| | 16 Case 16 scenario (increase urination)
Doorway information about patient
The patient is a 40-year-old woman who comes to the office due to increased urination
Vital signs
. Temperature : 36.7’C (98F)
. Blood pressure : 110/70 mmHg
. Pulse : 86/min
. Respirations : 16/min
Basic differential diagnosis
Increased urine volume
. Diabetes mellitus
. Diabetes insipidus (central, nephrogenic)
. Psychogenic : polydipsia
. Diuretic use
. hypercalcemia
increased urinary frequency
. Urinary tract infection
. Overactive bladder
. Excess caffeine intake
. Vaginitis , urethritis
—————
Case 16 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 40-year-old women complaining of increased urinary frequency
History of present illness
. Onset 2 months ago
. Urination 8-10 times during the day and 2-3 times a night
. increased urinary volume
. Increased feelings of thirst for last month
. Associated symptoms:
- Fatigue
- 4.5-kg (10-lb) weight loss (despite increased appetite)
- No dysuria or urgency
- No fever or chills
Past medical/family/soical history
. Bipolar disorder diagnosis 20 years ago
. Minor head injury after falling off bicycle 3 months ago ; seen in emergency department and discharged without intervention
. No surgeries or hospitalizations
. Medications : lithium 60 mg twice daily
. Medication allergies : None
. Married , live with husband
. 2 pregnancies with normal vaginal delivery ; both children are healthy
. Both parents have type 2 diabetes mellitus l no siblings
. Tobacco : No
. Alcohol : No
. Recreational drugs : No
Physical examination
HEENT :
. PERRLA , EOMI
. Visual fields intact
Heart :
. Regular rate and rhythm
. No murmurs , gallops , or rubs
Abdomen :
. Soft and non-tender with normal bowel sounds
. No suprapubic or CVA tenderness
Neurologic :
. Muscle strength 5/5 throughout
. Sensation in tact in all 4 extremities
. reflexes 2+ in all 4 extremities
—————
Case 16 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 problem
. Asked about the frequency of urination
. Asked about nocturia
. Asked about nocturne
. Asked about urine volume
. Asked about burning on urination
. Asked about urgency and hesitancy of urination
. Asked boy increased thirst and fluid intake
. Asked about appetite and changes in weight
. Asked about the trauma to the head
Past medical /family/social history
. Asked about similar problems in the past
. Asked about past medical issues , hospitalizations ,and surgeries
. Asked about psychiatric problems (history of bipolar disorder , schizophrenia)
. Asked about current medications
. Asked about family health(especially diabetes)
. Asked about tobacco , alcohol , and drug use
. Asked about occupation
Examination
. Washed heads before examination
. Examined without gown , not through gown
. Examined mucous membranes
. Examined heart and lungs
. Tested muscle power in both upper and lower limbs
. Tested sensation in the lower extremities
. Tested reflexes in the lower extremities
. Tested visual fields and examined funds
. Tested for suprapubic and costovertebral angle tenderness
Counseling
. Explained physical findings and possible diagnosis
. Explained further workup
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
. Diabetes mellitus
. Central diabetes insipidus
. Nephrogenic diabetes insidious (lithium side effect)
. Psychogenic polydipsia
. Hypercalcemia
Diagnostic study/studies
. Fasting blood sugar
. Urinalysis
. Serum electrolytes (Na,K, Cl , CO2 , BUN , Cr , and calcium)
. Urine and serum osmolality
—————
Case 16 clinical summary
Clinical Skills Evaluation
Case 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).
. 40-yo woman with 2 months of polyuria , polydipsia, nocturia , and polyphagia
. 2-3 month of 4.5-kg(10-lb) weight loss with fatigue
. No dysuria or urinary urgency
ROS : No fever or chills
PMHx : bipolar disorder diagnosed 20 years ago ; minor head trauma 3 months ago , seen in emergency department and discharged without intervention
PSHx : None
Meds : Lithium 600 mg 2 times daily
Allergies : None
FHx : Father and mother have diabetes
SHx : No history of tobacco or alcohol use
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(98.1F) ; blood pressure , 110/70mmHg; pulse , 86/min; and respirations , 16/min
. HEENT : PERRLA , EOMI, intact visual fields
. Abdomen : Non-tender without suprapubic tenderness, np CVA tenderness
. Neurologic L muscle strength 5/5 throughout sensation grossly intact bilateral lower extremities , DTR 2 + in 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 : Diabetes mellitus
History finding(s)
. Polyuria
. Polydipsia and polyphagia
. Family history of diabetes in father and mother
. Weight loss
Physical examination finding(s)
. None
Diagnosis #2 : Diabetes insipidus
History finding(s)
. History of bipolar disorder
. Lithium use
. Polyuria
Physical examination finding(s)
. None
Diagnosis #3 : Psychogenic polydipsia
History finding(s)
. history of bipolar disorder
. Polyuria
. Polydipsia
Physical examination finding(s)
. None
Diagnostic studies
. Fasting blood glucose
. Hemoglobin A1c
. Urinalysis
. Serum electrolytes , lithium level
. Urine and serum osmolality
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