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 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

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 29-year-old woman who comes to the emergency department with chest pain. <strong>History of present illness</strong> 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 <strong>Review of systems</strong> 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 <strong>Past medical/family/social history</strong> 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 <strong>Physical examination</strong> 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. <strong>History of present illness/review of systems</strong> 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 <strong>Past medical/family/social history</strong> 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 <strong>Examination</strong> 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 <strong>Counseling</strong> 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 <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 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 <strong>Differential diagnosis</strong> Chest syndrome due to sickle cell anemia Pneumonia Costochondritis Pericarditis Pulmonary thromboembolism Salmonella osteomyelitis <strong>Diagnostic study/studies</strong> CBC with differential Urinalysis Sputum Gram stain and culture Blood cultures Chest x-ray ECG (provided with doorway information) <strong>Case 4 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). 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. <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, 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 <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 exam maneuvers, laboratory tests, imaging, ECG, etc.). <strong>Diagnosis #1: Acute chest syndrome</strong> <strong>Diagnosis #2: Pneumonia</strong> <strong>Diagnosis #3: Pulmonary embolism</strong>

Diagnosis #2: Pneumonia

Diagnosis #3: Pulmonary embolism

Doorway Information About Patient

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Doorway Information About Patient

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