| | 11 Case 11 scenario (importance)
Doorway information about patient
The patient is a 50-year-old man who comes to the clinic due to importance
Vital signs
. Temperature : 36.7’C (98F)
. Blood pressure : 150/80 mmHg
. Pulse : 80/min
. respirations ; 16/min
Basic differential diagnosis
Cardiovascular
. Atherosclerotic vascular disease
Metabolic /endocrine
. Diabetes
. Hypogonadism
. Hyperprolactinemia
Neurotic
. Spinal cord disorders
Psychological
. Anxiety
. Depression
. Alcohol or otters substance abuse
Other
. Medications (eg, antihypertensives)
—————
Case 11 sim.pt. instruction
If the doctor asks you about anything other than these , just say “ no ,” or provide an answer that a normal patient might give.
You are a 50-year-old man who has erectile dysfunction
History of present illness
. Onset 3-4 months ago
. Gradually increasing difficulty getting an erection
. Normal interest unisexual activity
. Increased stress over last 6 months due to financial problems
Do not volunteer this information unless asked : You have awakened with a nocturnal erection for several months.
Review of systems
. Mild fatigue
. No headaches or visual changes
. No pain in the extremities
. No nausea , vomiting , or abdomen pain
Past medical history
. Diabetes for 10 years (home glucose ranges 150-200 mg/dL)
. Hypertension
. Generalized anxiety disorder
. Surgeries : None
. medications : Atenolol 50 mg , daily (started 4 months ago), lisinporil 20 mg daily, metformin 500 mg twice daily , glyburide 10 mg daily, fluoxetine 20 mg daily
. Allergies : None
. Immediate family members are healthy
. Occupation : truck driver
. Married, live with wife
. Tobacco 1-2 cigarettes week 9only when gong out with friends)
. Alcohol : 2-3 beers a day for 25 years
. Recreational drugs : No
Physical examination
HEENT:
. PERRLA
. EMOI
Abdomen
. Non-tender, Non-distended
. Normative bowel sounds throughout
. No hepatosplenomegaly
. No bruits
Extremities
. Posterior tibial and dorsals pedis pulse 2+ in both lower extremities
—————
Case 11 sim. pt. checklist
Following the encounter , check which of the following items were performed by the examinee
History of present illness/ review of systems
. Asked about the onset of symptoms
. Asked whether out is continuous or intermittent
. Asked whether it is getting worse
. Asked about any changes in sexual desire
. Asked about any problems with ejaculation
. Asked detailed sexual history including the number of sexual partners (if multiple , ask follow-up questions : Dose the dysfunction occur with one partner and not another?)
. Asked about nocturnal erections
. Asked about aggravating to triggering factors
. Asked about nay pain in the legs(claudication)
. Asked about anxiety and depression
. Asked about headache (pituitary tumors)
. Asked about trauma
Past medical /family/social history
. Asked about otters medical issue (especially hypertension , diabetes mellitus , sickle cell disease , pulmonary vascular disease),hospitalization , and surgeries
. Asked about current medications
. Asked about medication allergies
. asked about family health
. Asked about tobacco, alcohol, and drug use
. Asked about occupation
Examination
. Washed hands before examination
. Examined without gown , not though gown
. Palpated abdomen and listened for bruit
. Examined pulsations in lower limbs
Counseling
. Explained the physical findings aden possible diagnosis
. Explained the need for additional workup(include genitourinary examination)
. Discussed quoting smoking and reducing alcohol intake
Communication skills and professional conduct
. Knocked before entering the room
. introduced self and greeted you warmly
. Used your name to address you
. Paid attention to what you said and maintained good eye contact
. Asked opened questions
. Asked non-leading questions
. Asked one question at a time
. Listened to what you said without interrupting me
. Used plain English rather than technical jargon
. Used appropriate transition sentences
. Used appropriate draping techniques
. Summarized the history and explained physical findings
. Expressed empathy and gave appropriate reassurances
. Asked whether you have any concerns/questions
Differential diagnosis
. Medication induced
. Diabetes neuropathy
. Atherosclerotic vascular disease
. Anxiety
Diagnostic study/studies
. Genital examination
. Fasting blood sugar and hemoglobin A1c
. Complete blood count
. TSH , Serum prolactin , and testosterone
—————
Case 11 clinical summary
Clinical Skills Evaluation
Case 11 Patient Note
The following represents a typical note for this patient encounter . the detail may vary depending on the information given by the simulated patient.
History : Describe the history you just obtained form this patient . Include only information (Pertinent positives and negatives) relevant to this patient’s problem(s).
. 50-yo man with 4 months of worsening erectile dysfunction.
. New blood pressure medication (atenolol) started 4 months ago.
. Increased stress for past 6 months , mild fatigue.
. Poorly controlled diabetes with glucose near 200 mg/dl most of the day.
ROS : No headaches , leg pain , visual disturbances , nausea , vomiting , or abdominal pain
PNHx: Diabetes ,hypertension, anxiety
Meds ; Metformin, glyburide, fluoxetine , atenolol (started 4 months ago)
Allergies : None
FHx : Parents and siblings are healthy
SHx : Occasionally smokes and has had 2 or 3 beers/day for 25 years
Physical examinations : Describe any positive and negative findings relevant to this patient’s problem(s) . be careful to include only those parts of the examination performed in this encounter.
. Vital signs : Temperature, 36.7’C (98F) ; blood pressure , 150/80 mmHg ; pulse , 80/min ; respirations , 16/min
. HEENT : PERRLA, EOMI
. Abdomen : Non-tender , non-distended, normative bowel sounds throughout , no hepatosplenomegaly or bruits
. Extremities : Pulses 2+ in the bilateral lower extremities
Data interpretation : Based on what you have learned from the history and physical examination, list up to 3 diagnosis that might explain this patient’s complaint(s) . List your diagnoses from most to least likely . For some cases , fewer than 3 diagnosis will be appropriate . the , enter the positive and negative findings form the history and the physical examination (if present) that support each diagnosis . Finally , list initial diagnostic (if any) you would order for each listed diagnosis (eg,restricted physical examination maneuvers, laboratory tests , imaging ECG , etc).
Diagnosis #1 : Medication-induced ED
History finding(s)
. Started beta blocker 4 months ago
. No nighttime erection
. Difficulty having daytime erection
Physical examination finding(s)
. None
Diagnosis #2 : testosterone deficiency
History finding(s)
. Fatigue
. Erectile dysfunction
Physical examination finding(s)
. None
Diagnosis #3 : Anxiety
History finding(s)
. History of anxiety
. Increased stress over past 6 months
Physical examination finding(s)
. No focal findings on examination
Diagnostic studies
. Serum glucose and hemoglobin A1c
. Serum testosterone and TSH
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2018/08/15 03:28pm 
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