Exam 2: STEP 2 CS - Practice Cases

Correct Answer:

Verified

Instructions:
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 65-year-old woman who comes to the emergency department with 1 hour of right arm and leg weakness.
History of present illness
The symptoms started an hour ago with weakness in the right arm and leg
Gradually increasing numbness
Moderate (5/10 in severity) headache that is felt "all over" the head
Nausea but no vomiting
No slurred speech or difficulty swallowing
No blurred or double vision
No recent falls or loss of consciousness
No symptoms like this in the past
Review of systems
No fever
No chest pain or palpitations
No diarrhea or constipation
No urinary symptoms
No seizures
Past medical/family/social history
High blood pressure for 25 years
High cholesterol
Heart attack 6 years ago; heart bypass surgery at that time
Medications:  Simvastatin 20 mg daily, aspirin 81 mg daily, atenolol 50 mg daily
Medication allergies:  None
Both parents had hypertension and died in their 60s of heart attacks
Widow (husband died 8 years ago); lives alone
Brought to the hospital by neighbor ("Steve") who is closest contact and is "like a son to me"
Tobacco:  2 packs of cigarettes a day for 35 years and quit 6 years ago
Alcohol:  1-2 drinks, once a month
Recreational drugs:  None
Physical examination
Neurological:
Weaker on the right side of the body
Unable to lift right leg or arm without assistance
Unable to stand
Cranial nerves are normal
Reflexes are slightly exaggerated on the right
Babinski:  Upgoing on right and downgoing on left
Sensation is normal on both sides of body
The rest of the examination is normal.
Ask this question:  If the examinee does not discuss the possibility of a stroke, ask, "Doctor, is it a stroke?"
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 of weakness
Asked where the weakness is felt
Asked if the weakness is changing over time
Asked how you felt prior to onset of the weakness
Asked about associated symptoms Sensory changes or numbness
Loss of consciousness
Seizures/jerky movements
Fever
Nausea/vomiting
Chest pain, palpitations
Problems with speech or swallowing
Visual changes (eg, blurred vision, double vision)
Incontinence/bowel or bladder dysfunction
Asked about a history of frequent falls/spells
Asked about any history of recent head trauma
Past/family/social history
Asked about similar symptoms in the past
Asked about past/other medical issues (especially hypertension, diabetes mellitus, hypercholesterolemia, myocardial infarction, strokes, migraine headaches)
Asked about previous hospitalizations and surgeries
Asked about current medications
Asked about medication allergies
Asked about any family history of strokes, heart attacks, or aneurysms
Asked about smoking
Asked about alcohol intake
Asked about living situation
Examination
Examinee washed hands before examination
Examined without gown, not through gown
Checked cranial nerves II-XII
Tested muscle power bilaterally
Checked deep-tendon reflexes in both the upper/lower extremities
Checked for sensory modalities proximally and distally
Checked cerebellar function (eg, Romberg test)
Checked coordination and gait
Listened for carotid bruit
Checked for neck stiffness
Auscultated heart
Counseling
Explained the physical findings and possible diagnosis
Explained further workup
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
Asked one question at a time
Listened to what you said without interrupting
Used plain English rather than technical jargon
Used appropriate transition sentences
Used appropriate draping techniques
Expressed empathy and made appropriate reassurances
Asked whether you had any concerns/questions
Differential diagnosis
Stroke
Transient ischemic attack (TIA)
Subarachnoid hemorrhage
Diagnostic study/studies
CBC with differential
Basic metabolic panel (or glucose and electrolytes)
CT scan of the head without contrast
Doppler ultrasound of the carotid arteries
ECG
Transesophageal echocardiogram
Case 3 Patient Note
The following represents a typical note for this patient encounter. The details may vary depending on the information given by the simulated patient.
History:  Describe the history you just obtained from this patient.  Include only information (pertinent positives and negatives) relevant to this patient's problem(s).
65-yo female with an hour of acute-onset, right-sided weakness and headache.
Gradually progressing symptoms over the past hour.
Nausea without vomiting.
No history of fall or syncope.
ROS:  No fever, chest pain, shortness of breath, vision changes, dysarthria, seizures
PMHx:  HTN, hypercholesterolemia, CAD
PSHx:  CABG 6 years ago
Meds:  Aspirin, simvastatin, atenolol
Allergies: None
FHx:  Mother and father had HTN and died of MI, brother has HTN and hypercholesterolemia
SHx:  Smoked 2 PPD for 35 years but quit 6 years ago
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, 36.8 C (98.2 F); blood pressure, 160/90 mm Hg; pulse, 78/min; and respirations, 16/min
Lungs:  CTA bilaterally
Heart:  RRR without M/G/R
Neurological:  A&O ×3, CN 2-12 intact, motor 5/5 on LUE and LLE but 3/5 in RUE and RLE, sensory grossly intact, DTR 2+ on left but 3+ in RUE and RLE, upgoing toes on right and downgoing on left, gait unable to be assessed
Data interpretation:  Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patient's complaint(s).  List your diagnoses from most to least likely.  For some cases, fewer than 3 diagnoses will be appropriate.  Then, enter the positive or negative findings from 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 examination maneuvers, laboratory tests, imaging, ECG, etc.).
Diagnosis #1:  Evolving stroke

