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Case Learning Objectives

Case 1Student will become familiar with the differential diagnosis of acute chest pain and how to narrow the differential based on specific physical exam findings.

Student will be able to define and discuss the pathogenesis, signs, and symptoms of the acute coronary syndromes.

Student will gain an understanding of cardiovascular risk factors and the primary and secondary prevention of ischemic heart disease.

Student should be able to develop an appropriate diagnostic and treatment plan—including recommended lifestyle modifications—for a patient presenting with acute coronary syndrome.


Case 2Categorize the patient's symptoms as angina pectoris, atypical angina, or non-cardiac chest pain.

Obtain, document, and present an appropriately complete medical history that differentiates among the common etiologies of chest pain.

Obtain a history of a patient with chest pain that: (1) contains information about those clinical characteristics that are typical of angina pectoris, and (2) includes risk factors of coronary heart disease.

Perform a physical exam that includes identifying the presence of dyspnea and anxiety, obtaining accurate vital signs, and performing heart, lung, and vascular exams.

Order appropriate laboratory and diagnostic studies based on patient demographics and the most likely etiologies of chest pain.

Recommend primary and secondary prevention of ischemic heart disease through the reduction of cardiovascular risk factors (e.g. controlling hypertension and dyslipidemia, aggressive diabetes management, avoiding tobacco, and aspirin prophylaxis).

Prescribe appropriate anti-anginal medications when indicated and communicate potential adverse reactions.


Case 3List the common causes of syncope.

Determine the important aspects of the history and physical exam in a patient with syncope.

Discuss the approach to the evaluation and treatment of a patient with syncope.

Identify atrial fibrillation on an electrocardiogram.

List the common causes of atrial fibrillation.

Discuss the approach to the evaluation and treatment of a patient with atrial fibrillation.

Explain how atrial fibrillation and mitral stenosis may lead to syncope.

Understand how culture can affect the evaluation and treatment of conditions.


Case 4Interpret neck vein findings for jugular venous distension (JVD) and abdominal jugular reflux.

Identify and translate auscultatory findings of the heart, including: rate, rhythm, S3/S4, and murmurs.

List the major pathologic states that cause dyspnea.

Compare the differing etiologies and signs of left-sided vs. right-sided heart failure.

Utilize the staging system for heart failure.

Discuss the factors leading to symptomatic exacerbation of heart failure, including: ischemia, arrhythmias, anemia, hypertension, thyroid disorders, non-compliance with medications and dietary restrictions, and use of nonsteroidal anti-inflammatory drugs (NSAIDS).

Interpret B-type natriuretic peptide (BNP) results.

Recommend pharmacologic management of heart failure.


Case 5Define fatigue as a common presenting symptom with a broad differential in the primary care setting.

Screen for problem drinking with the CAGE tool.

Follow the U.S. Preventive Task Force recommendations for screening for major depression.

Utilize the Diagnostic and Statistical Manual, 5th Edition (DSM-5), criteria for the diagnosis of major depression.

Distinguish bipolar disorder, dysthymia, and normal reaction to grief or loss from major depression.

Recommend psychotherapy or counseling and appreciate the reluctance of some patients to see mental health professionals.

Select appropriate psychopharmacological therapy considering efficacy and potential side effects.

Identify major barriers to treatment of depression.

Assess the risk for suicide by recognizing risk factors and protective factors.

Determine when to obtain consultation of a psychiatrist.

Plan appropriate follow-up for managing major depression with suicidal features.


Case 6Know the JNC-8 criteria for diagnosing hypertension and initial treatment recommendations.

Learn the etiologies and prevalence of essential and secondary hypertension.

Understand current guidelines for screening.

Perform a targeted physical exam to look for end-organ effects of longstanding hypertension.

Obtain an accurate blood pressure reading.

Diagnose and prescribe treatment for chronic hypertension.

Diagnose and manage an episode of hypertensive urgency or emergency.

Effectively counsel patient about lifestyle modifications to reduce risk of end-organ damage.


Case 7Discuss the definition and differential diagnosis of hypotension, including how to use orthostatic signs and symptoms.

Use the American Diabetes Association (ADA) and the U.S. Preventive Task Force (USPTF) recommendations to screen for diabetes, including recognizing risk factors for diabetes.

