This case scenario will be presented in a different format in that the answers given by the SP will be given in parentheses
• In the whole patient encounter the SP will be in a most disinterested mood and will talk in a feeble voice
• The doctor should always make eye contact with the patient
• The paucity of speech from the patient should not frustrate the doctor
Simulated encounter
• Hello Mrs. Jones. My name is Dr. Smith. I am here to ask you a few questions and do a physical on you. Is that ok with you. (The SP will nod feebly)
• What brings you in today (I don’t know Doctor. I feel a bit down)
• Since when have you been feeling this way (3 months. Maybe)
• Mrs. Jones; do you think that something has brought this on.( She remains silent)
• Mrs. Jones; I know that you are in a lot of emotional stress. Are you willing to share your problems with me? (The patient looks at the doctor and then away)
• Do you think any thing has brought this on (I don’t think so)
• Do you have anybody to talk to you when you feel down (I have an aunt. She stays far away)
• Mrs. Jones…. How has your appetite been of late (I don’t feel like eating)
• Mrs. Jones…. Have you lost or gained any weight recently (my weight decreased by 7 lbs over the past one month)
• How has your sleep been? (I am getting up early in the morning)
• Do you feel guilty for any reason ( I don’t think I am being a good mom for my children)
• Do you feel any tiredness (I don’t feel that I have any energy at all. I just don’t want to get out of the couch)
• Mrs. Jones… Please describe your daily routine for me (I am a house wife. I do the housework and cook for my children. That’s about it.)
• Can you tell me if you have any hobbies and interests (I play violin and sing in the choir on Sundays; but now don’t feel like doing that anymore)
• Do you feel that you are losing your power of concentration (mmm I don’t know)
• Are you forgetting things more often (Yeah. I am forgetting to pay the bills etc)
• What do you enjoy most (Spending time with my children)
• Do you still enjoy it (I don’t feel like I want to be with any body right now)
• Mrs. Jones… Have you ever felt like ending your life because you felt that it wasn’t worth living? (Yeah – a couple of times)
• Do you have any ideas on how to do it (No)
• Do you have guns or pills at home (Yeah. I have a .32 at home)
• Do you feel cold when others don’t (no)
• Are you losing any hair (no)
• Have you ever listened to or seen anything that others don't ( no)
• Please do an MMSE at this juncture
• Do you think that some thing is going wrong with you (Yeah)
• Are you willing to get help from a counselor (I don’t know)
• I can get you in touch with one. (If you feel that would help me.)
Now I need to ask you a few questions about your health in the past. Is that ok with you (Yeah)
• Have you ever been hospitalized in the past (No except for the deliveries of my children)
• Have you ever felt like this in the past (no)
• Are you on any medications (no)
• Do you have any allergies of any kind (none that I know of)
• Do you have any problems with your urination (no)
• Do you have any problems with your digestion or your bowels (I have been constipated of late)
• Have you ever had any shortness of breath (no)
• Have you ever had any chest pain (no)
• Have you had cough that just wouldn’t go away? (no)
Now I need to ask you a few personal questions. Please do not feel embarrassed. Everything you say will be kept confidential.
• Are you sexually active (yes)
• How many sexual partners do you have-A couple of them
• Your sexual preference is ….(males )
• Do your sexual partners use condoms (Yes they do)
• Have you ever been diagnosed or treated for an STD (no)
• Have you ever been tested for HIV (no)
Now I need to ask you a few questions about your family so that I can get a clearer picture of your health
• Are you married (I was. Got a divorce 10 years ago)
• Are your parents living (no. They died of old age)
• Has any one in your family been diagnosed with a psychiatric disorder (no)
• How many children do you have(2. The elder one is 14. The younger one is 11)
Now I need to ask you a few questions about your lifestyle.
• Do you use tobacco (no)
• Do you drink any type of alcoholic beverages? (Yeah. I have 2 shots of scotch on the rocks. Been doing so for the past 10 years.)
• Do you use any recreational drugs (no)
• Do you drink coffee (Yeah. One cup every morning)
Now I need to do a physical on you. Please excuse me for a few seconds while I wash my hands
• I am going to check your thyroid gland (Not palpable)
• I am going to check your reflexes (2+)
• I am going to check your pulse now
• I am going to listen to your heart and lungs now.
Thank you Mrs. Jones for your cooperation.
• I am going to sit down and tell you what I think so far
• I feel that you are having an episode of depression though I wouldn’t definitely say it before the results of some tests that I am going to run on you.
• I am going to order a blood test on you to find out if you have any problems with your thyroid. After the results come in I would sit with you again and then we can discuss how we can make you feel better.
• Is there anything else that I can do for you?
