Mini-CPX 6

Part 3: Developing a differential diagnosis and diagnostic and management plan

Physical exam findings:

Vitals: Temp 97.1 HR 50 RR 12Orthostats: Supine BP: 144/80; sitting BP: 136/76; standing BP: 111/69

Gen: alert; pale complexion; appears comfortable, nontoxic; flat affect.

HEENT: no facial swelling; no acne. Normal distribution of scalp hair. No abnormal facial hair. Palpebral conjunctivae pale. Sclerae non-icteric and mildly injected bilaterally. Oral mucous membranes moist; buccal and gingival mucosae pale. No abnormal oral mucosal lesions. No gum bleeding. Mild injection and cobblestoning of the posterior pharynx; no posterior pharyngeal or tonsillar erythema or exudate. Mild periorbital edema. Nasal mucosa pale; turbinates boggy in bilateral nares; small amount of clear nasal discharge present bilaterally.

Neck: neck tissues are symmetric without visible masses; no palpable cervical LNs; thyroid is mildly, diffusely enlarged, nontender, and diffusely firm; no thyroid nodules palpated.

Chest wall: no abnormal breast masses; no palpable supraclavicular, infraclavicular, or axillary LNs.

CV: bradycardic rate. Regular rhythm. Normal S1 and S2. No S3 or S4. No murmurs or other extra heart sounds. PMI located in the left mid-clavicular line. JVP 2 cm above the sternal angle. Pulses 2+ centrally and peripherally. Cap refill 2 seconds.

Pulm: lungs clear to auscultation bilaterally. Normal respiratory rate and effort.

Abd: soft, nondistended; normal active bowel sounds; nontender throughout to both light and deep palpation. Liver span 8 cm; normal liver edge contour. Spleen non-palpable. No other masses.

Extr: hands and feet cool; no clubbing, cyanosis, or pitting edema. Nail beds pale and brittle; no splinter hemorrhages.

Skin: diffusely dry, rough, and pale; no jaundice; no rashes or other lesions, including no petechiae, purpura, ecchymoses, striae, or areas of hypo- or hyperpigmentation.

GU: no palpable inguinal LNs; no visible skin or mucosal lesions; no active vaginal bleeding; no abnormal discharge; cervix normal in appearance; normal bimanual exam. Normal rectal exam, without visible blood or perianal lesions.

Neuro: Oriented x 4. CNs II – XII intact, including normal visual fields. Strength 5/5 in all muscle groups in bilateral upper and lower extremities. Decreased sensation to light touch and pin prick on the plantar and dorsal surfaces of feet bilaterally. Upper and lower extremity DTRs 1+ throughout upper and lower extremities. Normal attention and short-term memory. Cerebellar function intact. Normal gait.

Instructions:

Based on the information given in this patient’s history and PE, complete your write-up to include the following, which will essentially simulate how you’ve completed your H&Ps for prior mini-CPX cases:

Your assessment, including:o Summary statement, including all major abnormalities noted in the history

and PEo Your revised differential diagnosis for the patient, explicitly noting your

leading diagnosis

Your plan, including:o Your diagnostic plan for the patiento Your management (treatment) plan for the patiento Your anticipatory guidance for the patiento Your disposition for the patient

For each diagnostic study on your list, you must indicate the specific reason you would obtain that study, in terms of how it is relevant to your revised differential diagnosis for this patient. You must include this information for every study, to receive credit.

Similarly, you must justify your management and your disposition for the patient, citing the reason from your differential diagnosis and assessment of the patient’s current clinical stability. You must include this information to receive credit.