Author: Tim Milligan

Case 3 – Amenorrhea

Tim Milligan Women's Health

You are seeing Cindy Albrecht, a 19 year old female, for amenorrhea. Please take a focused history for her complaint.

History

  • Distinguishes primary vs. secondary amenorrhea (patient has had previous menstrual periods)
  • Age of menarche
  • Onset of last menstrual period
  • Amount and changes in flow in recent menstrual periods
  • Length of menstrual period
  • Menorrhagia
  • Dysmenorrhea
  • Current use of birth control pills or other oral hormones
  • Presence of vaginal discharge/itching
  • Morning sickness
  • Abdominal pain/discomfort
  • Recent dieting
  • Recent fractures
  • Excessive exercise
  • Galactorrhea
  • Symptoms of hyperthyroidism (sweating, palpitations, heat intolerance)
  • Symptoms of hypothyroidism (feels slow, cold intolerance, constipation)
  • Symptoms of hypoestrogen state (hot flashes, night sweats, vaginal dryness)
  • Personal history of chronic disease
  • Pregnancy history
  • Current and past sexual history, including partners, method of intercourse, and contraception
  • Smoking and alcohol history
  • Family history of genetic abnormalities and infertility

Case 2 – Vaginal Discharge

Tim Milligan Women's Health

You are seeing Stacey Holland, a 23 year old female, for vaginal discharge. Please take a focused history for her complaint.

History

  • Onset and duration of vaginal discharge
  • Appearance of discharge
  • Association with menstruation
  • Presence of blood
  • Itching
  • Dyspareunia
  • Pain on defecation
  • Fever
  • Nausea/vomiting
  • Perineal/vaginal sores
  • Abdominal pain/discomfort
  • Rash or other lesions
  • Swollen joints
  • Vision changes
  • Dysuria
  • Hematuria
  • Increased frequency of urine
  • Last menstrual period
  • Menorrhagia
  • Dysmenorrhea
  • Regularity of menstruation
  • Past abdominal surgery
  • Pregnancy history
  • Current and past sexual history, including partners, method of intercourse, and contraception
  • Smoking and alcohol history
  • Medications – especially oral contraceptive pill
  • Allergies
  • Personal history of sexually transmitted infections and related investigations/treatment
  • Last Pap smear and result

Case 1 – Breast Mass

Tim Milligan Women's Health

You are seeing Mrs. Thompson, a 56 year old woman, in your outpatient clinic today. She is worried about a left breast mass, and would like your reassurance that it isn’t cancer. Take a focused history of her complaint and perform a focused physical exam.

History

  • Onset of awareness of mass
  • Size of the mass and change in size
  • How mass was identified
  • Mastalgia
  • Associated discharge, including pus and blood (none)
  • Size/tenderness association with menstrual cycle
  • Nipple changes
  • Skin changes (on affected breast)
  • Systemic symptoms – weight loss, low energy, anorexia
  • Associated shortness of breath or chest pain
  • Changes in personality – suggestive of brain metastases
  • Bone pain – suggestive of bone metastases
  • Inquires about date of menopause
  • Pregnancy history
  • Breastfeeding history
  • History of chest radiation
  • Age of menarche
  • Alcohol history
  • Smoking history (quantity in pack-years)
  • Past and current use of hormone replacement and oral contraceptive pills
  • Family history of breast, ovarian, or colon cancer
  • Past history of breast masses
  • Past mammography results
  • Addresses patient’s concerns regarding the mass

Physical Examination

Inspection

  • Drapes patient appropriately
  • Inspects breast skin for discoloration, retraction, peau d’orange, or bruising
  • Comments on presence of asymmetry
  • Examines nipples, commenting on absence of discharge, irregularities, or retraction
  • Examines areolas (no abnormalities)

Palpation

  • Uses radial or strip method to palpate both breasts,
  • Comments on texture, size, firmness, and mobility of any palpated masses
  • Palpates axillary nodes bilaterally
  • Palpates infraclavicular and supraclavicular nodes

Case 4 – Renal Colic

Tim Milligan Urology

You are seeing Ms. Hamilton, a 64 year old man, for left sided back pain. She says it began three days ago and isn’t getting any better. Take a focused history of her complaint and perform a physical examination.

