similar symptomatic episodes over the past year but has not sought
treatment. Positive for tightness in chest with cough episodes. Denies wheezing, night sweats, or hemoptysis.
CV:
Denies palpitations or chest pain
GI:
Denies nausea, vomiting or diarrhea, heartburn. BM without changes, Diet without change
NEUROLOGICAL:
He denies dizziness or gait disturbances.
IMMUNOLOGICAL:
Denies frequent cold or infections
INTEGUMENTARY:
Denies rashes or eruptions
PSYCHIATRIC:
Denies any anxiety, depression or suicidal ideations.
DATE OF CONSULTATION: MM/DD/YYYY

REQUESTING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Consultation requested for headache.

CHIEF COMPLAINT: The patient is a (XX)-year-old right-handed female complaining of headache.

HISTORY OF PRESENT ILLNESS: The patient notes that she has had migraine headaches since she was (XX) years
old. Her migraines tend to have consistent features; in addition, sometimes have variable symptoms. For example, the
patient notes that when she was a teenager and early on her migraine history, she would have left facial droop and
paresthesias of the left upper extremity prior to her headaches. More recently, the pattern has changed, to be described
further on below. The patient notes that her usual migraine frequency is once or twice a month, for the most part, along
with her menses, although they can occur independent of her menses less often. That has been her pattern for the past
1-1/2 years, but prior to that, she was only having one or two migraines per year. In November, her gynecologist began
to try hormonal manipulation to see if the migraines could be better controlled. The patient started by using a NuvaRing
and if anything this seemed to increase the frequency of her migraines, as she has had a migraine headache on the
average of once a week since this was instituted.

The patient had another migraine on Monday and called her gynecologist and decided to go off the NuvaRing at that
time. Instead, the gynecologist started Camila 0.35 mg daily, which she took for three days prior to admission. She
notes that her menses had been very irregular and in fact that she has been having some amount of vaginal bleeding for
the past 1-1/2 months as well. She is uncertain as to whether the additional hormones she has gotten has changed that
pattern. Typically, the patient does not take any treatment for her migraine; although, she has found that sleep will take
away the major portion of the pain, and that is how she has been treating these. She tries Tylenol Extra Strength, but it
does not give relief. Her migraine typically begins with visual disturbances. She will either have scotomata in her
peripheral visual fields or scintillating scotomata in the same regions. Yesterday at 10 o'clock, she had the sudden onset
of scotomata, which lasted for 15 minutes and then these became scintillating for another 15 minutes.

Next, the patient developed her typical weakness of the left upper extremity, which has been an associated feature with
her migraines for many years now. This is more of a heaviness without true weakness. Almost simultaneously, she
developed paresthesias of her right upper extremity, which is a symptom that she has never had. These symptoms
lasted for 15 to 20 minutes. In addition, the patient had some amount of slurred speech during these
events. Subsequently, the patient developed atypical headache, which usually involves the right cranium much more so
than left. This is usually behind the eye on the right and, yesterday, also involved the vertex and then spread in atypical
fashion to right capital occipital artery regions. The quality of the headache is that of a throbbing and pulsating
sensation. There is anorexia and nausea associated with it, with occasional vomiting. The headache typically worsens
with coughing, sneezing, straining for a bowel movement, or otherwise engaging in Valsalva maneuver.

The patient denies focal weakness of a significant nature, other numbness, tingling, or dysesthetic sensations of the face
or lower extremities. No other visual complaints. The patient has chronic tinnitus in the left ear. She complains of an
orthostatic sense of lightheadedness and presyncopal sensations without vertigo, which occurs when arising rapidly from
the supine or seated position. The symptoms are not precipitated by rapid movements of the head upon neck or by
bending over. Sometimes she feels these symptoms even when she is just sitting and doing nothing. No other bulbar
symptoms. No history of recent or remote head, neck or low back trauma, with or without loss of consciousness. Denies
previous CNS infections. No bowel, bladder or sexual dysfunction.

PAST MEDICAL HISTORY: Known mitral valve prolapse. The patient denies diabetes, hypertension, myocardial
infarction, cardiac arrhythmia, anginal pectoris, current chest pain or pressure, kidney or liver disease, previous stroke,
epilepsy or other neurologic or psychiatric illness.

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: She denies abuse of tobacco, alcohol, prescription drugs or illicit substances.

ALLERGIES: No known food, drug or contrast material allergies.

MEDICATIONS: See HPI. Vicodin as necessary for lingering headache pain.

