| | 38 Case 38 scenario ( anxiety )
Doorway information about patient
The patient is a 35-year-old woman who comes to the emergency department due to breathlessness and anxiety.
Vital signs
. Temperature : 36.1’C(97F)
. Blood pressure : 130/80 mmHg
. Pulse ; 94/min
. Respirations : 22/min
Basic differential diagnosis
. Anxiety secondary to medical condition (eg, hyperthyroidism, arrhythmias)
. Substance abuse
. Panic disorder
. Generalized anxiety disorder
. Adjustment disorder with anxious mood
. Acute stress disorder or post-traumatic stress disorder
. Hypochondriasis
—————
Case 38 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 woman experiencing shortness of breath
History of present illness
. Episodic shortness of breath for 3 months ; slight problems previously but never this severe
. Episodes last 30 minutes and are associated with palpitations , sweating ,and feeling that you are going to die
. Episodes occur about 2 or 3 times a week at any time but are worse in crowded places outside the house , and you have stopped going to outdoor activities to avoid triggering symptoms
. Symptoms seem to improve with sloe breathing and relaxation
. Multiple emergency department evaluations for the same symptoms ; all test have been normal/nondiagnostic
. Ask the doctor : “ Do you think that this is anxiety like my mother has?”
Review of systems
. No chest pain
. No headaches or tremors
. Occasional diarrhea alternating with constipation
. No nausea , vomiting , or abdominal pain
Past medical / family / social history
. No prior medical issues , surgeries , or hospitalizations
. No medications
. Allergies : Penicillin causes a rash
. Father is healthy , mother has generalized anxiety disorder, sister is healthy
. Married , live with husband and 2 children
. Occupation : Homemaker
. Tobacco : No
. Alcohol : Wine on social occasions only
. Recreational drugs : Used marijuana occasionally in college but non since then
. Caffeine : 1 cup of coffee daily
Physical examination
Neck:
. Supple without thyromegaly or lymphadenopathy
Lungs :
. Clear to auscultation
Heart :
. Regular rhythm
. No nurtures, rubs, or gallops
Neurologic :
. No treor in extremities
Psychological :
. Alert and oriented
. Affect mildly anxious but otherwise appropriate
. Speech clear
—————
Case 38 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 initial onset of symptoms and course over time
. Asked about the frequency and duration of attacks
. Asked about associated symptoms . especially :
- Chest pain
- Swelling in neck
- Fear/apprehension, sense of impending doom
- Palpitations
- Dizziness
- Tremor
- Sweating
. Asked about aggravating and relieving factors
. Asked about impact of symptoms on relationship and normal activities
Past medical /family/social history
. Asked about similar episodes in the past
. Asked about past medical issues (especially thyroid and psychological disorders)
. Asked about previous hospitalizations and surgeries
. Asked about current medications
. Asked about medication allergies
. Asked about family health
. Asked about occupation
. Asked bout tobacco , alcohol , and recreational drugs
Examination
. Washed heads before examination
. Examined without gown , not through gown
. Palpated neck for swelling
. Examined hands for tremor
. Examined heart and lungs
. Examined cranial nerves , motor strength , and reflexes
Counseling
. Explained the physical findings and possible diagnosis
. Explained further workup (if any)
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
. Panic disorder/ agoraphobia
. Generalized anxiety disorder
. Hyperthyroidism
. Substance abuse
Diagnostic study/studies
. ECG
. Electrolytes and glucose
. TSH
. Urine drug screen
—————
Case 38 clinical summary
Clinical Skills Evaluation
Case 38 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 woman with 3 months of episodic shortness of breath , palpitations , diaphoresis, and feeling of impending death
. Episodes lasting 30 minutes and occurring more frequently outside of house in crowded places
. Symptom improvement with slow breathing and relaxation
. Multiple ED trips with normal investigations and no definitive diagnosis
ROS : Occasional diarrhea alternating with constipation ; no chest pain, headache nausea , vomiting , tremors , neck swelling , or abdominal pain
PMHx : None
PSHx : None
Meds : None
Allergies : Penicillin (rash)
FHx : Father is healthy ; mother has generalized anxiety disorder
SHx ; No tobacco use , occasional glass of wine
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 ,36.1’C(97F); blood pressure , 130/80/mmHg; pulse ,94/min; and respirations , 22/min
. Neck : Supple without thyromegaly or lymphadenopathy
. Lung : Clear to auscultation
. Heart : Regular rhythm without murmurs , rubs, gallops
. Neurologic ; No tremor in extremities
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 : Panic disorder
History finding(s)
. Episodes of palpitations with dyspnea
. Family history of anxiety
. Symptoms worse in crowded places
. Symptoms relieved wth slow breathing
Physical examination finding(s)
. None
Diagnosis #2 : Hyperthyroidism
History finding(s)
. Episodes of palpitations
. Shortness of breath and diaphoresis
Physical examination finding(s)
. None
Diagnosis #3 : Cardiac arrhythmia
History finding(s)
. Palpitations
. Shortness of breath and diaphoresis
Physical examination finding(s)
. None
Diagnostic studies
. ECG
. TSH
. Serum electrolytes and glucose
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2018/09/13 08:02am 
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