History

  • Onset and duration of pain
  • Progression of pain
  • Location of pain (unilateral)
  • Frequency of pain (intermittent)
  • Quality of pain (sharp)
  • Radiation (to abdomen and groin)
  • Flank pain (yes)
  • Changes in amount of urine
  • Dysuria
  • Urgency
  • Hematura (some darkening)
  • Post-void dribbling
  • Fever (recently)
  • Nausea/vomiting
  • Diarrhea (none)
  • Diaphoresis
  • Current Medications
  • Diet history (focusing on calcium and oxalate intake)
  • Personal history of renal stones
  • Personal history of urinary tract infections
  • Family history of renal stones
  • Past medical history

Physical Examination

Inspection/Vitals

  • Comments on general appearance of patient (uncomfortable, diaphoretic)
  • Measures heart rate (elevated) and states that temperature should also be measured

Renal Examination

  • Palpates location of back in which pain is located
  • Assesses for CVA percussion tenderness
  • Attempts to palpates for kidneys with patient supine
  • Auscultates for renal bruits bilaterally

Abdominal Examination

  • Inspects abdomen for masses, scars
  • Auscultates in all four quadrants of the abdomen
  • Palpates all quadrants for tenderness, commenting on absence/presence of guarding
  • Assesses for rebound tenderness in the left and right lower quadrants
  • States that they would perform a digital rectal examination as part of the abdominal examination

Special Maneuvers

  • Examines for signs of appendicitis: McBurney’s point tenderness, Rovsing’s sign, Psoas sign

Case 3 – Testicular Mass

Tim Milligan Urology

You are seeing Bill Byrd, a 40 year old man in your outpatient clinic because he recently noticed a testicular mass. Perform a full genital examination.

Physical Examination

Scrotum

  • Inspects scrotum for asymmetry and skin lesions
  • Palpates testicles bilaterally
  • Comments on masses: size, location, consistency, tenderness, irregular shape
  • Palpates epididymis for tenderness, enlargement

Penis

  • Inspects penis for erythema, swelling, deformity
  • Palpates along penile shaft for irregularity
  • Examines foreskin for signs of infection
  • Exposes glans for inspection, and replaces the foreskin after completing the examination
  • Examines meatus for discharge

Hernias

  • Palpates inguinal region bilaterally for presence of hernias
  • Assesses for hernias with patient standing up
  • Asks patient to bear down during palpation of scrotum

Digital Rectal Examination

  • States that a digital rectal examination would be performed as part of the genitourinary examination

Case 2 – Hematuria

Tim Milligan Urology

You are seeing Mr. Ali, a 72 year old male, in your outpatient clinic today for ‘bloody urine.’ Take a focused history of his complaint.

History

  • Onset and duration of hematuria
  • Progression or worsening of hematuria
  • Clarifies color of urine (bright red blood)
  • Urinary frequency
  • Pain on urination
  • Urgency
  • Nocturia
  • Incomplete voiding
  • Hesitancy
  • Penile tip pain
  • Flank Pain
  • Abdominal discomfort/fullness
  • Systemic Symptoms – weight loss, fever, night sweats
  • Personal history of bleeding diathesis
  • Personal history of renal stones
  • Past history of renal disease
  • Current medications
  • Surgical history
  • Smoking history (quantity in pack-years)
  • Occupational history – especially exposure to exogenous toxins
  • Concerns as to what is causing the hematuria
  • Past history of urinary tract infections
  • Family history of urogenital cancers

Case 1 – Dysuria

Tim Milligan Urology

You are seeing Mrs. Singh, a 72 year old female, in your outpatient clinic today. She tells you that she has discomfort during urination and has difficulty controlling her urine. Take a focused history of his complaint.