Discuss the pathogenesis of type 1 and type 2 diabetes.

Diagnose type 2 diabetes mellitus using the four accepted criteria.

Know the diagnostic criteria for impaired fasting glucose and impaired glucose tolerance.

Calculate anion gap, osmolar gap, and correct sodium to distinguish hyponatremia from pseudohyponatremia.

Define hyperosmolar hyperglycemic state (HHS), including nonketotic coma.

Recognize precipitants and presenting symptoms and signs of HHS and diabetic ketoacidosis (DKA), as well as discuss the pathophysiology for the abnormal laboratory values of each.

Describe the basic management of diabetic ketoacidosis and nonketotic hyperglycemic states, including the similarities and differences in insulin therapy and fluid and electrolyte replacement.

List the ADA-recommended targets for glycemic control for adults.

Understand the differences between types of insulin and the indications for their use.

Counsel diabetic patients appropriately on dietary measures and exercise.


Case 8List the major causes of morbidity and mortality in diabetes mellitus.

Understand the basic management of hypertension and hyperlipidemia in the diabetic patient.

Perform a diabetic foot exam.

Counsel patient on behavior change.

Recognize value of a team approach to the management of diabetes.

Appreciate the impact diabetes mellitus has on a patient’s quality of life, well-being, ability to work, and the family.


Case 9Take a substance abuse history and provide counseling in a non-judgmental manner.

Recognize the clinical presentations of substance abuse and recommend treatment.

Apply diagnostic criteria for alcohol abuse, dependence, and addiction.

Recommend basic prevention and treatment for alcohol withdrawal.

Describe the pathophysiology of the principle types of abdominal pain: parietal, visceral, vascular, referred.

Determine when to consult a surgeon regarding abdominal pain.

Explain the indications and utility of hepatobiliary imaging studies including MRCP and ERCP.


Case 10Perform medication reconciliation upon admission and discharge.

Identify the common causes for and symptoms of upper and lower gastrointestinal blood loss, including recognizing the distinguishing features of each.

Define hematemesis, melena, and hematochezia.

Examine the role of contributing factors in gastrointestinal bleeding such as Helicobacter pylori infection, non-steroidal anti-inflammatory drugs, alcohol, coagulopathies, and chronic liver disease.

Demonstrate the indications for, contraindications to, and complications of blood transfusion, including describing system errors that produce transfusion reactions.

Identify and manage transfusion reactions.

Describe the difference between adverse events and medical errors.

Develop an appropriate evaluation and treatment plan for patients with a gastrointestinal bleed that includes: establishing adequate venous access.

Develop an appropriate evaluation and treatment plan for patients with a gastrointestinal bleed that includes: administering crystalloid fluid resuscitation.

Develop an appropriate evaluation and treatment plan for patients with a gastrointestinal bleed that includes: ordering blood and blood product transfusion.

Develop an appropriate evaluation and treatment plan for patients with a gastrointestinal bleed that includes: determining when to obtain consultation from a gastroenterologist for upper endoscopy.


Case 11Understand pathophysiology of conjugated and unconjugated hyperbilirubinemia.

Describe the common types of liver diseases and their risk factors (including inherited and acquired).

Obtain an appropriate history to elicit risk factors for viral hepatitis.

Be familiar with the CAGE screening tool for alcohol abuse.

Know when to order laboratory tests for evaluation of liver disease and when a liver biopsy might be indicated.


Case 12List symptoms and signs indicative of an acute/surgical abdomen.

Approximate a likelihood ratio of the common causes of abdominal pain based on pain pattern, the quadrant the pain is located, and abdominal exam findings.

Generate a prioritized differential of the most important and likely causes of a patient’s abdominal pain and recognize specific history, physical exam, and laboratory findings that distinguish between the various conditions.

Recommend a basic management plan for diverticulitis.

Describe indications for and methods of deep vein thrombosis prophylaxis.


Case 13Describe principles of disease prevention and screening.

Distinguish among primary, secondary, and tertiary prevention.

List general types of preventive health care issues (e.g., immunizations, exercise) to be addressed routinely in adult patients and understand the effect of patient age and clinical status on the approach to prevention.

Be aware of key factors to consider when selecting a diagnostic test, including: sensitivity, specificity, likelihood ratios, and pretest probabilities.

