| | 24 Case 24 scenario ( cough and chest pain )
Doorway information about patient
The patient is a 35-year-old man who comes to the office due to cough and chest pain.
Vital signs
. Temperature L 38.7’C (101.7F)
. Blood pressure : 130/80 mmHg
. Pulse ; 94/min
. Respirations : 24/min
Basic differential diagnosis
. Pneumonia
. Pleuretic pain
. Pleural effusion
. Pulmonary edema
. Tuberculosis
. Pulmonary embolism
. Lung cancer
. Infective endocarditis
. GERD
—————
Case 24 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 35-year-old man who comes to the clinic due to a cough
History of present illness
. Onset 2 days ago
. Started with “ feeling tired and sick”
. Productive cough with yellow sputum and blood streaks
. Sharp pain 5-6/10 severity at left chest ; worse with moving and any deep breath and better with exhalation
. Associated symptoms :
- Fever
- Chills
- Sweating
- Mild shortness of breath
. Exposure to “ pneumonia “ form a colleague at work
Ask the doctor : “ Do I have pneumonia too?”
Review of systems
. No changes in appetite
. No weight loss
. No abdominal pain
. No recent trauma
. No diarrhea or constipation
. No urinary symptoms
Past medical / family / social history
. Hospitalized once for chest pain 5 years ago with negative testing
. No surgieres
. No medications
. Allergies : Penicillin (rash)
. Father and mother are both healthy ; no siblings
. Occupations ; Investment advisor
. Tobacco : 1 pack a day for 15 years
. Alcohol : often go out with friends on weekends and drink average of 2 shot of liquor
. Recreational drugs : No
Physical examination
HEENT :
. Oropharynx clear
Neck :
. Supple without JVD and lymphadenopathy
. No thyromegaly
. No bruits
. No accessory muscle use
Lungs :
. Clear to auscultation bilaterally
. Fremitus symmetrical bilaterally
. Resonant to percussion bilaterally
. No bronchophony or egophony
Heart :
. Regular rate and rhythm
. No murmurs , gallops, or rubs
Abdomen :
. Non-Tender, non-distended
. No hepatosplenomegaly
. Normative bowel sounds
—————
Case 24 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 location and radiation of pain
. Asked about the intensity of pain
. Asked about the quality of pain
. Asked about the onset and duration of pain
. Asked about the course of pain one time
. Asked about any aggravating or relieving factors
. Asked about associated symptoms , especially :
- Vomiting
- Fever
- Coughing( and details of expectoration)
- Shortness of breath
- Hemoptysis
- Change in appetite
Past medical /family/social history
. Asked about similar episodes in the past
. Asked about past medical issues ( especially lung problems) , 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 sexual history
. Asked about occupation
Examination
. Washed heads before examination
. Examined without gown , not through gown’
. Inspected neck , accessory muscles of respiration , and jugular views
. Examined heart : inspection , palpation , auscultation
. Examined lungs including:
- Inspection of lung inflation
- Anterior and posterior auscultation
- Percussion
- Tests for consolidation (tactile fremitus ,, egophony)
. Palpated abdomen for splenomegaly and hepatomegaly
Counseling
. Explained the physical findings and possible diagnosis
. Explained further workup
. Discussed quitting smoking
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
. Pneumonia
. Pleuritic pain
. Pleural effusion
. Pericarditis
. Lung cancer
Diagnostic study/studies
. CBC with differential count
. Sputum Gram stain, C/S
. ECG
. Chest x-ray
. Blood culture
—————
Case 24 clinical summary
Clinical Skills Evaluation
Case 24 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).
. 35-yo man with 2 days go product cough of yellow , blood-tinged sputum
. 2 dash pf sharp . left-sided chest pain worse with inspiration and improved with expiration.
. Fever . chills , sweating , and mild shortness of breath
. Sick contact in office
ROS : No changes in appetite our weight , abdominal pain, recent trauma , diarrhea , constipation , or urinary problems
PMHx : None
PSHx : None
Meds : None
Allergies ; Penicillin (rash)
FHx : Father and mother are healthy
SHx : 1 PPD smoker for past 15 tears , 2 shots a week for past 10 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 , 38.7’C(101.7F) ; blood pressure , 130/80 mmHg ; pulse , 94/min ; and respirations , 24/min
. HEENT ; Oropharynx clear
. Neck : Supple without JVD or lymphadenopathy , no thyromegaly, no bruits , no accessory muscle use
. Lungs ; clear to auscultation bilaterally , fremitus symmetrical bilaterally , resonant to percussion bilaterally , no brochophony or egophony
. Heart : RRR without murmurs, gallops, our rubs
. Abdomen : Non-tender , non-distended , no hepatopslenomegaly , normative bowel sounds
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 : Acute bronchitis
History finding(s)
. Smoking history
. Fever
. Cough productive of yellow , blood-tinged sputum
Physical examination finding(s)
. Fever
Diagnosis #2 : Pneumonia
History finding(s)
. Fever and chills
. Cough productive of yellow, blood-tinged sputum
. Pleuritic chest pain
. Sick contact at office
Physical examination finding(s)
. Fever
. Respirations , 24/min
Diagnosis #3 : Lung cancer
History finding(s)
. Smoking history
. Cough productive of blood-tinged sputum
Physical examination finding(s)
. None
Diagnostic studies
. Chest x-ray
. Sputum Gram stain and culture
. CBC with differential
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2018/09/13 07:51am 
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