Reporting

History Taking
Pediatrics IM
1.​ General Data 1.​ General Data
2.​ CC 2.​ CC
3.​ HPI 3.​ HPI
4.​ ROS 4.​ Past Medical History
5.​ Past Personal 5.​ OB/Gyne (Female)
a.​ Maternal 6.​ Family Medical History
i.​ Gestational 7.​ Personal and Social
ii.​ Birth a.​ Add pets
iii.​ Neonatal b.​ Environment (place/house)
b.​ Feeding 8.​ Sexual
c.​ Developmental a.​ Active
d.​ HEEADSSS (home, education, eating, activity, b.​ Coitarche
drugs, sex, suicide, safety - adolescents only c.​ Number of sexual partners
from 10 to 20 years old only) d.​ Last sex
e.​ Past illnesses (Medical) e.​ Orientation of px and partners
6.​ Immunization 9.​ ROS
7.​ Family Medical History
8.​ Personal and Social
a.​ Primary caregiver
b.​ Living circumstances
c.​ Economic
d.​ Environment

ROS
General, Skin, HEENT, Breast, Respiratory, Cardio, GIT, GUT, MSK, Vascular, Endo, Hema, Neuro,
Psych

General Survey

Pediatrics
Patient is Ambulatory with good posture, is able to stand and walk steadily in vertical position (carried
by mother/wheel-chaired borne/stretcher-borne), with age appropriate for weight and height, and weight for
height. Patient appears well nourished and hydrated. No jaundice, no scars, and no distinctive facies like low
set ears, wide spaced eyes, or facial palsy were observed. Px appears to be comfortable, conversant, and not
in pain or cardiorespiratory distress (is crying and nonconversant).
* variable depends on age (neonate, pediatric, or adolescent)

INCLUDE IF ADOLESCENT:
PX is awake, Conscious, Coherent, Alert, oriented to 3 spheres (person, time, place), wears
appropriate clothes for weather and temperature, clothes are clean and appropriate for the environment. Px is
calm, euthymic, and not emotionally labile. Mood is appropriate and is consistent with what affect. Px speech is
clear and not rapid or slow. No spontaneous involuntary movements were observed. No illusions,
hallucinations, delusions, or suicidal thoughts were elicited.

IM
(make the patient walk first)
Patient is Ambulatory (wheel-chaired borne/stretcher-borne) with good posture, is able to stand and
walk steadily in a vertical position, with a sthenic (hypo/hyper/asthenic) symmetrical body habitus. No jaundice,
no scars, and no distinctive facies like low set ears, wide spaced eyes, or facial palsy were observed. Px
appears to be comfortable and not in pain or cardiorespiratory distress.

(ask patient person, place, and time, illusions, hallucinations, delusions, suicidal thoughts, mood, and memory)
PX is Conscious, Coherent, Alert, oriented to 3 spheres (person, time, place), wears appropriate
clothes for weather and temperature, clothes are clean and appropriate for the environment. Px is calm,
euthymic, and not emotionally labile. Mood is appropriate and is consistent with what affect. Px speech is clear
and not rapid or slow. No spontaneous involuntary movements were observed. No illusions, hallucinations,
delusions, or suicidal thoughts were elicited. Px’s immediate, recent, and remote memory is intact.
Perceptual Disturbance/Thought Disturbance
Assess if the patient is experiencing ILLUSIONS, ask if they see an object in a room and once they look away and give it a second look it is a different
object.
 ●​ e.g Commonly seen in movies or shows that the scene is in desert and the individual is very thirsty and having an illusion that the sand he is
seeing is water
2. Assess if the patient is experiencing HALLUCINATIONS, ask if they are experiencing a sensory experience (hearing, seeing, feeling etc.) but when
they check to see the source of the stimuli there is none.
●​ e.g “Minsan po ba may naririnig kayo tapos pag tingin niyo wala naman?”
●​ e.g The patient seems to be seeing something or someone that is not really there
●​ This is observed only
3.Assess if the patient is experiencing DELUSIONS, ask if they think about other people talking about them, but upon discovery the people are actually
not.
●​ e.g “Minsan po ba naiisip niyo na pinaguusapan kayo ng mga tao kahit di naman pala?”
●​ e.g “Minsan po ba naiisip niyo na baka may gustong manakit sa inyo o may gustong pumatay sa inyo?”

Immediate Memory provide pt with an address, color, and object seconds to minutes / hrs
Recent Memory same as immediate but ask to repeat AFTER end of NE can pt remember what he ate for breakfast? hrs to days, weeks
Remote Memory recall birthday, wedding date weeks, months, years

Vital Signs

Pediatrics
DO NOT BP WHEN <3 y/o

Temperature

(Bates)
Average Rectal Temp (Infancy & Early childhood): >37.2*C until after age 3 years. Fluctuate as much as 3*F during a
single day (up to 38.3*C in normal children) Never insert rectal thermometer into an infant who can sit up on his own,
especially if its made of glass with mercury
Oral temp should not be taken in children who are too young or unable to understand
Axillary temp are safer to obtain and are usually 0.5C lower than oral.
IM
HR/PR: 60 -100bpm​
RR: 12 -20
BP:
Category Systolic (increments of 20) Diastolic (increments of 10)

Normal <120 <80

Prehypertensive 120-139 80-89

Stage I HTN 140-159 90-99

Stage II HTN >160 >100

Hypotension:
●​ A pressure of 110/70 mm Hg would usually be normal, but could also indicate significant hypotension
if past pressures have been high.
●​ Orthostatic hypotension is a drop in systolic blood pressure of at least 20 mm Hg OR in diastolic
blood pressure of at least 10 mm Hg within 3 minutes of standing
​
Temperature:
●​ Normal 36.5 - 37.5°C
●​ Rectal 38 °C > Oral / Tympanic / Temple 37.5 °C > Axillary 37°C

Anthropometrics

Pediatrics
Head Circumference: (ALWAYS MEASURE if < 2 year)
●​ Prominent glabella to occiput
●​ Average HC: 35 cm at birth (13.5 in.)
●​ HC increases: 1 cm per month for first year (2 cm per month for first 3 months, then slower)
●​ Microcephaly and macrocephaly represent an occipitofrontal circumference 2 or more standard
deviations below or above the mean, respectively.
Growth chart:
●​ Height for age = stunting (moderate or severe)
●​ Weight for age = underweight or severely
●​ Weight for length = wastes or severely
●​ BMI for age = overweight or obese

IM

BMI=kg/m^2
FORMULA: MAMC = MAC (cm) - (0.314 x TSF (mm))

LOSS OF SUBCUTANEOUS FAT

1. Triceps regions of the arms
2. Midaxillary line at the costal margin
3. The interosseous and palmar areas of the hand
4. Deltoids of the shoulder