Describe the epidemiology of colorectal cancer, the utility of available screening methodologies, and current screening recommendations.

Describe the epidemiology of breast cancer, the utility of available screening methodologies, and current screening recommendations.


Case 14Obtain a history that differentiates among etiologies of dysuria.

Distinguish signs and symptoms of lower versus upper urinary tract infection.

Recommend when to order diagnostic and laboratory tests in evaluation of dysuria, including: urinalysis, wet prep, and KOH stain.

Describe current recommendations for cervical cancer screening.

Discuss safe sexual practices and efficacy of common methods of contraception.


Case 15Demonstrate an understanding of the microbiology of upper respiratory infections, highlighting the relative frequencies of viral and bacterial etiologies.

Contrast the pathophysiology and symptomatology of allergic rhinitis and the clinical features that may help differentiate it from the common cold and acute sinusitis.

Recommend symptomatic treatment for upper respiratory infections and the major side effects/contraindications of treatments including: decongestants, non-selective antihistamines, mucolytics, cough suppressants, and pain relievers.

Employ the five A’s and five R’s of smoking cessation: ask, advise, assess, assist, arrange, relevance, risks, rewards, roadblocks, and repetition.

Identify rales, rhonchi, wheezes and signs of pulmonary consolidation.

Decide when a chest x-ray is indicated.

Determine when to prescribe antibiotics and select the most appropriate antibiotic, if warranted.


Case 16Be aware of health implications of obesity.

Assess risk factors for obesity-related changes.

Describe possible physical findings of hypercholesterolemia.

List etiologies of primary and secondary dyslipidemias.

Describe screening recommendations for dyslipidemias in adults.

Understand basic management of common dyslipidemias, including therapeutic lifestyle changes.

Calculate daily caloric requirement to maintain weight and daily caloric requirement for weight loss.


Case 17Describe primary and secondary skin lesions and special features using standard nomenclature.

List the most common causes of a hyperpigmented lesion.

Recognize worrisome features using the ABCDE criteria to assess risk for melanoma.

Discuss the indications for skin biopsy in a patient with a suspicious skin lesion, and describe three ways to perform a skin biopsy.

Explain the dangers of excessive sun exposure and recommend sun protection to prevent sun-related skin injury.

Discuss the differential diagnosis, recognize the pathophysiology and typical presentations, and prescribe appropriate treatment for the common causes of maculopapular eruptions, eczematous dermatoses, leg ulcers, and common skin and oral manifestations of human immunodeficiency virus (HIV) infections and acquired immunodeficiency syndrome (AIDS), including Kaposi’s sarcoma.

Explain and practice prevention of community acquisition of methicillinresistant Staphylococcus aureus (MRSA), including good hygiene practices.


Case 18Describe typical changes in each organ system that occur as part of the normal aging process.

Perform a functional status assessment of the geriatric patient.

Identify risk factors for falls in the elderly patient.

Discuss the components of Medicare (including who and what services are covered).

Become familiar with the presentation of each type of urinary incontinence.

Differentiate among the subtypes of dementia and their associated findings.

Recommend labwork to perform to evaluate reversible causes of dementia.

With guidance, participate in discussing basic issues regarding advance directives with patient and his or her family.


Case 19

Classify the causes of anemia based on red blood cell size.

Understand the meaning and utility of various components of the hemogram (e.g., hemoglobin, hematocrit, mean corpuscular volume, and random distribution width).

Classify anemia into hypoproliferative and hyperproliferative categories using the reticulocyte count/index.

Use information regarding the diagnostic utility of the various tests for iron deficiency (e.g., serum iron, total iron binding capacity, transferrin saturation, ferritin) when selecting a lab evaluation for iron deficiency.

Identify key historical and physical exam findings in the anemic patient.

Recognize common morphologic changes on a peripheral blood smear.

Develop a further evaluation and management plan for a patient with anemia.


Case 20Distinguish between common etiologies of fever of unknown origin (FUO) in immunocompetent patients and those infected with the human immunodeficiency virus (HIV).

Learn the Centers for Disease Control’s (CDC’s) criteria for diagnosis of acquired immunodeficiency syndrome (AIDS).

Discuss principles of antiretroviral therapy, including importance of regimen adherence.