Diagnosis #2:  TIA or reversible ischemic neurological deficit

Diagnosis #3:  Subarachnoid hemorrhage

Correct Answer:

Verified

Instructions:
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 29-year-old woman who comes to the emergency department with chest pain.
History of present illness
Pain started 12 hours ago
Pain located in the middle of the chest and does not move
Pain started slowly but is increasing and is now 7-8/10 in severity
Pain worse with any movement or deep breathing
Took acetaminophen, which reduced the pain slightly
Fever as high as 38.3 C (101 F), cough with green sputum, and mild shortness of breath for the last 3 days
No blood in the sputum or recent chest trauma
Review of systems
No nausea, vomiting, diarrhea, or abdominal pain
No leg pain or swelling
No back pain
No urinary symptoms
Last menstrual period was 2 weeks ago
Past medical/family/social history
Sickle cell anemia: Diagnosed in childhood; had mild pain episodes at that time. 1 transfusion (age 18).  Admitted once for abdominal pain 5 years ago that resolved with supportive care in the hospital.
No surgeries
No pregnancies
Medications: Birth control pill, acetaminophen as needed
Allergies: No drug allergies
Mother also has sickle cell anemia; brother and father are healthy
Occupation: Teacher
Single, sexually active with 1 boyfriend and use condoms regularly
Tobacco: No
Alcohol: No
Recreational drugs: No
Physical examination
Head and neck:
No redness or exudates in the mouth/pharynx
No enlarged lymph nodes
Chest/lungs:
No tenderness to palpation of the chest wall
Clear to auscultation bilaterally
Heart:
Regular rhythm with borderline tachycardia
No murmurs
Abdomen:
Nontender, nondistended
Normoactive bowel sounds throughout
Tympanic to percussion
No hepatosplenomegaly
Extremities:
No cyanosis, clubbing, or edema
No tenderness in the legs
You should also try to breathe a little faster than normal to a rate near 20/min.  The rest of the examination is normal.
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 location of pain
Asked about the intensity of pain
Asked about the quality of pain
Asked about the origin and duration of pain
Asked about the progression of pain
Asked about any radiation of pain
Asked about the aggravating/relieving factors
Asked about associated symptoms, especially: Nausea and vomiting
Fever
Cough (including sputum and blood)
Shortness of breath
Asked about precipitating factors of sickle cell crisis (eg, diarrhea, dehydration, stress)
Asked about history of chest trauma
Asked about any leg pain/swelling/redness
Asked about blood in the urine
Asked about prior blood transfusion
Past medical/family/social history
Asked about any similar problems in past
Asked about other past medical issues
Asked about previous hospitalizations and surgeries
Asked about menstrual/reproductive history
Asked about current medications (prescription and over the counter)
Asked about medication allergies
Asked about family history of sickle cell anemia, heart problems, and blood clots
Asked about tobacco, alcohol, and drug use
Asked about occupation
Examination
Examinee washed hands before examination
Examined without gown, not through gown
Examined the oral cavity
Examined for enlarged lymph nodes
Performed inspection and palpation of the chest
Performed palpation of area
Auscultated the lungs and heart
Palpated abdomen (superficial and deep)
Examined hands and fingers
Examined legs for tenderness
Counseling
Explained the physical findings and possible diagnosis
Explained the complications of sickle cell disease (infections, hypoxia can precipitate pain)
Explained further workup
Discussed the importance of avoiding hypoxemia and maintaining hydration
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 few open-ended questions
Asked nonleading questions
Asked one question at a time
Listened to what you said without interrupting
Used plain English rather than technical jargon
Used appropriate transition sentences
Used appropriate draping techniques
Expressed empathy and made appropriate reassurances
Asked whether you had any concerns/questions
Differential diagnosis
Chest syndrome due to sickle cell anemia
Pneumonia
Costochondritis
Pericarditis
Pulmonary thromboembolism
Salmonella osteomyelitis
Diagnostic study/studies
CBC with differential
Urinalysis
Sputum Gram stain and culture
Blood cultures
Chest x-ray
ECG (provided with doorway information)
Case 4 Patient Note
The following represents a typical note for this patient encounter. The details may vary depending on the information given by the simulated patient.
History:  Describe the history you just obtained from this patient.  Include only information (pertinent positives and negatives) relevant to this patient's problem(s).
29-yo female with history of sickle cell anemia and 12 hours of acute-onset chest pain.
Gradual increase in pain to 7-8 on a scale of 10 over the past 12 hours.
Pain is worse with movement and respiration and improved with acetaminophen.
3 days of fever to 38.3 C (101 F), cough productive of green sputum, and mild shortness of breath.
ROS:  No nausea, vomiting, trauma to chest, dysuria, diarrhea, leg swelling, or leg pain
PMHx:  Admitted once 5 years ago for abdominal pain that resolved
PSHx:  None
Meds:  Birth control pills, Tylenol PRN
Allergies: None
FHx:  Mother has sickle cell anemia
SHx:  Denies use of tobacco, alcohol, and illicit drugs.  Had a blood transfusion as a child.
ECG shows sinus tachycardia with no diagnostic abnormalities.
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, 38.5 C (101.3 F); blood pressure, 120/75 mm Hg; pulse, 110/min; and respirations, 22/min
HEENT:  Oropharynx without erythema or exudates
Neck:  No cervical lymphadenopathy, trachea midline
Lungs:  CTA bilaterally, no chest tenderness to palpation
Heart:  RRR without M/G/R
Abdomen:  Nontender, nondistended, normoactive bowel sounds throughout; tympanic to percussion; no hepatosplenomegaly
Extremities:  No cyanosis, clubbing, or edema; no swelling or tenderness in the legs
Data interpretation:  Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patient's complaint(s).  List your diagnoses from most to least likely.  For some cases, fewer than 3 diagnoses will be appropriate.  Then, enter the positive or negative findings from 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 #1:  Acute chest syndrome