MUSCLE WASTING
5. Quadriceps femoris
6. Deltoid
1. Diabetes Mellitus

●​ Chief Complaint:​
“I’ve been extremely thirsty and urinating much more frequently than usual.”
●​ Historical Salient Features:
○​ Polyuria, polydipsia, and unexplained weight loss
○​ Blurred vision and fatigue
○​ History of gestational diabetes or a family history of diabetes
○​ Risk factors: obesity, sedentary lifestyle
●​ Physical Exam Salient Features:
○​ Overweight/obese habitus
○​ Dry mucous membranes (signs of dehydration)
○​ Acanthosis nigricans on the neck or axillae
●​ Differentials and Reasoning:
○​ Diabetes Insipidus:
■​ Less Likely: Typically presents with polyuria and polydipsia without weight loss, blurred vision, or
hyperglycemia.
■​ More Likely: In the absence of hyperglycemia, it would be considered; however, the presence of weight loss
and acanthosis nigricans favors diabetes mellitus.
○​ Stress-Induced Hyperglycemia:
■​ Less Likely: Generally a transient condition seen during acute illness; it doesn’t account for chronic
symptoms or obesity-related findings.
○​ Medication-Induced Hyperglycemia:
■​ Less Likely: Requires a history of steroid or other drug use, which is not provided.
○​ Conclusion: The patient’s risk factors and chronic symptoms point more strongly to diabetes mellitus.

2. Systemic Lupus Erythematosus (Lupus)

●​ Chief Complaint:​
“I have joint pain and a rash on my face that seems to flare up with sun exposure.”
●​ Historical Salient Features:
○​ Malar (“butterfly”) rash with photosensitivity
○​ Migratory arthralgias/arthritis affecting small joints
○​ Fatigue and possible serositis (e.g., pleuritic chest pain)
○​ Family history of autoimmune disorders
●​ Physical Exam Salient Features:
○​ Erythematous malar rash and possible discoid lesions
○​ Joint tenderness/swelling with signs of synovitis
○​ Possible pericardial or pleural rub if serositis is present
●​ Differentials and Reasoning:
○​ Rheumatoid Arthritis:
■​ Less Likely: RA typically shows symmetric joint involvement without the classic malar rash and
photosensitivity.
○​ Dermatomyositis:
■​ Less Likely: Presents with proximal muscle weakness and a heliotrope rash rather than a butterfly rash;
muscle enzymes are usually elevated.
○​ Drug-Induced Lupus:
■​ Less Likely: Would require a history of exposure to an offending medication and often lacks the full spectrum
of systemic findings seen here.
○​ Conclusion: The combination of photosensitive rash and multi-joint pain with systemic symptoms makes SLE the
most likely diagnosis.

3. Rheumatoid Arthritis

●​ Chief Complaint:​
“My hands are very stiff and painful every morning.”
●​ Historical Salient Features:
○​ Prolonged morning stiffness (often >1 hour)
○​ Symmetrical pain in the MCP and PIP joints
○​ Reports of rheumatoid nodules and systemic fatigue
○​ Progressive joint deformity over time
●​ Physical Exam Salient Features:
○​ Swollen, tender, and warm joints with decreased range of motion
○​ Possible joint deformities (swan-neck or boutonniere)
○​ Subcutaneous nodules on extensor surfaces
●​ Differentials and Reasoning:
○​ Osteoarthritis:
■​ Less Likely: OA usually causes pain that worsens with use rather than prolonged morning stiffness and is
typically asymmetric.
○​ Lupus:
■​ Less Likely: Lupus arthritis is less erosive and often accompanies other systemic features like a malar rash.
○​ Psoriatic Arthritis:
■​ Less Likely: May cause similar joint pain but usually includes skin lesions of psoriasis and often an
asymmetric distribution.
○​ Conclusion: The chronic, symmetric, and inflammatory nature of the joint pain with nodules strongly supports
rheumatoid arthritis.

4. Ankylosing Spondylitis

●​ Chief Complaint:​
“I’ve had chronic lower back pain that feels worse in the morning but gets better with movement.”
●​ Historical Salient Features:
○​ Inflammatory back pain with prolonged morning stiffness
○​ Improvement with exercise
○​ Onset typically in young males
○​ Possible history of uveitis or reduced chest expansion
●​ Physical Exam Salient Features:
○​ Decreased lumbar spine mobility and reduced chest expansion
○​ Tenderness along the paraspinal muscles
○​ Positive sacroiliac compression or FABER test
●​ Differentials and Reasoning:
○​ Mechanical Back Pain:
■​ Less Likely: Mechanical pain worsens with activity and improves with rest, unlike the inflammatory pattern
described.
○​ Degenerative Disc Disease:
■​ Less Likely: More common in older individuals and typically presents with localized pain without significant
morning stiffness.
○​ Psoriatic Arthritis:
■​ Less Likely: Although it can affect the spine, it usually includes skin lesions and a less classic inflammatory
back pain pattern.
○​ Conclusion: The young age, morning stiffness, and improvement with exercise make ankylosing spondylitis most
likely.

5. Autoimmune Encephalitis

●​ Chief Complaint:​
“I suddenly started having seizures and significant memory and behavior changes.”
●​ Historical Salient Features:
○​ Rapid onset of neuropsychiatric symptoms (confusion, mood changes)
○​ New-onset seizures or unusual movements
○​ History of a recent viral illness or possible paraneoplastic trigger
○​ Progressive cognitive decline over days to weeks
●​ Physical Exam Salient Features:
○​ Altered mental status with disorientation
○​ Focal neurological deficits, tremors, or myoclonus
○​ Possible signs of meningeal irritation in severe cases
●​ Differentials and Reasoning:
○​ Infectious Encephalitis (e.g., Herpes Simplex):
■​ Less Likely: Typically presents with fever and a focal temporal lobe involvement; a history of viral prodrome
is common but less systemic autoimmune features.
○​ Paraneoplastic Encephalitis:
■​ More Likely: In older patients or those with a known malignancy, but usually associated with autoantibodies;
however, the rapid onset can be seen in both.
○​ Metabolic or Toxic Encephalopathies:
■​ Less Likely: These conditions often have laboratory derangements or exposure histories that aren’t
described here.
○​ Conclusion: The acute neuropsychiatric changes with seizure onset lean toward an autoimmune process.

6. HIV Infection

●​ Chief Complaint:​
“I’ve been losing weight and getting infections that just don’t seem to go away.”
●​ Historical Salient Features:
○​ Unintentional weight loss, chronic diarrhea, and fatigue
○​ Recurrent opportunistic infections (e.g., oral thrush, pneumonia)
○​ History of high‐risk sexual behavior or IV drug use
○​ Night sweats
●​ Physical Exam Salient Features:
○​ Cachectic appearance with generalized lymphadenopathy
○​ Oral thrush or other mucosal lesions
○​ Skin lesions (e.g., Kaposi’s sarcoma) in advanced stages
●​ Differentials and Reasoning:
○​ Tuberculosis:
■​ Less Likely: TB can cause weight loss and night sweats but usually has a more localized pulmonary focus
and a less immunosuppressed history.
○​ Lymphoma:
■​ Less Likely: While lymphoma can mimic these systemic symptoms, the high-risk behaviors and recurrent
infections lean toward HIV.
○​ Other Immunodeficiency States:
■​ Less Likely: The combination of risk factors and opportunistic infections makes HIV the primary concern.
○​ Conclusion: The clinical history strongly supports HIV infection over other immunodeficiency conditions.