History

  • Clarifies symptom of dysuria
  • Onset of dysuria
  • Urinary frequency
  • Change in urine color (cloudiness, darkening)
  • Presence of hematuria (none)
  • Nocturia
  • Urgency
  • Overflow Incontinence
  • Incomplete voiding
  • Flank/back pain
  • Abdominal discomfort/fullness/pain
  • Nausea and vomiting
  • Fever
  • Gastrointestinal symptoms such as pain, diarrhea, blood in stool
  • Pregnancy history
  • Current medications (particularly anti-cholinergic medication, estrogen creams)
  • Past history of urinary tract infections
  • Past history of urinary incontinence and treatments
  • Exposure to pool/lake/ocean water
  • Recent antibiotic use
  • Effect on daily life

Case 4 – Pneumonia

Tim Milligan Respirology

You are seeing Mrs. Muller, a 45 year old female, in the ER for a new pneumonia. Please examine the patient and comment on his chest X-ray.

Physical Examination

Inspection

  • Comments on presence of central/peripheral cyanosis (frenulum, lips, fingernails)
  • Inspects for clubbing
  • Comments on respiratory status – tachypnea /intercostal indrawing/accessory muscle use, etc.
  • Examines for thoracic deformities

Percussion/Palpation

  • Percusses in all anterior and posterior fields and comments on findings.
  • Uses percussion to estimate diaphragmatic excursion on posterior.

Auscultation

  • Instructs patient to breathe when auscultating
  • States that they would auscultate both lung fields in at least 5 different locations
  • Listens to at least one full breath at each location
  • Auscultates posterior fields, asking patient to cross arms in order to shift scapulae out of lung fields.
  • Comments on of breath sounds and presence of adventitious sounds

Chest X-Ray

  • Comment on abnormality on X-Ray

Case 3 – Hemoptysis

Tim Milligan Respirology

You are about to see Mr. Singal in your outpatient clinic. He tells your nurse that he has recently noticed blood in his sputum. Take a focused history concerning his complaint.

History

  • Onset, duration, frequency of hemoptysis
  • Quality of hemoptysis
  • Volume of hemoptysis
  • Sputum production and volume
  • Distinguishes from hematemesis
  • Associated shortness of breath
  • Fever
  • Chest pain
  • Associated B-Symptoms – weight loss, night sweats, chills
  • Smoking history (quantity in pack-years)
  • Drug use (prescription and other)
  • Personal history of lung disease
  • Infectious contacts
  • Exposure to environmental airborne irritants
  • Family history of cancer, especially lung
  • TB exposure, including place of birth
  • Addresses patient’s concerns as to what caused the bloody sputum

Case 2 – Shortness of Breath

Tim Milligan Respirology

You are seeing Mrs. Clark, a 30 year old woman, in the Emergency Department today shortness of breath. Take a focused history of his complaint.

History

  • Onset and duration of shortness of breath
  • Alleviating factors, including any use of puffers
  • Aggravating factors, including exercise, second hand smoke, allergens
  • Progression or worsening of symptoms
  • Presence of nighttime symptoms
  • Frequency
  • Sputum production, presence of blood in sputum
  • Recent cough, sore throat, myalgias and other symptoms of URTI
  • Chest tightness
  • Presence of fever or chills
  • Recent respiratory illness
  • Smoking history (quantity in pack-years)
  • alcohol/drug history
  • Exposure to infectious contacts
  • Vaccination history – especially seasonal flu
  • Exposure to environmental allergens/irritants
  • Recent travel
  • Effect on daily activities, including work and home life
  • Exercise intolerance
  • Past occurrence of such symptoms
  • Personal history of asthma
  • Family history of atopy (asthma, eczema, etc.)