| | 34 Case 34 scenario ( amenorrhea )
Doorway information about patient
The patient is a 16-year-old girl who comes to the office due to amenorrhea
Vital signs
. Temperature : 36.7’C(98.1F)
. Blood pressure ; 120/70 mmHg
. Pulse : 76/min
. Respirations : 16/min
Basic differential diagnosis
. Pregnancy
. Primary amenorrhea
- Chromosomal disorders
- Abnormal mullerian development
- Androgen insensitive
. Secondary amenorrhea
- Eating disorder
- Hyperprolactinemia
- Thyroid disfunction
- Polycystic ovarian syndorme
- Functional hypothalamic amenorrhea
- Postpill amenorrhea
- Hypothalamic / pituitary mass
—————
Case 34 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 16-year-old girl who has not had a menstrual period for 2 months
History of present illness
. Menses began at age 13 and were regular with no missed periods until 2 months ago
. The cycle usually last 28-30 days with moderate bleeding for 3-4 days (3-4 full soaked pads a day)
. Increased stress at school for the past 4 months , and you are currently studying for mid-term examinations in 2 weeks
. 10-lb (4.5kg) weight loss over the last 4 months despite normal appetite
Do not volunteer this information unless asked :
. No palpations
. No diarrhea or constipation
. No hair or skin changes
. No breast tenderness or nipple discharge
. No vaginal discharge or otters genitourinary symptoms
During the interview , ask the examinee : “Do you think I’m pregnant ? I can’t be pregnant right now . My parents will not be happy .”
Past medical / family / social history
. No history of pregnancy (G0P0)
. No surgeries
. No medications
. No drug allergies
. Immediate family members ( father , mother , sister ) are healthy
. Single , live with parents
. Junior in high school ; during well in school and participate in multiple extracurricular activities
. Sexually active with boyfriend for last 6 months ; do not always use a condom
. Tobacco : No
. Alcohol : No
. Recreational drugs : No
Physical examination
HEENT :
. PERRLA , EOMI
. Oropharynx clear
Neck :
. Supple without lymphadenopathy or thyromegaly
Abdomen :
. Non-tender , non-distended
. Normative bowel sounds
. No hepatosplenomegaly
Psychiatric :
. Alert and oriented
. Anxious affect
—————
Case 34 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 duration of amenorrhea (i.e., last menstrual period)
. Asked about menarche and previous menses (frequency , duration , quantify of blood loss)
. Asked bout associated symptoms:
- Abdominal pain
- Vaginal discharge
- Change I’m appetite or weight
- Cold or heat intolerance
- Changes in skin or hair
- Breast changes or nipple discharges
- Headache
. Asked about sexual activity (and use of contraception )
. Asked about life stressors
Past medical /family/social history
. Asked about similar episodes in the past
. Asked about other medical problems
. Asked about surgeries and gynecologic procedures (eg , dilation and curretage )
. Asked about current and recent medications
. Asked about medication allergies
. Asked about family health
. Asked about tobacco , alcohol , and recreational drug use
Examination
. Washed heads before examination
. Examined without gown , not through gown
. Examined eyes (including visual fields)
. Examined neck ( including thyroid )
. Examined abdomen
Counseling
. Explained physical findings and possible diagnosis
. Explained further workup
. Discussed the need for pelvic and breadth examinations
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
. Pregnancy
. Eating disorder
. Thyroid dysfunction
. hyperprolactinemia
. Functional hypothalamic amenorrhea
Diagnostic study/studies
. Pelvic and breast examination
. Pregnancy test
. TSH
. Serum prolactin level
. Pelvic ultrasound
. Brain MRI
. LH and FSH levels
—————
Case 34 clinical summary
Clinical Skills Evaluation
Case 34 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).
. 16-yo girl with 2 month of amenorrhea
. Menarche at age 13 with regular and no missed periods until 2 months ago.
. Sexually active with boyfriend and dose not always use condoms.
. Increased stress at school
. Unintentional 4.52-kg (10-lb ) weight loss in past 4 months with good appetite.
ROS : No palpation , diarrhea , constipation , hair loss skin changes , breath tenderness , nipple discharge , vaginal discharge , or urinary problems
PMHx : G0P0
PSH : None
Meds : None
Allergies : None
FHx : Father , mother and sister are healthy
SHx : No tobacco or 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 120/70 mmHg; pulse : 76/min; and respiration , 16/min
. HEENT : PERRLA , EOMI , oropharynx clear
. Neck : Supple without lymphadenopathy or thyromegaly
. Abdomen ; Non-tender, non-distended , normative bowel sounds ,. no hepatosplenomegaly
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 : Pregnancy
History finding(s)
. Amenorrhea
. Sexually active, sometimes not using condoms
Physical examination finding(s)
. None
Diagnosis #2 : Hyperthyroidism
History finding(s)
. Amenorrhea
. Increased anxiety
. Weight loss with good appetite
Physical examination finding(s)
. None
Diagnosis #3 :Hyperprolactinemia
History finding(s)
. Amenorrhea
Physical examination finding(s)
. None
Diagnostic studies
. Pregnancy test
. TSH and T4
. Pelvic and breath examination
. Prolactin level
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