| | 42 Case 42 scenario ( new-onset seizure )
Doorway information about patient
The patient is a 30-year-old man who comes to the emergency department due to new-onset seizure
Vital signs
. Temperature : 37.2’C (99F)
. Blood pressure : 120/80 mmHg
. Pulse ; 82/min, regular
. Respirations : 18/min
Basic differential diagnosis
. Seizes (secondary to head trauma , infections , drugs , metabolic disorders)
. Hypoglycemia
. Syncope
. Migraine
. Stroke
. Psychogenic seizure
. Space-occupying lesion
. Alcohol or drug withdrawal
—————
Case 42 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 30-year-old man who is brought to the emergency department with a new seizure
History of present illness
. Seizure occurred a few hours ago
. Witnesses (coworkers) noted shaking lasting about 3 minutes , followed by 20 minutes of loss of consciousness
. Symptoms preceded by nausea
. Bit tongue but did not pass urine or feces during the episode
. Have noticed some weakness in the right hand for the past 3 months
. Chronic, occasional mild headaches , but recently the headaches are constant and more severe
. No history of head trauma
Review of systems
. Mild fever ; cold and flu-like symptoms for the past couple of days
. No ear discharge or sinus pain
. No neck pain
Past medical / family / social history
. Type 1 diabetes diagnosis 15 years ago and treated with insulin pump (If the examinee asks you if you think this could be due to hypoglycemia , say: “ I don’t think so because I know what that looks like.’ )
. No other medical issues , hospitalizations , or surgeries
. No otters medications
. No drug allergies
. Father , mother , and sister are healthy ( No family history of seizures)
. Single , not sexually active
. Occupation : Postal clerk
. Smoking : No
. Alcohol : Social occasions only ; last drink was 2 days ago
. Recreational drugs : No
Physical examination
HEENT :
. Normal , no injuries
Neck :
. Supple with no goiter or lymphadenopathy
Heart :
. regular rate and rhythm
. No murmurs
Chest / lungs :
. Clear to auscultation and percussion
Neurologic :
. Awake and alert
. Cranial nerve examination normal
. Motor strength and reflexes normal
—————
Case 42 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 bout a description of the seizure
- Duration
- Shaking
- Automatisms (eg, lip smaking)
- Fecal/urinary incontinence
- Biting of tongue or other injuries
- Post-seizure confusion /loss of consciousness
. Asked about aura (prodromal symptoms) and activities at the onset of seizures
. Asked about any recent head trauma
. Asked about associated symptoms:
- Palpitations , chest pain
- Headaches
- Nausea / vomiting
- Fever
- Muscle weakness
. Asked about any past seizures of loss of consciousness
Past medical /family/social history
. Asked about other medical issues(especially diabetes , meningitis /encephalitis, neurologic disorders)
. Asked about prior hospitalizations and surgeries
. Asked about current medications
. Asked bout medication allergies
. Asked about family health
. Asked about tobacco , alcohol , and recreational drug use ( including most recent alcohol use and any history of alcohol withdrawal)
. Asked about occupation
Examination
. Washed heads before examination
. Examined without gown , not through gown
. Examined for head injury and neck stiffness
. Checked motor power , reflexes, and sensation in all limbs
. Examined the cranial nerves
. Examined eyes with ophthalmoscope
. Examined ears with otoscope
. Examined heart and lungs
. Examined abdomen
Counseling
. Explained physical findings and possible diagnosis
. Explained further workup
. Discussed family support
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
. Intracranial mass
. Hypoglycemia
. Alcohol withdraw
. Meningitis / encephalitis
Diagnostic study/studies
. CBC with differential
. Serum electrolytes (Na,K, Cl, CO2, BUN, Cr, Ca, Mg) and glucose
. LFTs
. Urinalysis and urine toxicology screen
. Head CT scan
. Lumber puncture
. EEG
—————
Case 42 clinical summary
Clinical Skills Evaluation
Case 42 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).
. 30-yo man with new-onset seizure
. Onset a few hours ago
. Single episode of shaking (3 min) followed by loss of consciousness (20min)
. Proceeded by nausea and associated with biting of tongue
. Recent history of right hand weakness and increasing headaches
ROS : Mild fever and flu-like illness last few days
PMHx : Type 1 diabetes for 15 years
PSHx : None
Meds : Insulin via pump
Allergies : None
FHx : Father , mother , and sister are healthy
SHx : Single , works as postal clerk ; social alcohol , no tobacco or drug 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 , 37.2’C (99F); blood pressure , 120/80mmHg; pulse , 82/min; and respirations , 18/min
. HEENT : PERRLA , EOMI, no papilledema
. Neck ; Supple without thyromegaly or lymphadenopathy
. Heart : RRR with no murmurs
. Lungs : Clear to auscultation and percussion
. Neurologic ; Awake and cranial nerves II-XII intact , motor strength and reflexes normal
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 : Intracranial mass
History finding(s)
. New seizure
. Increasing headaches
. Recent subjective weakness
Physical examination finding(s)
. None
Diagnosis #2 : Hypoglycemia
History finding(s)
. Type 1 diabetes
. Use of insulin pump
Physical examination finding(s)
. None
Diagnosis #3 : Alcohol withdraw
History finding(s)
. New Seizure
. Last alcohol intake 2 days ago
Physical examination finding(s)
. None
Diagnostic studies
. CT scan of the head
. CBC with differential
. Serum electrolytes and glucose
. Urine toxicology screen
. Lumbar puncture
. EEG
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2018/09/13 08:06am 
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