7. Scleroderma

●​ Chief Complaint:​
“My skin has become unusually tight, and my fingers turn white and painful in the cold.”
●​ Historical Salient Features:
○​ Gradual onset of skin thickening and tightening
○​ History of Raynaud’s phenomenon with color changes in the fingers/toes
○​ Dysphagia and reflux indicating esophageal involvement
○​ Fatigue and joint discomfort
●​ Physical Exam Salient Features:
 ○​ Thickened, shiny skin especially on the hands (sclerodactyly)
○​ Telangiectasias and digital ulcerations
○​ Reduced range of motion in affected joints
●​ Differentials and Reasoning:
○​ Mixed Connective Tissue Disease:
■​ Less Likely: Although it shares features, MCTD often includes high titers of anti-U1 RNP antibodies and
overlapping signs not prominent here.
○​ Systemic Lupus Erythematosus:
■​ Less Likely: Lupus typically presents with a malar rash and less prominent skin thickening.
○​ Dermatomyositis:
■​ Less Likely: Usually has proximal muscle weakness and a heliotrope rash rather than diffuse skin tightening.
○​ Conclusion: The combination of skin tightening, Raynaud’s, and esophageal symptoms points most strongly to
scleroderma.

8. Cardiovascular Disease (Coronary Artery Disease)

●​ Chief Complaint:​
“I experience a squeezing chest pain when I’m exerting myself, and sometimes it even travels down my left arm.”
●​ Historical Salient Features:
○​ Exertional chest pain (angina) that improves with rest or nitroglycerin
○​ Shortness of breath and fatigue during activity
○​ Presence of risk factors (hypertension, diabetes, hyperlipidemia, smoking)
○​ Family history of early heart disease
●​ Physical Exam Salient Features:
○​ Often normal at rest; during an episode, tachycardia or mild distress may be noted
○​ A possible S4 heart sound or soft systolic murmur
●​ Differentials and Reasoning:
○​ Stable vs. Unstable Angina:
■​ More Likely: The description of predictable pain with exertion suggests stable angina rather than an acute
coronary syndrome.
○​ Gastroesophageal Reflux Disease (GERD):
■​ Less Likely: GERD pain is usually burning and positional, not typically exertional with radiation to the arm.
○​ Musculoskeletal Chest Pain:
■​ Less Likely: Musculoskeletal pain is often reproducible with palpation and does not typically come with
exertional dyspnea.
○​ Conclusion: The classic description and risk factor profile make coronary artery disease the most likely diagnosis.

9. Chronic Fatigue Syndrome

●​ Chief Complaint:​
“I feel exhausted all the time, even after a full night’s sleep.”
●​ Historical Salient Features:
○​ Persistent, unexplained fatigue lasting more than 6 months
○​ Post-exertional malaise and “brain fog”
○​ Nonrestorative sleep
○​ Multiple evaluations with no clear alternative diagnosis
●​ Physical Exam Salient Features:
○​ Generally normal exam; the patient may appear listless or low energy
○​ No focal abnormalities on examination
●​ Differentials and Reasoning:
○​ Depression:
■​ Less Likely: While fatigue is common in depression, the profound post-exertional worsening and absence of
pervasive low mood may favor CFS.
○​ Hypothyroidism:
■​ Less Likely: Hypothyroidism would usually include other signs (e.g., weight gain, cold intolerance) that are
either absent or already accounted for.
○​ Fibromyalgia:
■​ Less Likely: Fibromyalgia features widespread pain and tender points, which are not the primary complaints
here.
○​ Sleep Apnea:
■​ Less Likely: Typically associated with obesity and witnessed apneas; the history doesn’t mention such
features.
○​ Conclusion: The chronic, unexplained fatigue with post-exertional malaise makes chronic fatigue syndrome most
likely.

10. Chronic Renal Disease (Chronic Kidney Disease)

●​ Chief Complaint:​
“I’ve been feeling very tired, and my legs are swollen.”
●​ Historical Salient Features:
○​ Decreased urine output and episodes of fluid retention
○​ Fatigue, nausea, and poor appetite
○​ History of diabetes and/or hypertension
○​ Uremic symptoms in more advanced stages
●​ Physical Exam Salient Features:
○​ Periorbital and peripheral (pitting) edema
○​ Elevated blood pressure
○​ Pallor and signs of fluid overload (e.g., pulmonary crackles, S3 gallop)
●​ Differentials and Reasoning:
○​ Congestive Heart Failure:
 ■​ Less Likely: While CHF can cause edema, the history of abnormal kidney function and uremic symptoms
makes CKD more likely.
○​ Liver Cirrhosis:
■​ Less Likely: Cirrhosis may cause edema but typically has stigmata of chronic liver disease (e.g., jaundice,
ascites) that are not present here.
○​ Acute Kidney Injury:
■​ Less Likely: The chronicity of symptoms (tiredness, edema over time) supports CKD rather than an acute
injury.
○​ Conclusion: The long-term history of risk factors combined with uremic signs and fluid overload points toward
chronic kidney disease.

11. Crohn's Disease

●​ Chief Complaint:​
“I’ve been having crampy abdominal pain and chronic diarrhea with occasional blood.”
●​ Historical Salient Features:
○​ Intermittent, crampy abdominal pain worsening after meals
○​ Chronic diarrhea, sometimes bloody, with weight loss and malnutrition
○​ History of perianal disease (fistulas, abscesses)
○​ Possible extraintestinal manifestations (joint pain, skin lesions)
●​ Physical Exam Salient Features:
○​ Abdominal tenderness, especially in the right lower quadrant
○​ Possible palpable masses or distention
○​ Perianal inspection may reveal fissures or fistulas
●​ Differentials and Reasoning:
○​ Ulcerative Colitis:
■​ Less Likely: Typically presents with continuous colonic involvement and rectal bleeding rather than skip
lesions and perianal disease.
○​ Irritable Bowel Syndrome:
■​ Less Likely: IBS does not cause weight loss, bleeding, or systemic inflammatory signs.
○​ Infectious Colitis:
■​ Less Likely: Usually more acute in onset and not associated with the chronic course seen here.
○​ Conclusion: The chronic, relapsing course with systemic and perianal findings makes Crohn’s disease the most
likely diagnosis.

