| | 32 Case 32 scenario ( difficulty swallowing )
Doorway information about patient
The patient is a 50-year-old man who comes to the office due to difficulty swallowing
Vital signs
. Temperature : 36.7’C (98.1F)
. Blood pressure ; 130/90 mmHg
. Pulse : 85/min
. Respirations : 16/min
Basic differential diagnosis
. Oropharynx dysphagia
- Neuromuscular (stroke , parkinsonism , multiple sclerosis)
- Mechanical obstruction (Zener diverticulum , thyromegaly)
- Skeletal muscle disorders ( myasthenia gravis , muscle dystrophies ,polymyositis)
- Miscellaneous (medication ,radiation)
. Esophageal dysphagia
- Mechanical obstruction (esophageal carcinoma, benign strictures ,webs and rings [Schazki])
- Abnormal motility (achalasia , scleroderma)
- Gastroesphageal reflux disease
- Miscellaneous (diabetes , alcoholism)
—————
Case 32 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 clinic due to difficulty swallowing
History of present illness
. Onset 3 months ago
. Initially had difficulty swallowing soils (food would get stuck in the middle of the chest before slowly going down)
. Symptoms progressed slowly and now you have had difficulty swallowing liquids for the past 3 weeks
. Food regurgitates into the chest 2-3 hours after eating
. No problem chewing of transferring food out of the mouth into the throat
. 10-lb (4.5kg) weight loss in the past 3 months ; decreased appetite for the past 3 weeks
Review of systems
. No weakness in the arm or legs
. No shortness of breath or chest pain
. No nausea , vomiting , diarrhea , or constipation
Past medical / family / social history
. Gastroseophageal reflux (symptoms 2-3times a week for the past 25 years ; relieved with antacids)
. No surgires
. No other medications
. No drug allergies
. Father, mother , and 2 siblings are healthy
. Married , live with wife
. Occupation : Stockbroker
. Tobacco : 1 pack a day for last 30 years
. Alcohol : Occasional wine
Physical examination
—————
Case 32 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 an open-ended question about describing the dysphagia
. Asked about the onset and progression over time
. Asked bout exact location where food gets stuck
. Asked whether the dysphagia is for solid , liquid , or both
. Asked which started first( sold or liquids)
. Asked whether there is any associated pain
. Asked about any aggravating or relieving factors
. Asked about episodes of chocking or regurgitation/ aspiration
. Asked about any nausea and vomiting
. Asked about heartburn / gastroesophageal reflux
. Asked about history of ingestion of corrosive materials
. Asked about appetite and changes in weight
Past medical /family/social history
. Asked about similar episodes in the past
. Asked about past medical issues
. Asked bout medications
. Asked about medication allergies
. Asked about family health
. Asked about occupation
. Asked about tobacco , alcohol , and recreational drug use
Examination
. Washed heads before examination
. Examined without gown , not through gown
. Palpated neck for swelling
. Examined mouth and throat
. Gave you water and asked you to swallow
. Palpated lymph nodes in neck , axilla , and about the clavicles
. Auscultated abdomen
. Palpated abdomen(superficial and deep)
. Examined heart and lungs
Counseling
. Explained physical findings and possible diagnosis
. Explained further workup
. Discussed smoking cessation
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
. Carcinoma of the esophagus
. Achalasia
. Reflux esophagitis
. Stricture
Diagnostic study/studies
. CBC
. Esophagram
. Esophagogastroduodenoscopy
. Chest x-ray
—————
Case 32 clinical summary
Clinical Skills Evaluation
Case 32 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 3 months of dysphagia , initially with solids and now with liquids for the past 3 weeks.
. No problem with chewing and transferring food to throat , but feels food getting struck in the middle of the chest
. Decreased appetite and 4.-kg (10-lb) weight loss
. Food regurgitation 2-3 hours after eating
ROS : No weakness in the arms or legs , shortness of breath , nausea , vomiting , chest pain ,diarrhea , constipation , or urinary problems
PMHx : GERD for 25 years ,relieved with OTC antacids
PSHx : None
Meds : OTC antacids
Allergies : None
FHx : Father , mother , and 2 sibling are healthy
SHx ; 1 PPD smoker for 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 : 36.7’C(98.1F) ; blood pressure , 130/90 mmHg; pulse, 80/min; respirations , 16/min
. HEENT : Oropharynx clear , difficulty swallowing water
. Neck : supple with no lymphadenopathy
. Lymph nodes: No axillary or supraclavicular adenopathy
. Lungs : Clear to auscultation bilaterally
. Heart : RRR with no murmurs , gallops, or rubs
. Abdomen : Non-tender , non-distended , normative bowel sounds , no hepatopslenomeagly, no CVA tenderness
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 : Esophageal cancer
History finding(s)
. Dysphagia with solids and then liquids
. Weight loss with decreased appetite
. Smoking history
Physical examination finding(s)
. None
Diagnosis #2 : Achalasia
History finding(s)
. Dysphagia with solids and liquids
. Weight loss
Physical examination finding(s)
. None
Diagnosis #3 : Reflux esophagitis / stricture
History finding(s)
. History of GERD
. Food regurgitation 2-3 hours after eating
. OTC antacid use
Physical examination finding(s)
. None
Diagnostic studies
. Chest-x-ray
. Barium swallow
. Upper GI endoscopy
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2018/09/13 07:57am 
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