| | 26 Case 26 scenario ( fatigue )
Doorway information about patient
The patient is a 35-year-old man who comes to the office due to fatigue
Vital signs
. Temperature : 37’C (98.6F)
. Blood pressure : 120/80 mmHg
. Pulse : 82/min
. Respirations : 16/min
Basic differential diagnosis
. Depression
. Anemia
. Thyroid disorder
. Chronic fatigue syndrome
—————
Case 26 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 office due to fatigue
History of present illness
. Onset 2 months ago
. Previously well until victim of robbery
. Tired during the day with constant anxiety and impaired concentration
. Difficulty falling asleep at night with frequent nightmare
. You have cut back on daily activities and feel emotionally distant and lonely
. No other significant stress at work or home
Do not volunteer this information unless asked :
Review of systems
. No shortness of breath
. No palpations
. No seating , fever , or chills
. No weight loss
. No change in appetite
Past medical / family / social history
. No significant illness , surgeries , or hospitalizations
. No medications
. No allergies
. Immediate family members are all healthy
. Live with girlfriend
. Occupation : Florist
. Tobacco : 1 pack a day for last 15 years
. Alcohol : Social occasions only
. Recreational drugs : No
Physical examination
HEENT
. No pallor
. Oropharynx clear
Neck
. Supple without lymphadenopathy
. No thyromegaly
Heart
. Regular rate and rhythm
. No murmurs, gallops, or rubs
Lungs :
. Clear to auscultation
Abdomen :
. No masses or tenderness
Psychiatric
. Alert and oriented to person , place , and time
—————
Case 26 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 onset of symptoms
. Asked about severity and change over time
. Asked if you are having difficulty falling or staying asleep
. Asked nightmares
. Asked if you had any traumatic events recently
. Asked about feeling of guilt
. Asked about suicidal intentions
. Asked if you have been feeling lonely
. Asked about anxiety
. Asked about associated symptoms , especially
- Palpitations
- Dizziness
- Sweating
- Tremors
- Changes in appetite or weight
- Shortness of breath
- Swelling /limps in neck
- Changes in bowel or bladder habits
. Asked about stress at work or home
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 occupation
. Asked bout tobacco , alcohol , and recreational; drug use
. Asked about sexual history
Examination
. Washed heads before examination
. Examined without gown , not through gown
. Examined oral mucous membranes for pallor
. Palpated neck for masses or swelling
. Checked memory , orientation , and judgement
Counseling
. Explained physical findings and possible diagnosis
. Explained further workup
. Offered to help and support while getting treated
. Discussed the importance of quitting smoking and offered help
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
. Post-Traumatic stress disorder/anxiety disorder
. Depression
. Hypothyroidism
. Occult medical disease
Diagnostic study/studies
. CBC with differential
. TSH
. Electrolytes , glucose , BUN , Creatinine
. HIV test
—————
Case 26 clinical summary
Clinical Skills Evaluation
Case 26 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 months of fatigue after robbery
. Insomnia increased daytime fatigue , nightmares every night , generalized anxiety throughout the day , and inability to concentrate at work
. Feels emotionally alone and distant , no increased stress at work or home
. No hallucinations or delusions.
. Constipation for 3-4 months
ROS : No shortness of breath , chest pain , palpations , sweating, fever , chills , weight loss, or change in appetite
PMHx : None
PSHx : None
Meds : None
Allergies : None
FHx : Father , mother , and 3 siblings are healthy
SHx : 1 PPD smoker for 15 years , occasional 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’C (98.6F) ; blood pressure , 120/80 mmHg;pulse , 82/min; and respirations , 16/min
. HEENT : No pallor , oropharynx car
. Neck : Supple without lymphadenopathy or thyromegaly
. Heart : RRR without murmurs, gallops, or rubs
. Lungs ; Clear to auscultation
. Abdomen ; no masses or tenderness
. Psychiatric : Alert and oriented to person , place,and time
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 : Post-traumatic stress disorder
History finding(s)
. Symptom onset after robbery 2 months ago
. Insomnia
. Difficulty concentrating , nightmares
Physical examination finding(s)
. None
Diagnosis #2 : Depression
History finding(s)
. Fatigue
. Insomnia
. Feels alone and distant
Physical examination finding(s)
. None
Diagnosis #3 : Hypothyroidism
History finding(s)
. Constipation for 3-4 months
. Fatigue
. Inability to concentrate at work and home
Physical examination finding(s)
. None
Diagnostic studies
. TSH
. CBC with differential
. Electrolytes, glucose, BUN , creatinine
. HIV test
| | |
|
|
|
頂端 
加到"我的最愛"
主題管理：
總固頂 
取消總固頂 
Message
查看
搜尋
通訊錄
複製
引用
回覆
2018/09/13 07:52am 
IP: 已設定保密