Case I Cc: cough HPI: This is RJ, an 18 month old brought into the office by his mother with

complaints of cough and increasing fussiness. This is his first visit here. According to his mother, RJ was fine until four days ago, when he started having coughing episodes that last about 1-3 minutes. He is having episodes about 3-4 times per hour. She states that the cough is dry, and she has not noticed any blood. She has not noticed anything making the cough better, but she does notice that at times the coughing episodes start around feeding time. Nothing else affects the cough. She feels the cough is getting worse because now he is also having it at night, and has started having a runny nose. She denies fever or trouble breathing. ROS: as per HPI, otherwise as follows: Gen: fussy, not wanting to eat as much as he usually does. Sleeping less due to cough HEENT: watery eyes, stuffy and runny nose Resp: cough, gurgling chest CV: no complaints Heme/Endo: no easy bruising or bleeding, excessive thirst or urination GI: no nausea, vomiting, diarrhea, or constipation, having approximately 2 stool diapers daily GU: no changes in urine color or frequency, having approximately 6 urine diapers daily Neuro/behavior: no concerns Derm: has a red mole on the back of his neck since birth, has been growing Birth history: born of a term, planned pregnancy, spontaneous vaginal delivery. APGARs were 9/9 at birth, though he had to stay in the hospital because he turned yellow Immunizations: up to date as far as mom can recollect, she does not have her vaccine record PMHx: the child has been very healthy, with only occasional colds, and he has not been hospitalized since birth. Meds: Motrin occasionally Allergies: NKDA PSHx: None Family Hx: history of asthma in the mother, otherwise noncontributory Social Hx: the child lives with parents and older brother (5, healthy). Nobody smokes at home, and there are no pets in the household.

Physical Exam VS: T 99.1 P 118 R 22 HC 48 cm L 85 cm W 12.4 Kg

Gen: child appears mildly ill, no acute distress, being held by his mother, has bout of cough Skin: pink, no jaundice, dry appearance, no rash Head: NCAT, fontanelles closed, 3x5cm well-circumscribed erythematous plaque behind R ear, face symmetric. Eyes: PERRLA, EOMI Ears: pinnae normal sized, TMs clear, no erythema or cerumen in canal Nose: nares patent, mucosal membranes bluish, no erythema, slight clear mucus discharge Throat and mouth: MM slightly dry, no pharyngeal erythema, no thrush, teeth in good condition, palate intact Neck: normal contour, no enlarged lymph nodes, trachea midline Chest: symmetric, no retractions, scapulas and clavicles normal Lungs: good air flow bilaterally, no rales or wheezes. Resonant to percussion throughout. Heart: regular rate and rhythm, normal S1 and S2, no murmurs, rubs, or gallops. Abdomen: convex, soft, non-tender, non-distended, bowel sounds normal throughout, no masses palpated GU: normal male genitalia, testes descended bilaterally without hydroceles, anus patent Extremities: moves all extremities well, good hip adduction and abduction, pulses 2+ bilaterally (femoral, popliteal, dorsalis pedis, posterior tibial), muscle tone good, no muscle atrophy Spine and back: straight spine, no spinal defect, no masses Neuro: active, good tone, irritable, negative Babinski, normal cerebellar, cranial nerves intact

Case II Cc: headache HPI: This is MP, a 21 year-old female with no prior medical history who comes into the office with a complaint of recurrent headaches for the past few months. She does not associate any specific life event with the onset of headaches, and she cannot remember if anything she does in particular changes when they occur. She reports that the headaches start at different times during the day, not usually at night. They used to occur about once a week or less, but now she has them 2-3 times per week. She describes the headaches as throbbing and they usually affect her right side, although they have also occurred on the left. They start right behind her eye and then move toward the back, and they are so severe that it feels like her hair hurts and they throw her down for hours at a time. The pain is about a 12 on the scale of 10. She does say that she has been nauseated before with the headaches, but she has never vomited. She does not recall seeing floaters or lights, or anything when she gets the headache. Light and noise make the pain worse, and headaches do not wake her up at night. She states that she has tried Advil and Tylenol as well as Midrin, and they used to work, but nothing seems to work anymore. ROS: as per HPI, otherwise as follows: Gen: denies recent weight loss, fatigue, or trouble sleeping. No fever, chills, or recent illnesses. HEENT: no hair problems, head lumps, hearing loss, vision changes, nasal discharge, neck lumps, or sore throat. Resp: no cough, SOB, wheezing, or snoring CV: no chest pain, palpitations, loss of consciousness Heme/Endo: no easy bruising or bleeding, excessive thirst or urination GI: no trouble swallowing, heartburn, blood in stool, diarrhea, or constipation. GU: no excessive vaginal bleeding, dysuria, hematuria, or nocturia. Menstrual cramps. Neuro/behavior: no excessive anxiety, depression, or other concerns Derm: multiple small moles on her back, freckles on her face and upper chest PMHx: none Meds: Advil, Tylenol, and Midrin as needed Allergies: Penicillin-rash PSHx: Tonsillectomy Family Hx: Mother-migraines, anxiety disorder; Father and sister-none Social Hx: She is unmarried, lives with a roommate, currently attends college and is studying criminal justice. She also works as a waitress at a local bar and grill, which is very stressful. Denies smoking, and drugs, and occasionally drinks one or two beers on the weekend with friends.