12. Dactylitis

●​ Chief Complaint:​
“My finger is swollen from end to end and it hurts a lot.”
●​ Historical Salient Features:
○​ Diffuse “sausage-like” swelling of an entire digit accompanied by pain
○​ History of similar episodes, especially with known psoriatic arthritis
○​ Intermittent nature with associated joint pain elsewhere
○​ No significant trauma
●​ Physical Exam Salient Features:
○​ Uniform swelling and tenderness along the entire digit
○​ Reduced range of motion in the affected finger
○​ Overlying skin may be slightly erythematous
●​ Differentials and Reasoning:
○​ Septic Arthritis:
■​ Less Likely: Septic arthritis is usually monoarticular with systemic signs of infection (fever, severe localized
pain) and not typically diffuse over the entire digit.
○​ Gout:
■​ Less Likely: Gout often involves the first metatarsophalangeal joint and has a more acute onset with intense
pain and redness, often in older patients.
○​ Trauma-Related Swelling:
■​ Less Likely: There is no history of injury or trauma, making an inflammatory arthropathy (e.g., psoriatic
arthritis) more likely.
○​ Conclusion: The description of a “sausage digit” with a recurrent pattern strongly supports an inflammatory cause
such as psoriatic arthritis.

13. Kawasaki Disease (Pediatric)

●​ Chief Complaint (Parent’s Report):​

“My child has had a high fever for over five days, and I’ve noticed red eyes and a rash.”
●​ Historical Salient Features:
○​ Prolonged fever (≥5 days) unresponsive to typical antipyretics
○​ Red, cracked lips, “strawberry tongue,” and irritability
○​ Polymorphous rash and swelling/redness of hands and feet
○​ Cervical lymphadenopathy reported by parents
●​ Physical Exam Salient Features:
○​ Bilateral conjunctival injection (nonpurulent)
○​ Red, cracked lips and a strawberry tongue
○​ Diffuse rash over the trunk and extremities
○​ Swollen hands/feet and palpable cervical lymph nodes
●​ Differentials and Reasoning:
○​ Scarlet Fever:
■​ Less Likely: Scarlet fever usually presents with a sandpaper-like rash and is associated with streptococcal
infection, but lacks the classic mucosal changes seen in Kawasaki.
○​ Viral Exanthems:
 ■​ Less Likely: These are typically milder, with a shorter duration of fever and less pronounced mucosal
involvement.
○​ Stevens-Johnson Syndrome:
■​ Less Likely: SJS involves mucosal erosions and a more severe clinical course; the presentation here is
more consistent with Kawasaki’s clinical criteria.
○​ Conclusion: The constellation of prolonged fever, mucocutaneous findings, and limb changes makes Kawasaki
disease the most likely diagnosis.

14. Leukonychia

●​ Chief Complaint:​
“I’ve noticed white spots on my nails.”
●​ Historical Salient Features:
○​ Small white spots or lines on the nails
○​ Often associated with minor nail trauma or habitual nail biting
○​ No associated pain or systemic symptoms
●​ Physical Exam Salient Features:
○​ Localized white discoloration on the nail plates
○​ Otherwise normal nail bed appearance without inflammation
●​ Differentials and Reasoning:
○​ Nail Trauma:
■​ More Likely: A common cause of leukonychia, especially with a history of trauma or nail biting.
○​ Fungal Infection:
■​ Less Likely: Fungal infections often cause additional nail thickening or discoloration beyond isolated white
spots.
○​ Nutritional Deficiencies/Arsenic Poisoning:
■​ Less Likely: These would typically present with other systemic findings; isolated nail changes without
systemic signs make these less likely.
○​ Conclusion: The history and isolated finding make trauma-induced leukonychia the most likely explanation.

15. Mucous Retention Cyst (Mucocele)

●​ Chief Complaint:​
“I have a small, painless bump on the inside of my lower lip.”
●​ Historical Salient Features:
○​ Intermittent appearance of a soft, painless bump inside the mouth
○​ History of repeated lip biting or local trauma
○​ No systemic symptoms or fever
●​ Physical Exam Salient Features:
○​ A well-circumscribed, fluctuant nodule on the inner lip
○​ Non-tender on palpation with a smooth surface
●​ Differentials and Reasoning:
○​ Fibroma:
■​ Less Likely: Fibromas are usually firmer and result from chronic irritation rather than the cystic, fluctuating
nature of a mucocele.
○​ Salivary Gland Cyst:
■​ More Likely: Similar in presentation, but mucoceles are more common on the lower lip.
○​ Minor Salivary Gland Neoplasm:
■​ Less Likely: Neoplasms tend to be persistent and may not have the intermittent course seen with
mucoceles.
○​ Conclusion: The intermittent, painless nature with a history of trauma supports a diagnosis of mucocele.

16. Pincer Nail

●​ Chief Complaint:​
“My nails are curving inward and causing painful pressure on my fingertips.”
●​ Historical Salient Features:
○​ Gradual onset of nail curvature leading to discomfort
○​ Pain at the fingertips, especially with pressure
○​ Difficulty with daily tasks; no acute injury reported
○​ Possible family history or association with psoriasis
●​ Physical Exam Salient Features:
○​ Marked transverse curvature of the nail plates
○​ Tenderness along the nail bed with visible deformity
○​ Inward curving that may compress the underlying soft tissue
●​ Differentials and Reasoning:
○​ Onychomycosis (Fungal Infection):
■​ Less Likely: Fungal infections often produce thickened, discolored nails rather than a distinct pincer
deformity.
○​ Traumatic Nail Dystrophy:
■​ Less Likely: Requires a history of acute injury; the gradual onset makes a chronic process more likely.
○​ Psoriatic Nail Dystrophy:
■​ More Likely: Nail changes in psoriasis can include pincer nail deformities, supporting an underlying
inflammatory process.
○​ Conclusion: The clinical history and exam findings favor a pincer nail likely secondary to an inflammatory or chronic
process.

17. Psoriasis
●​ Chief Complaint:​
“I have red, scaly patches on my elbows and knees that are really itchy.”
●​ Historical Salient Features:
○​ Recurring, well-demarcated red, scaly patches on extensor surfaces and scalp
○​ Episodes triggered by stress or seasonal changes
○​ Reports of itching and sometimes joint pain (psoriatic arthritis)
○​ Family history of similar skin issues
●​ Physical Exam Salient Features:
○​ Erythematous plaques with silvery scales on elbows, knees, or scalp
○​ Nail pitting or onycholysis
○​ Possible joint swelling or tenderness if psoriatic arthritis is present
●​ Differentials and Reasoning:
○​ Eczema:
■​ Less Likely: Eczema tends to have a more ill-defined, weepy appearance rather than well-demarcated
plaques.
○​ Seborrheic Dermatitis:
■​ Less Likely: Usually affects the scalp and face with greasy scales rather than extensor surfaces.
○​ Fungal Skin Infections:
■​ Less Likely: These would typically present with annular lesions and central clearing, unlike psoriasis.
○​ Conclusion: The classic appearance and distribution make psoriasis the most likely diagnosis.

