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 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

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 50-year-old man who comes to the clinic due to difficulty swallowing. <strong>History of present illness</strong> 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 <strong>Review of systems</strong> No weakness in the arms or legs No shortness of breath or chest pain No nausea, vomiting, diarrhea, or constipation <strong>Past medical/family/social history</strong> 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 <strong>Physical examination</strong> 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. <strong>History of present illness/review of systems</strong> 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 <strong>Past medical/family/social history</strong> 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 <strong>Examination</strong> 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 <strong>Counseling</strong> Explained physical findings and possible diagnosis Explained further workup Discussed smoking cessation <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 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 <strong>Differential diagnosis</strong> Carcinoma of the esophagus Achalasia Reflux esophagitis Stricture <strong>Diagnostic study/studies</strong> CBC Esophagram Esophagogastroduodenoscopy Chest x-ray <strong>Case 32 Patient Notes</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). 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 <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 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 <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 (eg, restricted physical examination maneuvers, laboratory tests, imaging, ECG) <strong>Diagnosis #1: Esophageal cancer</strong> <strong>Diagnosis #2: Achalasia</strong> <strong>Diagnosis #3: Reflux esophagitis/stricture</strong>

Diagnosis #2: Achalasia

Diagnosis #3: Reflux esophagitis/stricture

Doorway Information About Patient

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