Physical Exam VS: T 98.8 P 76 R 16 H 1.72 m W 64.3 Kg BMI 21.7

Gen: pleasant young female in no acute distress, wearing glasses Head: NCAT Eyes: PERRLA, EOMI, conjunctiva clear, visual acuity 20/20 bilaterally, visual fields without deficits, fundi without papilledema Ears: normal Nose: nares patent, no discharge Throat and mouth: mucous membranes moist, no pharyngeal erythema, no thrush, teeth in good condition Neck: normal contour, no enlarged lymph nodes, trachea midline Chest: symmetric, scapulas and clavicles normal Lungs: good air flow and clear to auscultation bilaterally, resonant to percussion in all fields Heart: regular rate and rhythm, normal S1 and S2, no murmurs, rubs, or gallops. Abdomen: soft, non-tender, non-distended, bowel sounds normal throughout, no masses, no HSM GU: Deferred Extremities: full ROM, pulses 2+ bilaterally (femoral, popliteal, dorsalis pedis, posterior tibial), normal muscle tone, no muscle atrophy, no clubbing, cyanosis, or edema Spine and back: straight spine, no tenderness Neuro: alert and oriented x4, CN II-XII intact, muscle strength 5/5 upper and lower extremities bilaterally, sensation intact bilaterally, deep tendon reflexes 2+ bilaterally, negative Babinski, cerebellar intact Skin: diffuse, scattered hyper-pigmented macules on face, upper chest, and upper back. No rash.

Case III Cc: cough and leg swelling HPI: This is AR, a 67 year-old male with past medical history of diabetes, hypertension, and osteoarthritis who presents to the clinic with a complaint of cough and leg swelling. He was in his usual state of health until a week ago, when he began having a nagging cough productive of yellow phlegm. The cough comes and goes, but is present daily, is worse at night, and has been getting worse despite him using over the counter cough medicine. He has not noted anything that makes it worse. He also states that he has been feeling congested and has had a runny nose. He denies facial pain, just reports a lot of pressure. He does report chills and one episode of fever last night, though he did not measure the temperature. He denies ear pain or hearing loss. No night sweats. No exposure to sick contacts that he can remember. In addition to the cough, he has also noticed that his legs have been swelling up to his knees since about 1 month ago. He states that his legs are usually fine in the morning, but they get very heavy at the end of the day. He has not noticed any pain associated with the leg swelling, and does not think it is getting worse, but became concerned since he has never had that problem before. He denies any injuries recently. ROS: as per HPI, otherwise as follows: Gen: denies recent weight loss, fatigue, or trouble sleeping. HEENT: no hair problems or head lumps, slight trouble hearing in both ears for a while, no blurry vision or neck lumps. Sore throat for 2 days Resp: no SOB, wheezing, or snoring CV: no chest pain, palpitations, loss of consciousness, no PND, orthopnea, or dyspnea on exertion Heme/Endo: no easy bruising or bleeding, excessive thirst, feels like he urinates more frequently GI: no trouble swallowing, heartburn, blood in stool, diarrhea. Occasional constipation GU: no blood in urine, dysuria, or hematuria. Nocturia, 2-3 times per night Neuro/behavior: no excessive anxiety, depression, or other concerns Derm: no rash, one big mole on his upper back that has always been there PMHx: 1. Diabetes mellitus type 2, diagnosed ten years ago 2. Hypertension, diagnosed ten years ago 3. Osteoarthritis, diagnosed five years ago Meds: 1. 2. 3. 4. 5. 6.

Metformin, 1000 mg PO BID Glyburide, 5 mg PO daily Hydrochlorothiazide, 50 mg PO daily Lisinopril, 20 mg PO daily Amlodipine, 10 mg PO daily Ibuprofen, 400 mg PO TID as needed

Allergies: NKDA PSHx: 1. Tonsillectomy as a child 2. Appendectomy, about 30 years ago Family Hx: Mother-DM 2, osteoarthritis; Father- BPH, Sister-HTN, Brother-HTN Social Hx: He is married, lives with his wife. They had two children who are healthy. He works as a plumber, and is retiring this year after 40 years. Has been smoking since age 25, 1-2 packs per day. Used to drink heavily but stopped about ten years ago. Has never used any illegal drugs

Physical Exam VS: T 98.6 P 80 R 19 H 1.78 m W 94 Kg BMI 29.7

Gen: pleasant, overweight male, visibly ill and coughing occasionally Head: NCAT, well-groomed, mild tenderness to palpation over the maxillary sinuses, sinuses clear on trans-illumination Eyes: PERRLA, EOMI, conjunctiva clear Ears: normal Nose: nares patent, mucous membranes with slight erythema, yellow mucus present Throat and mouth: mucous membranes moist, mild pharyngeal erythema and no exudates, no thrush, missing first 2 mandibular molars on right Neck: normal contour, no enlarged lymph nodes, trachea midline Chest: symmetric, scapulas and clavicles normal Lungs: clear to auscultation bilaterally, resonant to percussion in all fields, no wheezes or rales Heart: regular rate and rhythm, normal S1 and S2, no murmurs, rubs, or gallops. Abdomen: large abdomen, soft, non-tender, non-distended, bowel sounds present, no masses or HSM GU: Deferred Extremities: full ROM, pulses 1+, normal muscle tone, no muscle atrophy, clubbing, or cyanosis. 2+ non-pitting edema present up to knees on lower extremities bilaterally Spine and back: straight spine, no tenderness Neuro: alert and oriented x4, CN II-XII intact, sensation intact bilaterally, feet with dry and scaly nails Skin: No rash or discoloration. Two 4 mm well-circumscribed, evenly hyperpigmented papules on back over right scapula