Doorway Information About Patient

Question

Examlex · Accepted Answer

The Answer is 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

Instructions: <strong>If the doctor asks you about anything other than these, just say no, or provide an answer that a normal patient might give.</strong> You are a 65-year-old woman who comes to the emergency department with 1 hour of right arm and leg weakness. <strong>History of present illness</strong> 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 <strong>Review of systems</strong> No fever No chest pain or palpitations No diarrhea or constipation No urinary symptoms No seizures <strong>Past medical/family/social history</strong> 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 <strong>Physical examination</strong> 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. <strong>Ask this question: If the examinee does not discuss the possibility of a stroke, ask, Doctor, is it a stroke? </strong> Checklist: Following the encounter, check which of the following items were performed by the examinee. <strong>History of present illness/review of systems</strong> 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 <strong>Past/family/social history</strong> 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 <strong>Examination</strong> 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 <strong>Counseling</strong> Explained the physical findings and possible diagnosis Explained further workup <strong>Communication skills and professional conduct</strong> 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 <strong>Differential diagnosis</strong> Stroke Transient ischemic attack (TIA) Subarachnoid hemorrhage <strong>Diagnostic study/studies</strong> 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 <strong>Case 3 Patient Note</strong> <strong>The following represents a typical note for this patient encounter. The details may vary depending on the information given by the simulated patient.</strong> <strong>History:</strong> 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 <strong>Physical examination:</strong> 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 <strong>Data interpretation:</strong> 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.). <strong>Diagnosis #1: Evolving stroke</strong> <strong>Diagnosis #2: TIA or reversible ischemic neurological deficit</strong> <strong>Diagnosis #3: Subarachnoid hemorrhage</strong>

Diagnosis #2: TIA or reversible ischemic neurological deficit

Diagnosis #3: Subarachnoid hemorrhage

Doorway Information About Patient

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Doorway Information About Patient

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