Describe relationship between the CD4+ lymphocyte count and risk of opportunistic infection.

Recognize common HIV-associated infections.

List appropriate diagnostic tests for HIV-positive patient presenting with fever.


Case 21Distinguish among the types of shock and their presentations.

Discuss the common causes for and symptoms of lower gastrointestinal blood loss.

Recommend appropriate empiric therapy for urosepsis based on an understanding of urinary tract infection pathogenesis and resistance patterns.

List elements of physical exam in patient with suspected GI bleed.

Take an accurate blood pressure.

Interpret a urinalysis.

Recommend laboratory and diagnostic tests to evaluate GI bleeding.

Understand the physician’s role when a patient is no longer capable of making medical decisions.


Case 22Discuss the common causes of acute dyspnea, their pathophysiology, symptoms, and signs.

List the common pneumonia pathogens (viral, bacterial, mycobacterial, and fungal) in immunocompetent and immunocompromised hosts.

Describe radiographic findings associated with specific pathogens.

Identify bronchial breath sounds, rales (crackles), rhonchi, and wheezes, signs of pulmonary consolidation, and pleural effusion on physical exam.

Recognize the most common complications of pneumonia.

Recommend when to order diagnostic laboratory tests—including complete blood counts, sputum gram stain and culture, blood cultures, and arterial blood gases—how to interpret those tests, and how to recommend treatment based on these interpretations.

Select an appropriate empiric antibiotic regimen for community-acquired, nosocomial, immunocompromised-host, and aspiration pneumonia, taking into account pertinent patient features.

Discuss the Centers for Medicare and Medicaid Services (CMS) and Joint Commission’s quality measures for smoking cessation advice and vaccination against pneumonia and influenza in patients with pneumonia and other pulmonary disorders.


Case 23List the most common causes of chronic kidney disease.

Describe pathophysiology and clinical signs of uremia.

Tell about the pathophysiology of hyperkalemia, hypocalcemia, and hyperphosphatemia in the setting of chronic kidney disease.

Educate patients about the significance of proteinuria in chronic kidney disease.

Appropriately recommend the use of angiotensin converting enzyme (ACE)-inhibitors and angiontensin receptor blockers (ARBs) in the management of chronic kidney disease.

Outline treatment with phosphate binders and calcium replacement.

Summarize the staging of chronic kidney disease based on glomerular filtration rate (GFR).


Case 24Discuss types of patient isolation procedures and their indications.

Describe indications, contraindications, and complications of lumbar puncture.

Demonstrate knowledge of cerebrospinal fluid analysis and its interpretation.

List risk factors for and precautions against the acquisition of nosocomial infection.


Case 25Recognize that altered mental status in an older inpatient is a medical emergency and requires that the patient be evaluated immediately.

Differentiate between delirium, dementia, and depression.

Identify the risk factors for developing altered mental status, including: dementia, advanced age, substance abuse, comorbid physical problems (such as sleep deprivation, immobility, dehydration, pain, and sensory impairment), and ICU admission.

Thoroughly review prescription medications, over-the-counter drugs, and supplements, and inquire about substance abuse when evaluating delirium.

Recognize the symptoms and signs of the most common and most serious causes of altered mental status, including metabolic causes, such as hyponatremia.

Perform a thorough diagnostic evaluation of altered mental status.

Manage the most common causes of altered mental status.

Describe the pathophysiology, presenting signs and symptoms, laboratory interpretation, and the management of hyponatremia, including the risk of too rapid or too delayed therapy of hyponatremia.

Write appropriate fluid and replacement orders for patients with common electrolyte and metabolic disturbances.


Case 26Identify the presenting signs and symptoms of intoxication and overdose of common substances of abuse.

Discuss the pathophysiology of simple and mixed acid- base disorders.

Calculate the anion gap and explain its relevance to determining the cause of a metabolic acidosis.

Recognize the presenting signs and symptoms and list the differential diagnosis of hypernatremia.

Understand how homelessness can influence patient’s access to illicit substances and interfere with ability to enable effective treatment.

Describe the pathophysiology of ethylene glycol toxicity.

Evaluate for calcium oxalate crystalluria and relate the presence to ethylene glycol toxicity and other disorders.

List the differential of anion-gap metabolic acidosis.

List the differential of hypernatremia.

