| | 29 Case 29 scenario ( blurred vision )
Doorway information about patient
The patient is a 50-year-old man who comes to the office due to blurred vision
Vital signs
. Temperature : 36.7’C (98.1F)
. Blood pressure : 160/90 mmHg
. Pulse : 70/min
. Respirations : 22/min
Basic differential diagnosis
. Diabetes mellitus
. Cataract
. Hypertensive retinopathy
. Glaucoma
. Macular degeneration
. Brain lesion
. Hyperviscosity syndorme (eg, polycythemia)
. Illicit drugs
. Temporal arthritis (usually starts unilaterally)
. Trauma to or infections of the eye (if unilateral)
—————
Case 29 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 comes to the office due to blurry vision
History of present illness
. Onset 2 month ago
. Objects are becoming increasingly blurry with no halos around them
. No headache , eye pain , or eye discharge
. Over-the -counter reading glasses have made only minimal improvement
. Last physician visit was 10 years ago
Do not volunteer this information unless asked :
Review of systems
. 10-lb weight loss
. Increased appetite , thirst , and urination
. No nausea or vomiting
. No muscle weakness
. No dizziness or loss pf consciousness
. No numbness or tingling in the extremities
Past medical / family / social history
. No prior ,medical issue , surgeries , or hospitalizations
. Medications : None
. No medication allergies
. Father has hypertension and motor has diabetes(you have no siblings)
. Married;live with wife
. Occupation ;Truck driver
. Tobacco ; 1 pack a day for the last 30 years
. Alcohol : Occasional beer
. Recreational drugs : None
Physical examination
HEENT :
. PERRLA , EOMI
. Funds show no hemorrhage or AV nicking
Neck :
. Supple
. No lymphadenopathy or thyromegaly
. No bruits
Heart :
. Regular rate and rhythm without murmurs , gallops, or rubs
Extremities :
. Pulse 2+ in bilateral lower extremities
Neurologic :
. Motor strength 5/5 bilaterally
. Sensation grossly intact bilaterally
—————
Case 29 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 symptoms were in 1 or both eyes
. Asked about the severity and course over time
, Asked about the eye discharge
. Asked about halos around the light
. Asked about eye pain
. Asked about any headache
. Asked about nausea and vomiting
. Asked bout any weakness or sensory changes in the areas and legs
. Asked about excessive thirst and urination
. Asked about changes in the appetite and weight
Past medical /family/social history
. Asked about similar episodes in the past
. Asked about past medical issues (especially diabetes and hypertension)
. Asked about current medications
. Asked about medication allergies
. Asked about family health
. Asked bout tobacco , alcohol , and recreational drug use
. Asked bout occupation
Examination
. Washed heads before examination
. Examined without gown , not through gown
. Examined eyes , including extra ocular movements , pupillary reflexes , and ophthalmoscope examination
. Did a neurological examination with emphasis on sensory examination
. Auscultated heart and carotid arteries
. Examined peripheral pulses
Counseling
. Explained physical findings and possible diagnosis (especially diabetes)
. Discussed dietary changes and weight reduction
. Explained further evaluation
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
. Diabetic retinopathy and /or diabetes osmotic changes in the lens
. Hypertensive retinopathy
. Cataracts
. Glaucoma
. Macular degeneration
Diagnostic study/studies
. Fasting blood glucose and /or hemoglobin A1c
. Urinalysis for microscopic proteinuria
. Lipid profile
. Carotid ultrasound
—————
Case 29 clinical summary
Clinical Skills Evaluation
Case 29 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 2 months of blurry vision , polyuria , polydipsia , polyphagia , and 4.5-kg (10-lb ) weight loss
. Has not seen a doctor in 10 years
. Objects blurry without complete loss of vision or halos around it
ROS : No nausea , vomiting , headache , arm/leg weakness , eye discharge , eye pain , dizziness , loss of consciousness, or numbness or tingling in the extremities
PMHx : None
PSHx : None
Meds : none
Allergies : None
FHx : Father has hypertension , mother has diabetes
SHx : 1 PPD smoker for past 30 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 , 36.7”C(98.1F) ; blood pressure , 160/90 mmHg; pulse , 70/min; and respirations , 16/min
. HEENT : PERRLA , EOMI < funds without hemorrhages or AV nicking
. Neck : Supple without lymphadenopathy , thyromegaly, or bruits
. Extremities : Pulses 2+ in bilateral lower extremities
. Neurologic : Motor 5/5 bilaterally , sensory grossly intact 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 : Diabetic retinopoathy
History finding(s)
. Polyuria , polydipsia , polyphagia
. Weight loss
. Blurry vision
Physical examination finding(s)
. None
Diagnosis #2 : Hypertension retinopathy
History finding(s)
. Blurry vision
Physical examination finding(s)
. BP 160/90 mmHg
Diagnosis #3 : Glaucoma
History finding(s)
. Decreased vision
Physical examination finding(s)
. None
Diagnostic studies
. Fasting blood glucose and hemoglobin A1c
. Eye examination to mesure pressure
. Lipid profile
. CBC with differential
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2018/09/13 07:54am 
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