| | 23 Case 23 scenario ( frequent falls )
Doorway information about patient
The patient is a 70-year-old man who comes to the office due to frequent falls.
Vital signs
. Temperature : 37.1’C (98.7F)
. Blood pressure : 130/80 mmHg
. Pulse : 78/min
. Respirations : 20/min
Basic differential diagnosis
Neurologic
. Cerebellar disease (alcohol, tumor , stroke)
. Parkinson disease
. Brain tumor
. Seizure
. Depressed vision
Metabolic
. Diabetic neuropathy
. Hypoglycemia
. Thyroid disease
Cardiovascular
. Valvular disease
Miscellaneous
. Medication side effect
. Vitamin B12 deficiency
. Vertigo
—————
Case 23 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 70-year-old man who comes to the clinic due to frequent falls.
History of present illness
. Several falls over he last 2 months
. Initially once a week , now twice a week
. Decreased balance while standing
. No major injury/fracture but you are concerned that you may develop one
. Also have tremor that makes it difficult to hold things ; worse when reaching for an object
. Headache in the morning
. Friend said you speech is different
Review of systems
. No weakness , numbness , or tingling in arms or legs
. No dizziness/vertigo
. No fever
. No chest pain
. No nausea , vomiting , diarrhea , constipation , or abdominal pain
. No urinary symptoms
. No sin or hear changes
Past medical history
. Diabetes for last 10 years (under good control)
. No surgires
. Medications : Metformin 500mg twice a day
. No allergies
. Father and mother both died of”old age”; no siblings
. Retired machinist
. Widower (wife passed away 5 years ago), live alone
. Tobacco : No
. Alcohol : 2 beers a day for 40 years
. Recreational drugs : No
Physical examination
HEENT:
. Visual acuity and visual fields normal
Neck :
. Supple without IVD or lymphadenopathy
. No thyromegaly
. No bruits
Lungs :
. Clear to auscultation bilaterally
Heart :
. Regular rate and rhythm
. No murmurs , gallops , or rubs
Neurologic :
. Motor 5/5 bilaterally
. Sensory grossly intact bilaterally
. Resting tremor
. Mild dysmetria (finger to nose ) present
. Mild dysdiadochokinesia (alternating movements)
. DTR2+ bilaterally
—————
Case 23 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 and frequent of falls
. Asked about any injury associated with falls
. Asked about loss of consciousness
. Asked about any difficult in initiating , controlling , stopping movements
. Asked about progression of the problem
. Asked about associated symptoms:
- Tremors
- Headache
- Nausea /vomiting, bowel problem
- Fever
- Palpations and syncope
- Thyroid symptoms(eg, temperature intolerance , skin or hear changes)
- Changes in appetite or weight
- Problems with speech or memory
- Problems wit attention or calculation
- urinary problem
. Asked abort living conditions and support systems
Past medical /family/social history
. Asked about similar episodes in the past
. Asked about past medical issues , hospitalizations , and surgeries
. Asked about current medications
. Asked about medication allergies
. Asked about family health
. Asked about tobacco, alcohol , and recreational drug use
. Asked about occupation
Examination
. Washed heads before examination
. Examined without gown , not through gown
. Checked orthostatic vital signs
. Examined eyes
. Examined heart and lungs
. Performed mini-mental status exam
. Examined touch , pain , and temperature sensations in legs add hands
. Tested muscle power in limbs
. Tested for muscle tone/rigidity
. Asked you to get up and walk and turn around and sit again (“ Get up and go “ test)
. Performed finger nose test
. Performed alternating movements test
. Performed Romberg test
. Checked reflexes
Counseling
. Explained the 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
. Cerebellar disease
. Parkinson disease
. Diabetic neuropathy
. Brain tumor
. Thyroid disease
. Vitamin B12 deficiency
Diagnostic study/studies
. CBC with differential
. CT or MRI of brain
. Serum electrolytes, glucose, creatinine
. Hemoglobin A1c
. ECG
. TSH
—————
Case 23 clinical summary
Clinical Skills Evaluation
Case 23 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).
. 70-yo man with 2 months of frequent fall
. Balanced problems while standing up ; no syncope
. Tremor in hands worse when reaching for objects.
. Change in speech , occasional morning headache.
. No sensory symptoms (numbness , tingling) in legs.
. No dizziness or vertigo
ROS : No fever , nausea , hair loss, chest pin , abdominal , pain , recent trauma, diarrhea , constipation , or urinary problems
PMHx : Diabetes
PSHx : None
Meds : Metformin 500 mg BID
Allergies : None
FHx : Father and mother both fiddled of old age
SHx : No smoking , 2 beers daily for past 40 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 , 37.1’C (98.8F) ; blood pressure , 130/80 mmHg ; pulse , 78/min ; and respirations , 20 /min
. HEENT : PERRLA , EOMI , normla visual acuity
. Neck : Supple without JVD or lymphadenopathy , no thyromegaly , no bruits
. Lungs : Clear to auscultation bilaterally
. Heart : RRR without murmurs, gallops , and rubs
. Neurologic ; Motor 5/5 bilaterally , sensory grossly intact bilaterally , resting tremor , mild dysmetria (finger to nose) , mild dysdiadochokinesia (alternating movements) , DTR 2+ bilaterally
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 : Cerebellar disease due to alcohol use
History finding(s)
. History of chronic alcohol use
. Difficulty with balance
Physical examination finding(s)
. Dysmetria
. Disdiadochokineasia
Diagnosis #2 : Parkinson disease
History finding(s)
. Tremor
. Balance problems
Physical examination finding(s)
. Resting tremor
Diagnosis #3 : Brain tumor
History finding(s)
. Speech difficulties, headache
. Balance problems
. 2 months of symptoms
Physical examination finding(s)
. None
Diagnostic studies
. Orthostatic vitals
. Brain imaging (CT scan or MRI)
. Basic metabolic panel
. Thyroid function tests; vitamin B 12 levels
. Complete blood count
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