History of Present Illness
Review of Systems
Past Medical History
Physical Examination
Differential Diagnosis
Initial Studies
Lab Results
Diagnosis
Differential Diagnosis 2
Relevant Testing
Test Results
Imaging Results
Test Interpretation
Treatment Orders
Question 1
Question 2
Question 3
About the Case
31-year-old woman with nausea and increased thirst
Physical Examination
General appearance
: Well-appearing female with normal body habitus. She is carrying a bottle of water from which she sips during the evaluation.
Vital signs
:
Temperature: 36.9° C
Pulse: 88 beats/min
Respirations 14/min, oxygen saturation 96%
BP 135/82 mm Hg
Skin
: Normal fair skin.
HEENT
: Unremarkable
Neck
: Jugular venous pressure 5 cm above the clavicle at 45 degrees. Delayed carotid upstrokes.
Pulmonary
: Bilateral and symmetric air entry; no rhonchi, crackles or wheezes.
Cardiovascular
: Normal heart sounds, and jugular venous pressure is normal; no peripheral edema.
Gastrointestinal
: Abdomen is soft, nontender on palpation; bowel sounds are normal. Rectal examination shows moderate amount of soft, brown, heme-negative stool.
Genitourinary
: Unremarkable
Musculoskeletal
: Unremarkable
Neurologic
: Alert and oriented. Muscle tone is generally normal, power is 5/5 in all muscles tested. Reflexes are 2/4 and symmetric in upper and lower extremities; plantar reflexes are downgoing.
Mental status
: Patient reports a decreased mood but no suicidal thoughts.
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