PBL Sessions: Vascular Diseases 2


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Page 2

History of Present Illness:

Your physical examination shows vital signs with T 36.2 C, P 77, R 18, and BP 125/85 mm Hg. He is 171 cm tall and weighs 81 kg. His heart rate is regular with no murmurs. The lungs are clear to auscultation, but there is some dullness to percussion at the right lung base posteriorly. Palpation of the abdomen reveals no masses or areas of tenderness, and active bowel sounds are present. You note the presence of a 7 cm long well-healed scar in the right lower quadrant. The rectal examination reveals no masses, and the stool guaiac is negative. Pulses in the extremities are 2+ bilaterally, except for the right femoral pulse which is 1+. There is a left carotid bruit. Motor strength is not decreased. Reflexes are normal. Cranial nerves II through XII are intact and there are no localizing neurologic signs. Funduscopic examination is unremarkable.

Tasks

  • What problems can you identify?

  • What hypotheses can you suggest that might be causing his problems?

  • Explain your reasoning for the hypotheses you choose.

  • What learning issues are being identified?

  • What additional information might you request?

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