18. Adrenal Disorders (e.g., Addison’s Disease)

●​ Chief Complaint:​
“I’ve been extremely fatigued, lost weight, and noticed my skin getting darker.”
●​ Historical Salient Features:
○​ Progressive fatigue and significant unintentional weight loss
○​ Reports of hyperpigmentation in unusual areas (creases, scars)
○​ History of nausea, salt cravings, and episodes of lightheadedness
○​ Possible family history of autoimmune disorders
●​ Physical Exam Salient Features:
○​ Diffuse hyperpigmentation, especially in skin creases and scars
○​ Low blood pressure with signs of dehydration
○​ A thin, wasted appearance in advanced disease
●​ Differentials and Reasoning:
○​ Hypothyroidism:
■​ Less Likely: While fatigue and weight gain (or loss) may overlap, hypothyroidism does not cause
hyperpigmentation.
○​ Chronic Fatigue Syndrome:
■​ Less Likely: CFS lacks the hyperpigmentation and salt craving characteristic of adrenal insufficiency.
○​ Secondary Adrenal Insufficiency:
■​ Less Likely: Typically lacks the hyperpigmentation because ACTH levels are low.
○​ Conclusion: The presence of hyperpigmentation and salt craving strongly favors primary adrenal insufficiency
(Addison’s disease).

19. Thromboangiitis Obliterans (Buerger’s Disease)

●​ Chief Complaint:​
“I experience severe pain in my hands and feet when I’m active, and sometimes small sores develop.”
●​ Historical Salient Features:
○​ Intermittent claudication with pain in the distal extremities
○​ History of non-healing ulcers or sores on fingers and toes
○​ Strong, long-term tobacco use
○​ Pain may occur at rest in cold weather
●​ Physical Exam Salient Features:
○​ Diminished or absent peripheral pulses in affected limbs
○​ Cool, pale extremities with trophic changes (ulcerations, gangrene)
○​ Signs of collateral vessel formation in some cases
●​ Differentials and Reasoning:
○​ Atherosclerotic Peripheral Arterial Disease:
■​ Less Likely: Typically occurs in older patients with generalized atherosclerotic risk factors rather than a
young smoker.
○​ Other Systemic Vasculitides:
■​ Less Likely: These often involve systemic inflammatory signs and multi-organ involvement, not isolated to
the distal extremities.
○​ Raynaud’s Phenomenon:
■​ Less Likely: While it causes color changes, it rarely leads to ulcerations or severe claudication.
○​ Conclusion: The strong history of tobacco use combined with distal ischemic changes makes Buerger’s disease
most likely.

20. Cancer (Example: Lung Cancer)

●​ Chief Complaint:​
“I’ve had a persistent cough that just won’t go away, and I’ve lost a lot of weight recently.”
●​ Historical Salient Features:
○​ Chronic cough progressively worsening over months
○​ Unexplained significant weight loss, fatigue, and occasional hemoptysis
○​ History of smoking or environmental toxin exposure
○​ Poor response to standard treatments for respiratory infections
●​ Physical Exam Salient Features:
○​ Cachectic appearance and possible digital clubbing
 ○​ Lung exam may reveal wheezes, crackles, or decreased breath sounds
○​ Palpable lymphadenopathy in cervical/supraclavicular regions in some cases
●​ Differentials and Reasoning:
○​ Infectious Processes (e.g., TB, Pneumonia):
■​ Less Likely: While infections can cause cough and weight loss, the chronicity, smoking history, and clubbing
are more suggestive of malignancy.
○​ Benign Lung Nodules:
■​ Less Likely: They typically do not cause systemic “B” symptoms such as significant weight loss.
○​ Other Inflammatory Lung Diseases:
■​ Less Likely: These rarely produce the marked constitutional symptoms seen in lung cancer.
○​ Conclusion: The patient’s long-term risk factors and systemic signs strongly favor a diagnosis of lung cancer.

21. Gardner’s Syndrome

●​ Chief Complaint:​
“I was told I have multiple colon polyps, and now I’m noticing bony bumps on my jaw.”
●​ Historical Salient Features:
○​ History of colon polyps detected on routine screening
○​ Reports of extra-colonic manifestations such as osteomas or dental abnormalities
○​ Family history of familial adenomatous polyposis (FAP) or early colon cancer
○​ Occasional mild abdominal discomfort or altered bowel habits
●​ Physical Exam Salient Features:
○​ Palpable bony prominences (osteomas) on the jaw or skull
○​ Dental abnormalities noted during oral examination
○​ Subcutaneous nodules or cysts may be present
●​ Differentials and Reasoning:
○​ Other Variants of FAP:
■​ More Likely: Gardner’s syndrome is considered a variant of FAP with extracolonic features.
○​ Sporadic Colon Polyps:
■​ Less Likely: The presence of bony lesions and family history makes sporadic polyps less likely.
○​ Desmoid Tumors:
■​ Less Likely: While seen in FAP, they are not typically associated with the bony changes described here.
○​ Conclusion: The combination of colonic polyps and extracolonic findings supports Gardner’s syndrome.

22. Hypertension

●​ Chief Complaint:​
“I’ve been having frequent headaches and occasional dizziness, and my home blood pressure readings have been high.”
●​ Historical Salient Features:
○​ History of recurrent headaches and dizziness
○​ Multiple elevated blood pressure readings at home
○​ Sedentary lifestyle with a high-salt diet
○​ Family history of hypertension or cardiovascular disease
●​ Physical Exam Salient Features:
○​ Elevated blood pressure on measurement
○​ Fundoscopic exam may reveal signs of hypertensive retinopathy in chronic cases
○​ Often a normal cardiac and lung exam, though obesity may be noted
●​ Differentials and Reasoning:
○​ White Coat Hypertension:
■​ Less Likely: Although it can cause transient elevation in the clinic, home readings remain high in this case.
○​ Secondary Hypertension (Renal, Endocrine):
■​ Less Likely: These are considered if there is refractory hypertension or other specific signs; the risk factor
profile here is more consistent with primary hypertension.
○​ Anxiety-Related Symptoms:
■​ Less Likely: Anxiety might cause transient increases in BP but not sustained hypertension with associated
end-organ effects.
○​ Conclusion: The consistent high blood pressure readings along with risk factors support primary hypertension.

23. Hypothyroidism

●​ Chief Complaint:​
“I feel constantly tired, have gained weight, and can’t seem to stay warm.”
●​ Historical Salient Features:
○​ Persistent fatigue, weight gain, and cold intolerance
○​ Reports of constipation, dry skin, slowed thinking, and menstrual irregularities
○​ Family history of thyroid disorders
●​ Physical Exam Salient Features:
○​ Bradycardia and a generally slowed demeanor
○​ Dry, coarse, and cool skin with non-pitting edema (myxedema)
○​ Delayed relaxation of deep tendon reflexes
○​ Possible goiter or thyroid enlargement
●​ Differentials and Reasoning:
○​ Depression:
■​ Less Likely: While fatigue is common in depression, the constellation of cold intolerance, weight gain, and
specific physical findings (goiter, myxedema) strongly point to hypothyroidism.
○​ Chronic Fatigue Syndrome:
■​ Less Likely: CFS does not typically cause weight gain, cold intolerance, or the specific physical signs noted
here.
○​ Adrenal Insufficiency:
■​ Less Likely: Adrenal insufficiency usually features weight loss and hyperpigmentation rather than weight
gain and cold intolerance.
 ○​ Anemia:
■​ Less Likely: Although anemia causes fatigue, it does not explain the weight gain, cold intolerance, and skin
changes.
○​ Conclusion: The combination of symptoms and exam findings strongly favors hypothyroidism.

