Putting It All Together How to help students put the pieces together –Helping students be complete in their history taking and then summarizing the important findings on history –Helping students be complete in their physical examination and summarizing the important findings –Helping students put these symptoms and signs together to determine the most likely diagnosis and differential diagnosis

A 16 year old girl from a village 100 km east of Vientiane presents with a new onset of right sided weakness. She also has one month history of intermittent fever. She has no associated respiratory symptoms. She has otherwise been healthy. On physical examination, she has a temperature of 38º and her other vital signs are normal. Examination of the hands reveals splinter hemorrhages under the nails. Examination of the cranial nerves identifies weakness of right lower face. The other cranial nerves are normal. She also has mild weakness and clumsiness of right arm and hand. There are no other neurological signs. The remainder of the head and neck exam is normal. Respiratory exam is normal. On cardiac exam you find a normal JVP, normal S1 & S2 and a Grade III/VI pansystolic murmur. This murmur is best heard over the cardiac apex radiating towards the axilla. The abdominal exam is normal.

Where is the lesion in the nervous system responsible for the right face and right arm weakness? a. Right facial nerve b. Right brachial plexus c. Left cerebral hemisphere d. Left cerebellum e. Cervical spinal cord

What is the most likely pathology causing this neurologic deficit? a. Stroke due to occlusion of internal carotid artery b. Cerebral hemorrhage c.Brain tumor d. Cerebral infarction due to embolus from heart e. Brain abscess

What is the valvular disease causing the heart murmur? a. Aortic stenosis b. Aortic regurgitation (insufficiency) b. Mitral stenosis c. Mitral regurgitation (insufficiency) e. Pulmonary regurgitation (insufficiency)

What is the pathology of the valve? Bacterial Endocarditis

A 30 year old male from Vientiane presents with cough as his chief complaint. He was also in a minor traffic accident 2 weeks ago but did not go to the hospital at that time because he did not seem to have any major injuries. He is otherwise healthy and has no significant past medical history. On examination, he has a temperature of 38º and his other vital signs are normal. His head & neck exam is normal. On respiratory exam his chest is normal on inspection. He has normal chest expansion bilaterally. He has no chest wall tenderness and no crepitus. He has dullness to percussion over the lower posterior right chest. He has decreased air entry and increased tactile fremitus in this same area. His abdominal exam is normal. What is the most likely diagnosis? a. Right pneumothorax b. Right pleural effusion c. Right lower lobe pneumonia d. Right pulmonary embolus e. Right rib fractures

A 45 year old female from Vientiane presents with her chief complaint being palpitations. She has had occasional palpitations for several months, but they are becoming more frequent. She has no associated shortness of breath. Her only associated symptoms include nonbloody diarrhea. On physical examination, she is afebrile, has a normal BP, but has an increased pulse rate of 110. Her pulse is regular. She has proptosis of her eyes. She has no masses in her neck and no generalized lymphadenopathy. Her cardiac, respiratory, and abdominal exam is normal. She has a tremor but her MSK and neurologic exam is otherwise normal. What is the most likely diagnosis? a. Paroxysmal atrial tachycardia b. Bacterial endocarditis c. Parkinson’s disease d. Viral gastroenteritis e. Hyperthyroidism

A 55 year old female who lives in a village 60 km east of Vientiane presents with a one day history of sudden and severe right lower quadrant pain. She has no history of diarrhea but has vomited twice since the pain started. She is postmenopausal and has had no postmenopausal bleeding and no abnormal vaginal discharge. She has no other GI or GU associated symptoms. She has no past medical problems. On physical examination, she is not febrile and her vital signs are normal. Her head and neck, cardiac, and respiratory examination is normal. On abdominal exam, inspection and auscultation are normal. On percussion she has no significant tenderness. She is not tender on light palpation, but on deep palpation in the RLQ, she has mild guarding. She has right flank tenderness on percussion. She has no palpable organomegaly. She has no lymphadenopathy and no groin masses. Rectal examination is normal. What is the most likely diagnosis? a. Perforated appendicitis b. Right ovarian cancer c. Renal colic d. Pelvic inflammatory disease e. Incarcerated right inguinal hernia

A 40 year old married male from Vientiane presents with a 4-6 month history of weight loss (approximately 20 kg). He is a business man and frequently travels out of town. He does smoke. His associated symptoms include at least a one month history of intermittent fever, diarrhea, and cough with nonbloody hemoptysis. On his physical examination, he has a fever of 38º and his other vital signs are normal. He looks thin and unwell. On examination of his mouth, he has oral candidiasis and a herpetic lesion on his lip. He has generalized lymphadenopathy. His cardiac examination is normal. On chest exam he has decreased expansion, decreased air entry, and decreased tactile fremitis in the left lower lobe. Abdominal examination is normal. He has no musculoskeletal or neurologic signs. What is the most likely diagnosis? a. Lung cancer b. Streptococcal lobar pneumonia c. Tuberculosis d. AIDS e. Paragonimiasis

A 45 year old male is a farmer and lives in a village near Saisombun. He came to Vientiane to attend a funeral and while here, developed a one day history of fever. His only associated symptoms include severe headache, and nausea. On physical examination, he has a fever of 39º and his other vital signs are normal. He has a macular rash over his chest and abdomen. His respiratory and cardiac exams are normal. On abdominal exam, he has splenomegaly. He has generalized lymphadenopathy. He has no neurological findings and no muscle weakness. What is the most likely diagnosis? a. Lymphoma b. Scrub typhus c. Malaria d. Melioidosis e. Paragonimiasis

A 7 year old boy who lives in Vientiane presents with a one day history of bloody diarrhea. His mother describes the diarrhea as being frequent (7 times in the last 24 hours). It is loose and contains dark blood. He has some abdominal cramps. He has not had any recent weight loss and has had no health problems in the past. Review of systems identifies no other symptoms. On physical examination his vital signs are normal. His head & neck, respiratory, and cardiac exam is normal. He has diffuse tenderness on abdominal exam on deep palpation. What is the most likely cause of his diarrhea? a. Cholera b. Intestinal worms c. Non-typhoid salmonella d. Rotavirus e. Intussuception