| | 6 Case 6 scenario (fatigue and weight loss)
Door way information about patient
The patient is a 50-year-old man who comes to the office due to fatigue and weight loss.
Vital signs
. Temperature : 36.7’C (98.1F)
. Blood pressure : 120/76 mmHg
. Pulse : 78 /min
. Respirations : 18 /min
Basic differential diagnosis
Infection
. HIV
. Tuberculosis
Metabolic disorders
. Diabetes
. Thyroid disorder
. Adrenal insufficiency
Malignancy
. Solid tumor
. Hematologic malignancy
Gastrointestinal
. Hepatitis
. Malabsorption
Other
. Depression
. Eating disorder
. Medication side effect
—————
Case 6 sim. pt. instruction
If the doctor asks you about anything otters 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 with fatigue
History of present illness
. The symptoms stated 5 months ago
. Symptoms were initially mild but have been worse over the last 3 months
. Generalized weakness but no focal weakness
. Symptoms are associated with intermittent “ gas pain “ around the umbilicus
. Feel full after eating only small meals
(Include the following information only of asked what may have caused / trigged your symptoms.)
. Symptoms got worse after your spouse died 3 months ago
. Decreased appetite with a 13.6-kg(30-lb) weight loss
. Decreased interest in activities
. Difficulty falling asleep at night ; also waking up frequently at night and unable to get back to sleep
. No thoughts about suicide , but have feelings of guilt
. Difficulty concentrating on tasks
. Thinking that your family dose not understand what you are going though and feeling isolated form many of your friends
Review of systems
. No fever , chills
. No nausea, vomiting , diarrhea , or constipation
. No chest pain, or shortness of breath
. No jaundice
. No numbness, tingling , or tremor
Past medical / family / social history
. No prior medical problems
. No surgeries
. No medications
. No drug allergies
. Mother died at age 60 of pancreatic cancer ; after died at age 55 of heart attack ; no siblings
. Widower, living aloe
. 2 children (ages 28, 25)
. Occupation : restaurant manager
. Tobacco: No
. Alcohol : 2-3 drinks on social occasions
. Recreational drugs: No
Physical examination
Head and neck:
. No readiness or exudates in the mouth
. No enlarged lymph nodes
. No thyromegaly
Chest / Lungs :
. No tenderness to palpation of the chest wall
. Clear to auscultation bilaterally
Heart:
. Regular rate and rhythm
. No murmurs
Abdomen:
. Non tender, non distended
. Normative bowel sounds throughout
. Tympanic to percussion
. No hepatoslenomegaly
. No jaundice
Extremities:
. No cyanosis , clubbing , edema
Neurological:
. Normal motor strength and deep-tendon reflexes
—————
Case 6 sim. pt. check list
Following the encounter , check which of the following items were performed by the examinee
History of present illness/review of the system
. Asked about the onset and progression of weakness. fatigue (open-ended question)
. Asked about associated symptoms , especially:
- Fever , chills , night sweats
- Enlarged lymph nodes
- Temperature intolerance (hot or cold)
- Chest pain, cough , and shortness of breath
- Nausea and vomiting
- Change in appetite and weight
- Difficulty swallowing
- Abdominal pain
- Jaundice
- Blood in stools or black stools
- Insomnia/sleep
. Enquired about any precipitating factors
. Asked about mood/emotional state
. Asked about interest in life
. Asked about any guilt feelings
. Asked about any ideas , plans , attempts for suicide
Past medical / family / social history
. Asked about similar episodes in the past
. Asked about past medical issue
. Asked about previous hospitalization and surgeries
. Asked about medications
. Asked about medication allergies
. Asked about family health
. Asked about occupation
. Asked about tobacco, alcohol, and drug use
Examination
. Examinee washed hands
. Examined without gown , not though gown
. Examined eyes
. Examined oral cavity
. Examined neck for thyromegaly and lymphadenopathy
. Auscultated test (heart and lungs)
. Palpated abdomen , both superficially and deeply
. Checked leg for edema
. Check muscle power
. Looked for ankle jerk / reflex
Counseling
. Explained the physical findings and possible diagnosis
. Explained further workup
. Inquired regarding need for any additional emotional 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 open-ended questions
. Asked non leading questions
. Listened to what you said without interrupting
. Used plain English rather than technical jargon
. Used appropriate draping techniques
. Summarized the history and explained physical findings
. Expressed empathy and gave appropriate reassurances
. Asked whether you had any concerns/ questions
Differential diagnosis
. Occult malignancy
. Hyper/hypothyroidism
. Depression
Diagnostic study/ studies
. Rectal examination and stool examination for occult blood
. CBC with differential
. Glucose and electrolytes
. TSH
. Liver function tests
—————
Case 6 clinical summary
Clinical Skill Evaluation
Case 6 Patient Note
The following represents a typical note for this patient encounter . the details may vary depending on the information given by simulated patient
History : Describe the history you just obtained form this patient. Include only information (pertinent positive and negatives) relevant to this patient’s problem(s).
. 50-yo male with 5 months of increased fatigue.
. Spouse died 3 months ago and symptoms have worsened since then.
. 13.6-kg (30-lb) weight loss, decreased appetite , periumbilical abdominal pain , early satiety.
. Loss of interest in activities and terminal insomnia but not suicidal
ROS: No dysphagia , fever , chills , night sweats , chest pain , shortness of breath, or cough
PMHx: None
PSHx: None
Meds: None
Allergies: None
FHx: Mother died at age 60 form pancreatic cancer , after died at age 55 form heart attack
SHx: Denies tobacco use
Physical examination: 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 (98F) ; blood pressure , 120/76 mmHg ; pulse , 78/min : and respirations , 18/min
. Head / neck : No redness or exudates in the mouth , no enlarged lymph nodes , no jaundice , no thyromegaly
. Chest /lungs: No tenderness to palpation of the chest wall , clear to auscultation bilaterally
. Heart : RRR
. Abdomen : Non tender , non distended , normative bowel sounds throughout ; tympanic to percussion ; no hepatosplenomegaly
. Extremities : No cyanosis , clubbing, or edema
. Neurological : Motor 5/5 throughout , DTR 2+ bilaterally
Data interpretation : Based on what you have learned form the history and physical examination, list up to 3 diagnosis that might explain this patient’s complaint(s). List your diagnosis form most to least likely. For some cases , fewer than 3 diagnosis will be appropriate . then , enter the positive or negative findings form the history and the physical examination (if present) that support each diagnosis. Lastly , list initial diagnostic studies(if any) you would order for each listed diagnosis (e.g., restricted physical exam maneuvers , laboratory tests, imaging, ECG, etc.).
Diagnosis #2 : Depression
history finding(s)
. Fatigue
. Weight loss
. Death of spouse
. Terminal insomnia
Physical Exam finding(s)
. None
Diagnosis #1 : GI malignancy (eg , colon cancer, Gastric cancer )
History finding(s)
. Fatigue
. Weight loss
. Early satiety
Physical exam finding(s)
. None
Diagnosis #3 : hyperthyroidism
History finding(s)
. Weight loss
. Fatigue
Physical Exam finding(s)
. None
Diagnosis Studies
. TSH and T4
. CBC with differential
. Rectal examination with FOBT
. Colonoscopy
. CT scan ion the abdomen
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2018/08/15 03:22pm 
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