REVIEW OF SYSTEMS: Please see the HPI for neurologic and other pertinent review of systems, otherwise the
following systems are noncontributory including constitutional, eyes, ears, nose, and throat, cardiovascular, respiratory,
gastrointestinal, genitourinary, musculoskeletal, skin and/or breast, endocrine, hematologic/lymph, allergic/immunologic
and psychiatric.

PHYSICAL EXAMINATION:
GENERAL: The patient is pleasant, cooperative, appears her stated age. Her body habitus is endomorphic and she is
mildly overweight.
VITAL SIGNS: Currently stable. The patient is afebrile.
SKIN AND EXTREMITIES: No skin rashes or lesions are noted. No cyanosis, clubbing or edema of the extremities.
HEAD AND NECK: Head is normocephalic and atraumatic. The head and neck are nontender without thyromegaly or
adenopathy. Carotid upstrokes are 1+/4. No cranial or cervical bruits. The neck is supple with a full range of motion.
HEART: Regular rate and rhythm.
LUNGS: Clear to auscultation.
ABDOMEN: Soft and nontender.
BACK: Back is straight without midline defect.
NEUROMUSCULAR: Higher cortical function/mental status: The patient is alert. She is oriented x3 to time, place and
person. There is no gross evidence of aphasia, apraxia or agnosia. Recent and the remote memory appear
Cranial nerves: Pupils are 4 mm, reacting briskly to 2
normal. The patient has a good fund of knowledge.
mm without afferent pupillary defect. Visual fields are intact to confrontation testing. Funduscopic
examination reveals sharp disk margins with normal vasculature. No papilledema, hemorrhages
or exudates. Extraocular movements are full and smooth with normal pursuits and saccades. No
nystagmus noted. The face is symmetric. The remainder of the cranial nerves are intact and
symmetrical. Strength is 5/5 throughout with normal tone and bulk with the following exceptions,
4/5 intrinsic muscles of the hands and feet. No involuntary movements noted. Reflexes are 2/4
and symmetrical in the upper extremities, 2/4 and symmetrical at the knees and 1/4 and
symmetrical at the Achilles tendon. Plantar responses were downgoing
bilaterally. Sensation: Intact to pinprick, light touch, vibration and
proprioception. Coordination: The patient normally performs finger-nose-to-finger, heel-to-knee-
to-shin and rapid alternating movements in a symmetrical fashion. Gait and station: The patient
walks with a narrow-based gait. She is able to heel-toe and tandem walk forward and backwards
without difficulty. Romberg and monopedal Romberg are negative.

LABORATORY STUDIES: On admission, CBC is normal. Electrolytes are normal other than CO2 of 22. Normal SMAC
and magnesium.

DIAGNOSTIC STUDIES: CT scan of the brain without contrast infusion is normal. Results of the MRI of the brain and
MR angiogram are pending.

IMPRESSION: It appears that the patient suffers from migraine headaches with aura and other variable complicated
symptomatology, which in the past has been primarily catamenial in its nature. However, more recently, the patient has
had an increase in the frequency of her migraines, possibly related to trials of estrogen and progesterone that have been
initiated by her gynecologist versus the possibility that she is entering into hormonal fluctuations related to menopause as
an alternative explanation.
RECOMMENDATIONS: The patient has recently decided to discontinue her hormone replacement therapies and I
agree with this approach. With some time, it might be possible to see as to whether the migraines were increasing in
frequency as a result of these treatments, or whether they will continue to be this frequent, in which case it may be
related to the earliest phases of menopause. I agree with the current narcotic analgesic treatment that the patient is
receiving for her lingering migraine headaches. The results of the MRI scanning of the brain, as well as MR angiography
are currently pending.

As an outpatient, the patient should be on a migraine prophylaxis with either beta blockers, tricyclic antidepressant
medications or anticonvulsants like Depakote. These would be treatments that would be best applied on an outpatient
basis. The patient is asked when she leaves the hospital to begin taking an Ecotrin tablet 325 daily with her
breakfast. At times, even the simple use of the daily aspirin therapy will provide adequate prophylaxis against migraine
headaches.

For symptomatic relief, she is asked to take Excedrin Extra Strength and she will take 2 tablets every 3 to 4 hours for her
more severe migraines. If that should fail and the migraine continues to progress, then as an outpatient, the patient
should resume the use of Midrin, which she has used successfully in the past, taking 1 or 2 capsules of the brand
medication (as the generic clearly does not work as well) - up to a maximum of 6 in any one day. Her use of sleep as
rescue therapy is also entirely appropriate if nothing else works. The patient agrees to follow up with me in the office after
discharge.