24. Influenza

●​ Chief Complaint:​
“I developed a high fever, body aches, and a cough almost overnight.”
●​ Historical Salient Features:
○​ Sudden onset of high fever, chills, myalgia, and headache
○​ Respiratory symptoms: cough, sore throat, and nasal congestion
○​ Possible gastrointestinal upset (nausea, vomiting)
○​ History of exposure (e.g., outbreak at work or school) during flu season
●​ Physical Exam Salient Features:
○​ Elevated temperature with tachycardia
○​ Diffuse muscle tenderness
○​ Pharyngeal erythema and swollen cervical lymph nodes
○​ Lung exam typically with clear or minimally affected breath sounds
●​ Differentials and Reasoning:
○​ Common Cold (Rhinovirus):
■​ Less Likely: The severity and systemic symptoms (high fever, significant myalgia) exceed what is typically
seen with a common cold.
○​ COVID-19:
■​ Less Likely: Although there is overlap, the loss of taste and smell are more characteristic of COVID-19; here,
the presentation is more typical for influenza.
○​ Bacterial Pneumonia:
■​ Less Likely: Bacterial pneumonia usually presents with localized lung findings (e.g., crackles, consolidation)
and a more protracted course.
○​ Respiratory Syncytial Virus (RSV) Infection:
■​ Less Likely: RSV is more common in young children or the elderly and typically presents with wheezing; the
classic flu picture is more consistent with influenza.
○​ Conclusion: The acute, severe systemic symptoms during flu season strongly support influenza as the diagnosis.

1. Acute Viral Hepatitis

●​ Chief Complaint:​
“I’ve been feeling very fatigued, and my eyes and skin have started to turn yellow over the past week.”
●​ Historical Salient Features:
○​ Sudden onset of malaise, anorexia, nausea, and right upper quadrant discomfort
○​ Dark urine and pale-colored stools
○​ Recent travel to an endemic area or possible exposure (e.g., contaminated food/water, IV drug use)
●​ Physical Exam Salient Features:
○​ Icteric sclera and generalized jaundice
○​ Tender hepatomegaly with right upper quadrant tenderness
○​ Low-grade fever may be present
●​ Differentials and Reasoning:
○​ Acute Hepatitis A/B:
■​ More Likely: The acute onset with classic jaundice and stool/urine changes along with risk factors supports
viral hepatitis.
○​ Autoimmune Hepatitis:
■​ Less Likely: Typically presents with a more insidious onset and may be associated with other autoimmune
markers.
○​ Obstructive Cholestasis (e.g., Gallstones):
■​ Less Likely: Although dark urine and pale stools can occur, the absence of colicky pain and the acute viral
prodrome make this less likely.
○​ Conclusion: The overall clinical picture strongly favors an acute viral hepatitis diagnosis.

2. Alcoholic Liver Disease (Alcoholic Hepatitis/Cirrhosis)

●​ Chief Complaint:​
“I’ve noticed my skin turning yellow, my abdomen feels swollen, and I’m extremely tired.”
●​ Historical Salient Features:
○​ Long-term heavy alcohol consumption with possible binge episodes
○​ History of previous episodes of jaundice or abdominal pain
○​ Poor nutritional status and possible cognitive changes (suggestive of hepatic encephalopathy)
●​ Physical Exam Salient Features:
○​ Jaundice with a nodular, shrunken liver on palpation
○​ Ascites, spider angiomata, and palmar erythema
○​ Asterixis or other signs of hepatic encephalopathy in advanced cases
●​ Differentials and Reasoning:
○​ Non-Alcoholic Fatty Liver Disease (NAFLD):
■​ Less Likely: In the presence of a clear history of heavy alcohol use, NAFLD is less favored.
○​ Acute Viral Hepatitis:
■​ Less Likely: The chronicity and stigmata of advanced liver disease (e.g., portal hypertension) favor an
alcoholic etiology over an acute viral process.
○​ Autoimmune Hepatitis:
■​ Less Likely: Would be considered in the absence of heavy alcohol use and with different serological
markers.
○​ Conclusion: The chronic heavy alcohol consumption combined with stigmata of end‐stage liver disease points to
alcoholic liver disease with cirrhosis.
3. Non-Alcoholic Fatty Liver Disease (NAFLD/NASH)

●​ Chief Complaint:​
“I was told my liver looks enlarged on an ultrasound, and I’ve been feeling unusually tired with some right upper quadrant
discomfort.”
●​ Historical Salient Features:
○​ Often asymptomatic or vague symptoms like fatigue
○​ Associated with obesity, type 2 diabetes, dyslipidemia, and metabolic syndrome
○​ Sedentary lifestyle and poor dietary habits
●​ Physical Exam Salient Features:
○​ Mild hepatomegaly with a smooth liver edge
○​ Overweight or obese body habitus with central adiposity
○​ No stigmata of advanced liver disease (e.g., no jaundice, ascites, or spider angiomata)
●​ Differentials and Reasoning:
○​ Alcoholic Liver Disease:
■​ Less Likely: If the patient denies significant alcohol use, NAFLD becomes more likely.
○​ Acute Viral Hepatitis:
■​ Less Likely: The absence of acute symptoms (jaundice, dark urine, pale stools) favors a chronic metabolic
process.
○​ Conclusion: The metabolic risk factors and mild hepatomegaly point toward NAFLD/NASH.

4. Cirrhosis (End-Stage Liver Disease)

●​ Chief Complaint:​
“I’ve developed a swollen abdomen, my legs are very puffy, and I’ve been getting confused lately.”
●​ Historical Salient Features:
○​ History of chronic liver disease (due to alcohol, viral hepatitis, or NAFLD)
○​ Progressive fatigue, anorexia, and weight loss
○​ Episodes of confusion or disorientation suggesting hepatic encephalopathy
●​ Physical Exam Salient Features:
○​ Jaundice, ascites (shifting dullness), and peripheral edema
○​ Splenomegaly and signs of portal hypertension (caput medusae)
○​ A nodular, firm liver on palpation
●​ Differentials and Reasoning:
○​ Acute Hepatic Failure:
■​ Less Likely: The chronic history and portal hypertension features favor cirrhosis rather than an acute
process.
○​ Cardiac Congestion (Right Heart Failure):
■​ Less Likely: While congestive hepatopathy can mimic some findings, the presence of stigmata like spider
angiomata and a nodular liver is more consistent with cirrhosis.
○​ Conclusion: The long-standing history combined with physical exam findings of portal hypertension supports a
diagnosis of cirrhosis.