Diagnosis #2:  Pneumonia

Diagnosis #3:  Pulmonary embolism

Correct Answer:

Verified

Instructions:
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 solids (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 or transferring food out of the mouth into the throat
10-lb (4.5 kg) weight loss in the past 3 months; decreased appetite for the past 3 weeks
Review of systems
No weakness in the arms or legs
No shortness of breath or chest pain
No nausea, vomiting, diarrhea, or constipation
Past medical/family/social history
Gastroesophageal reflux (symptoms 2-3 times a week for the past 25 years; relieved with antacids)
No surgeries
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
Recreational drugs: No
Physical examination
HEENT:
Oropharynx clear, difficulty swallowing water
Neck:
Supple with no visible deformity
Lymph nodes:
No cervical, axillary, or supraclavicular adenopathy
Lungs:
Clear to auscultation bilaterally
Heart:
Regular rate and rhythm
No murmurs, gallops, or rubs
Abdomen:
Nontender, nondistended
Normoactive bowel sounds
No hepatosplenomegaly
No CVA tenderness
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 about exact location where food gets stuck
Asked whether the dysphagia is for solids, liquids, or both
Asked which started first (solids or liquids)
Asked whether there is any associated pain
Asked about any aggravating or relieving factors
Asked about episodes of choking 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 about medications
Asked about medication allergies
Asked about family health
Asked about occupation
Asked about tobacco, alcohol, and recreational drug use
Examination
Washed hands 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 above 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 open-ended questions
Asked nonleading questions
Asked one question at a time
Listened to what you said without interrupting
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
Differential diagnosis
Carcinoma of the esophagus
Achalasia
Reflux esophagitis
Stricture
Diagnostic study/studies
CBC
Esophagram
Esophagogastroduodenoscopy
Chest x-ray
Case 32 Patient Notes
The following represents a typical note for this patient encounter.  The details may vary depending on the information given by the simulated patient.
History:  Describe the history you just obtained from 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 stuck in the middle of the chest.
Decreased appetite and 4.5-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 siblings are healthy
SHx:  1 PPD smoker for 30 years, occasional alcohol use
Physical examination:  Describe any positive and negative findings relevant to this patient's problem(s).  Be careful to include only those parts of examination performed in this encounter.
Vital signs:  Temperature, 36.7 C (98.1 F); blood pressure,130/90 mm Hg; pulse, 85/min; and 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:  Nontender, nondistended, normoactive bowel sounds, no hepatosplenomegaly, no CVA tenderness
Data interpretation:  Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patient's complaint(s).  List your diagnoses from most to least likely.  For some cases, fewer than 3 diagnoses will be appropriate.  Then enter the positive or negative findings from 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 (eg, restricted physical examination maneuvers, laboratory tests, imaging, ECG)
Diagnosis #1:  Esophageal cancer

Diagnosis #2:  Achalasia

Diagnosis #3:  Reflux esophagitis/stricture