Manage ethylene glycol toxicity, including the use of the antidote fomepizole.

Describe how to correct hypernatremia.


Case 27Be aware of red flags in history of back pain.

Become familiar with helpful techniques to use when it is necessary to give bad news to a patient.

Outline the evaluation and management of fever in the neutropenic patient.


Case 28Accurately interpret arterial blood gas.

Explain PFT results and use them to recommend appropriate therapy.

List major pathologic states causing dyspnea.

Relate the utility of supplemental oxygen and the potential dangers of overly aggressive oxygen supplementation.

Describe the indications for, benefits of, and side effects of therapies for COPD including: beta-agonists, anticholinergics, methylxanthines, and inhaled and systemic corticosteroids.

Recommend appropriate laboratory evaluation for suspected COPD exacerbation.

Describe the benefits of immunizing adults with COPD against influenza and pneumococcal infection.


Case 29Describe the common causes of tachypnea.

Accurately record a respiratory rate.

List indications for thoracentesis.

Know laboratory findings of transudative and exudative effusions.

Demonstrate understanding of indications for performing a purified protein derivative (PPD) test and how results should be interpreted given a range of clinical scenarios and patient histories.

Understand principles of treatment of tuberculosis.


Case 30List risk factors for the development of a deep vein thrombosis.

Recognize the signs and symptoms of deep vein thrombosis and pulmonary embolism.

Generate a prioritized differential diagnosis of deep vein thrombosis/pulmonary embolism based on specific physical findings using pre-test probability tools.

Understand the indications for and utility of various diagnostic tests and describe their interpretation.

Develop an appropriate management plan for deep vein thrombosis/pulmonary embolism, including appropriate use and monitoring of heparin and warfarin.


Case 31Develop a systematic approach to the evaluation of joint pain.

List typical presentations of common causes of knee pain.

Use knowledge of time course of symptoms in developing a differential diagnosis of the etiology.

Know the indications for and risks of arthrocentesis.

Use interpretation of synovial fluid assays to guide the diagnosis.

Know simple, nonmedicinal symptomatic treatment measures to prescribe for joint pain.


Case 32Know the approach to patients with possible rheumatologic disease.

Know typical clinical and laboratory findings of rheumatoid arthritis, systemic lupus erythematosus, dermatomyositis, and systemic vasculitis.

Compare and contrast the various causes of inflammatory polyarthritis.


Case 33Compare the pathophysiology of major etiologies of acute renal failure including decreased renal perfusion (pre-renal), intrinsic renal disease, and acute renal obstruction (post renal).

Calculate fractional excretion of sodium and apply it to distinguish between pre-renal and intrinsic renal disease.

Develop appropriate initial management plan for acute renal failure including volume management, dietary recommendations, drug dosage alterations, electrolyte monitoring, and indications for dialysis.

Identify risk factors for contrast-induced nephropathy and recommend steps to prevent this complication.

Interpret a urinalysis, including microscopic examination for casts, red blood cells, white blood cells, and crystals.

Calculate the anion gap and generate a differential diagnosis for metabolic acidosis.


Case 34List the various etiologies of lower back pain.

Recognize signs and symptoms of the various causes of back pain.

Perform a focused physical exam, including neurologic and specific range of motion testing of the lower extremities.

Generate a prioritized differential diagnosis based on review of systems and physical exam findings.

Define indications for laboratory and radiographic studies.


Case 35Become familiar with the definition of fever of unknown origin.

Consider etiologies of fever in normal hosts and in special populations (e.g., patients with human immunodeficiency virus [HIV], recent travel or immigration, intravenous drug use).

Obtain and present an age-appropriate patient history that helps differentiate among likely etiologies for fever.

Understand when to obtain diagnostic and laboratory tests for fever.

Develop an appropriate treatment plan for patient with fever of unknown origin.


Case 36Know the signs, symptoms, and complications of portal hypertension.

Describe the presenting signs and symptoms of spontaneous bacterial peritonitis.

Complete an abdominal exam, including evaluation for presence of ascites.

Understand the indications for paracentesis and how to analyze the ascitic fluid using the serum to ascites albumin gradient (SAAG).

Describe the components of obtaining informed consent.

Become familiar with the indications for hepatic transplantation referral in end stage liver disease.

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