5. Hepatocellular Carcinoma (HCC)

●​ Chief Complaint:​
“I’ve been losing weight unexpectedly and have a constant, dull pain in my right upper abdomen; my doctor mentioned a liver
mass on my scan.”
●​ Historical Salient Features:
○​ History of chronic liver disease or cirrhosis (from alcohol, viral hepatitis, or NAFLD)
○​ Unintentional weight loss, anorexia, and malaise
○​ Sometimes a history of hepatitis B or C infection
●​ Physical Exam Salient Features:
○​ Firm, nodular liver with a palpable mass in the right upper quadrant
○​ Signs of chronic liver disease (jaundice, ascites, spider angiomata) may be present
○​ Cachectic appearance in advanced disease
●​ Differentials and Reasoning:
○​ Liver Metastases:
■​ Less Likely: In the absence of a known primary malignancy elsewhere and with a history of cirrhosis, HCC is
more likely.
○​ Benign Liver Adenoma:
■​ Less Likely: Typically occurs in young women on oral contraceptives and does not usually present with
systemic “B” symptoms.
○​ Conclusion: The history of chronic liver disease combined with a discrete liver mass strongly raises suspicion for
HCC.

Respiratory Infections
1. COVID-19
●​ Chief Complaint:​
“I suddenly developed a fever, a dry cough, and lost my sense of taste and smell.”
●​ Historical Salient Features:
○​ Sudden onset of fever, chills, and muscle aches
○​ Dry cough accompanied by loss or change in taste and smell
○​ Mild shortness of breath and chest tightness
○​ Recent exposure to a confirmed COVID-19 case or attendance at a high-risk gathering
○​ Occurred during a known local outbreak or pandemic period
●​ Physical Exam Salient Features:
○​ Elevated temperature and tachypnea
○​ Mild hypoxia on pulse oximetry
 ○​ Diffuse, bilateral crackles or decreased breath sounds on auscultation
○​ Patient appears fatigued, possibly using accessory muscles for breathing
●​ Differentials and Reasoning:
○​ Influenza or Other Viral URIs
■​ More Likely: Both can cause fever, cough, and myalgia.
■​ Less Likely: Loss of taste and smell is more characteristic of COVID-19, and the exposure history during a
pandemic favors COVID-19 over influenza.
○​ Common Cold (Rhinovirus)
■​ More Likely: If symptoms were mild and primarily upper respiratory (e.g., runny nose, sneezing).
■​ Less Likely: The high fever, severe myalgia, and anosmia are not typical of a common cold.
○​ Allergic Rhinitis (if seasonal)
■​ More Likely: In cases with predominant sneezing, itchy eyes, and clear nasal discharge during allergy
season.
■​ Less Likely: Allergic rhinitis does not cause high fever or loss of taste and smell, making it unlikely in this
context.

2. Tuberculosis (TB)
●​ Chief Complaint:​
“I’ve had a cough that just won’t go away, and I’m losing weight without trying.”
●​ Historical Salient Features:
○​ Persistent cough for three or more weeks, sometimes with blood-tinged sputum
○​ Unintentional weight loss, night sweats, and low-grade fevers
○​ History of exposure to TB or travel/residence in an endemic area
○​ Chronic fatigue and loss of appetite
●​ Physical Exam Salient Features:
○​ Cachectic or ill-looking appearance
○​ Low-grade fever on exam
○​ Lung auscultation may reveal localized crackles or bronchial breath sounds
○​ Possible cervical lymphadenopathy
●​ Differentials and Reasoning:
○​ Chronic Bronchitis or Lung Abscess
■​ More Likely: In older smokers with a productive cough.
■​ Less Likely: The presence of systemic symptoms (night sweats, weight loss) and a known TB exposure
make TB more compelling.
○​ Fungal Lung Infections (e.g., Histoplasmosis)
■​ More Likely: If there is a history of exposure in endemic areas.
■​ Less Likely: TB is more common with the described constitutional symptoms and exposure history unless
proven otherwise by specific tests.
○​ Lung Cancer (in smokers)
■​ More Likely: In older patients with a heavy smoking history and localized findings.
■​ Less Likely: In a younger patient with a prolonged cough, night sweats, and TB exposure, TB is favored.

3. Pneumonia
●​ Chief Complaint:​
“I suddenly started experiencing high fever, a productive cough, and sharp chest pain when I breathe.”
●​ Historical Salient Features:
○​ Acute onset of high fever, chills, and severe malaise
○​ Productive cough with yellow or green sputum
○​ Pleuritic chest pain (worsening with deep breaths)
○​ Shortness of breath or rapid breathing during activity
○​ Often follows or coincides with an upper respiratory infection
●​ Physical Exam Salient Features:
○​ High fever, tachypnea, and elevated heart rate
○​ Dullness to percussion over areas of consolidation
○​ Bronchial breath sounds, crackles, or rales on auscultation
○​ Increased tactile fremitus and egophony in affected segments
●​ Differentials and Reasoning:
○​ Bacterial vs. Viral Pneumonia
■​ More Likely: Bacterial pneumonia is favored by high fever, productive cough, and localized exam findings.
■​ Less Likely: Viral pneumonia tends to have a more diffuse pattern and less productive cough, though
overlap exists.
○​ Acute Bronchitis
■​ More Likely: If the cough were the predominant feature without significant consolidation signs.
■​ Less Likely: The presence of pleuritic chest pain and consolidation findings on exam favor pneumonia.
○​ Pulmonary Embolism
■​ More Likely: If there were a mismatch between severe dyspnea/chest pain and minimal auscultatory
findings.
■​ Less Likely: The presence of high fever, productive cough, and focal lung findings makes embolism less
likely in this scenario.

Cardiac Anomalies
4. Atrial Septal Defect (ASD) – Adult Presentation
●​ Chief Complaint:​
“I’ve been getting unusually short of breath during exercise and sometimes feel my heart racing.”
●​ Historical Salient Features:
 ○​ Long-standing mild exercise intolerance and fatigue
○​ Occasional palpitations during physical activity
○​ History of a childhood heart murmur that was never fully investigated
○​ Chronic, subtle symptoms without acute chest pain or syncope
●​ Physical Exam Salient Features:
○​ Fixed splitting of the second heart sound (S2)
○​ Ejection systolic murmur in the pulmonary area due to increased flow
○​ Benign-appearing exam aside from these cardiac findings
○​ Normal peripheral pulses and no signs of heart failure in mild cases
●​ Differentials and Reasoning:
○​ Other Causes of Exertional Dyspnea (Asthma or Anemia)
■​ More Likely: If there are signs of respiratory distress (wheezing) or laboratory evidence of anemia.
■​ Less Likely: The fixed splitting of S2 and history of a childhood murmur point toward an ASD rather than a
non-cardiac cause.
○​ Arrhythmias (e.g., Premature Atrial Contractions)
■​ More Likely: If palpitations are frequent and documented on ECG.
■​ Less Likely: The specific auscultatory finding (fixed S2 splitting) supports a structural defect over isolated
rhythm issues.
○​ Other Congenital Heart Defects
■​ More Likely: If additional murmur characteristics or imaging suggest another anomaly.
■​ Less Likely: In the presence of classic ASD findings, these are less favored.

5. Ventricular Septal Defect (VSD) – Pediatric Presentation

●​ Chief Complaint (Parent’s Report):​
“My child gets tired very quickly during play and seems to struggle with breathing sometimes.”
●​ Historical Salient Features:
○​ Easy fatigability during play and routine activities
○​ History of recurrent respiratory infections or labored breathing
○​ Poor weight gain or feeding difficulties in infancy
○​ Known heart murmur detected during routine check-ups
●​ Physical Exam Salient Features:
○​ Holosystolic murmur best heard at the left lower sternal border
○​ Signs of increased pulmonary flow (tachypnea, mild respiratory distress)
○​ In larger defects, evidence of volume overload (e.g., hepatomegaly, mild peripheral edema)
○​ Normal peripheral pulses in small, restrictive defects
●​ Differentials and Reasoning:
○​ Other Congenital Heart Defects (e.g., Patent Ductus Arteriosus, ASD)
■​ More Likely: If murmur characteristics differ; however, the holosystolic murmur favors VSD.
■​ Less Likely: If the physical exam and history are consistent with a VSD, other defects are less likely.
○​ Chronic Lung Conditions (Recurrent Infections)
■​ More Likely: If respiratory symptoms are predominant without a murmur.
■​ Less Likely: The presence of a heart murmur and feeding difficulties points more toward a congenital defect.
○​ Anemia
■​ More Likely: If lab work shows low hemoglobin causing exercise intolerance.
■​ Less Likely: A characteristic murmur makes anemia a less likely sole explanation.

6. Heart Failure
●​ Chief Complaint:​
“I’ve been feeling increasingly short of breath, even when I’m just sitting down, and my legs have been swelling a lot.”
●​ Historical Salient Features:
○​ Progressive dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea
○​ Persistent fatigue and reduced exercise tolerance
○​ Notable episodes of leg swelling and unexpected weight gain (fluid retention)
○​ Often a history of hypertension, coronary artery disease, or diabetes
●​ Physical Exam Salient Features:
○​ Elevated jugular venous pressure (JVP) and positive hepatojugular reflux
○​ Bilateral pitting edema in the lower extremities
○​ Pulmonary crackles (rales) suggesting pulmonary edema
○​ Cardiac exam may reveal a displaced or diffuse apical impulse and an S3 gallop
●​ Differentials and Reasoning:
○​ COPD with Right Heart Strain (Cor Pulmonale)
■​ More Likely: In patients with a significant smoking history and primarily right-sided symptoms.
■​ Less Likely: When left-sided failure signs (pulmonary edema, S3) are present, as in this case.
○​ Constrictive Pericarditis
■​ More Likely: If there is a history of pericarditis or radiation therapy, along with a pericardial knock.
■​ Less Likely: The presence of pulmonary congestion and an S3 gallop points toward heart failure rather than
constriction.
○​ Renal or Hepatic Fluid Overload
■​ More Likely: If lab tests reveal significant renal or liver dysfunction.
■​ Less Likely: The history of cardiac risk factors and specific heart exam findings favor heart failure as the
primary diagnosis.

7. Myocardial Infarction (MI)

●​ Chief Complaint:​
“I experienced a sudden, crushing chest pain that radiated to my left arm, and I felt nauseated and sweaty.”
●​ Historical Salient Features:
○​ Sudden, severe, pressure-like or squeezing chest pain unrelieved by rest
○​ Pain radiating to the left arm, neck, or jaw
 ○​ Associated nausea, vomiting, diaphoresis, and shortness of breath
○​ A sense of impending doom and known cardiovascular risk factors (hypertension, diabetes, smoking)
●​ Physical Exam Salient Features:
○​ Patient in acute distress, diaphoretic, and pale
○​ Tachycardia and sometimes hypotension
○​ Cardiac exam may reveal an S4 gallop indicating stiff ventricular compliance
○​ Pulmonary exam might reveal rales if left ventricular failure is present; weak or thready peripheral pulses in shock
●​ Differentials and Reasoning:
○​ Unstable Angina
■​ More Likely: If chest pain occurs at rest without definitive biomarker elevation, suggesting ischemia without
infarction.
■​ Less Likely: The severity and radiation of pain, plus associated symptoms, favor a full MI rather than
unstable angina.
○​ Aortic Dissection
■​ More Likely: If the pain is described as tearing or ripping and radiates to the back with unequal blood
pressures.
■​ Less Likely: In this case, pain radiates classically to the left arm and is associated with coronary risk factors,
making MI more likely.
○​ Pulmonary Embolism
■​ More Likely: In patients with sudden onset dyspnea and pleuritic chest pain accompanied by risk factors for
thrombosis.
■​ Less Likely: The crushing, radiating chest pain and cardiovascular risk profile favor MI.
○​ Gastroesophageal Reflux Disease (GERD)
■​ More Likely: If the pain were burning, postprandial, and relieved by antacids.
■​ Less Likely: The exertional onset, radiation to the arm, and associated autonomic symptoms make MI far
more concerning.
○​ Pericarditis or Musculoskeletal Chest Pain
■​ More Likely: If the pain varies with position or is reproducible on palpation.
■​ Less Likely: The classic ischemic pain pattern and systemic symptoms argue against these etiologies.

Gastroesophageal Reflux Disease (GERD)

8. GERD
●​ Chief Complaint:​
“I keep getting a burning sensation in my chest and throat, especially after meals and when I lie down.”
●​ Historical Salient Features:
○​ Recurrent burning pain in the chest (heartburn) and throat irritation
○​ Reports of regurgitation with a sour or bitter taste
○​ Symptoms worsen when lying down or bending over, improve when upright
○​ Frequent episodes after consuming spicy, fatty foods or large meals
○​ History of self-medicating with over-the-counter antacids that provide temporary relief
●​ Physical Exam Salient Features:
○​ Often a normal cardiovascular and pulmonary exam
○​ Abdominal exam may reveal mild epigastric tenderness
○​ In chronic cases, signs such as dental enamel erosion or halitosis may be observed
○​ Obesity or a protuberant abdomen may be present, suggesting risk factors for GERD
●​ Differentials and Reasoning:
○​ Esophagitis (Erosive or Non-Erosive)
■​ More Likely: If the patient experiences persistent heartburn with evidence of mucosal inflammation on
endoscopy.
■​ Less Likely: If symptoms are strictly positional and respond well to antacids, then a simple GERD diagnosis
is more fitting.
○​ Hiatal Hernia
■​ More Likely: If imaging or endoscopy reveals a herniated stomach segment, contributing to reflux.
■​ Less Likely: In the absence of such findings, reflux alone is more likely the primary issue.
○​ Esophageal Motility Disorders (e.g., Diffuse Esophageal Spasm)
■​ More Likely: When chest pain is intermittent and not clearly related to meals, with dysphagia as an additional
feature.
■​ Less Likely: In this patient, the classic reflux pattern makes a motility disorder less likely.
○​ Functional Heartburn
■​ More Likely: If all structural evaluations (endoscopy, pH monitoring) are normal despite persistent
symptoms.
■​ Less Likely: When there is clear evidence of reflux symptoms correlating with meal timing and positional
changes.