Differential Diagnosis
• Depression
• Hypothyroidism
• Occult carcinoma
Workup
• T3 T4 TSH
• CBC with differential
• Urine and serum toxicology screen
2) 52 O/F with a Complaint of hot flashes
Vital:
• B.P 140/80
• Pulse 80/min and regular
• RR is 16/min
• Temp. 98.80F
Communication and Data gathering:
• Hello Mrs. Lewis ; I am Dr. Jones (hello Dr), good morning (good morning Dr), nice to meet you (nice to meet you Dr)
• What brings you in to day (I don’t know Dr; I feel some hot flashes that seem to run through me)
• Since when has this started ( around 3 months ago Dr)
• How often do these hot flashes come (About 10 times daily )
• Do you feel anything else when these flashes occur (I sweat a lot and I feel my heart racing)
• Do you know that you are going to get a hot flash beforehand-I mean do you feel it coming even before it really starts. (Yes Dr-sometimes I do, It some times even disturbs my sleep)
• How are you feeling during most of the days-I mean what is your mood like during the last 3 months. (I don’t know Dr. I seem to be dull some times and some times I have these uncontrollable temper episodes and some times I just want to be left alone. I just don’t feel on top of things. This whole thing is driving my husband crazy)
• Do you feel any burning or pain when urinating (yes I do and I feel that I have to rush to the bathroom some times and I wake up a lot during nights to go to the toilet)
• When did you have your last menstrual period Mrs. Armstrong (about a year ago)
• Do you have any problems with your bowels (no)
• Have you had any thyroid problems in the past. (yes Dr, I had a goiter 10 yrs back but it was operated and removed)
• Do you have any other problems like high blood pressure, diabetes...(no)
• Make eye contact and then say Mrs. Armstrong I am going to ask some sensitive questions. It might be embarrassing to you, but it is in your best interests that we have to go ahead with these questions and please feel free.
• How has your sexual life been of late (I don’t know Dr. I get a lot of burning sensation and I generally don’t show much interest because of the pain even though my husband wants to do it)
• Is he supportive (Yeah I guess but he is frustrated with the way I have been behaving)
• Do you have any other problems for which you have taken consultation or medication (No Dr This is the first time that I am sick )
• Have any of your relatives been diagnosed with Breast or uterine cancer (Yes Dr my sister had one breast removed for breast cancer)
• Have you ever had any swollen and painful limbs, any blood clots in your legs.? (no)
• Have you ever had any pain in the legs or back (for osteoporosis).? (no)
• Do you smoke (no)
• Do you drink any type of alcoholic beverages (no)
• Do you have any allergies (no)
• Do any of your family members have a history of clotting disorders (no)
Examination:
• Do a Heart , lung, and abdominal exam very quickly and superficially.
• Check for muscle pain in the back
• Check for hyperactive reflexes
Counseling:
• Tell the pt that the most probable diagnosis is menopause
• Offer help to educate the husband about the possible diagnosis
• Tell her that she is a candidate for HRT even though her sister had breast cancer
• Inform her about the adverse affects of HRT
• Offer her estrogen cream for the vagina to ease her dyspareunia and her dysuria
• Inform her that she needs to supplement Calcium in her diet to reduce the risk of osteoporosis. Inform her of the beneficial effect of adequate wt bearing exercise.
D.D for this Case:
• Menopause
• Hyperthyroidism
• Occult malignancy
• Factitious disorder
• Chronic fatigue syndrome
Work Up:
• CBC with ESR
• Thyroid profile
• Serum FSH and LH
• DEXA
• Pap smear
3) 70 Yr. O/F Complaining of Forgetfulness
Vitals
• Temperature 98.6
• pulse 76/min, regular
• B.P 150 /85
• RR 16/min
Make a Differential Diagnosis
• Alzheimer's Disease
• Vascular dementia
• Normal pressure Hydrocephalus
• Vitamin B12 deficiency
• Hypothyroidism
• Masked depression
• Chronic Subdural Hematoma
Simulated clinical encounter:
I am giving only the questions to ask not the manner in which they should be asked. For that I think you will have to read the history gathering section of this site.
• Hello Mrs. Eve; I am Dr. Jones; how are you doing today. If you can hear me please nod.
• How are you feeling nowadays. Are you feeling sad or lonely
• Do you find any difficulty while walking
• Do you have any problems driving to the grocery store
• Do you have any problem eating food, or in making meals for yourself
• Do you have any trouble with your toilet habits.
• Do have any problems while shopping and housekeeping
• Are you finding any difficulty in managing your accounts
• Have you noticed any wt loss over the past few months.
• Do you have any problems with sleep.
• How are your bowel habits
• Do you have any spells of dizziness or feeling of a pounding heart
• Did you notice any cold or heat intolerance
• Did you have any medical problems in the past
• Do you have somebody to take care of you in case of an emergency or do you want me to get you in touch with a social organization
• Please describe your regular diet for me
• Are you having any problems with your memory
• Are you able to find your way through your house
• Do you smoke
• Do you drink any type of alcoholic beverages
• Are you sexually active
• Have you ever had any sexually transmitted diseases
• Do you have any family members who had a hereditary medical condition.
Examination:
• Do the following questionnaire as part of the mental status exam
• Mrs. Thomson, Can you tell me your full name
• Can you tell me what day it is today
• Can you tell me where we are now
• Please spell the word WORLD back for me
• Please repeat the three objects that I a going to tell you right now. I want you to tell them to me right away and then again after some time; so please remember them
• Please put your left hand on your right hand and bring both hands towards your chest and then back to their original position.
• Do a focused neurological exam
• Do the get up and go test
• Do a fast heart, lungs exam
• Do not forget to do a fundoscopy
Counseling:
• Tell her the diagnostic possibilities ‘workup and prognosis
• If you suspect that she has Alzheimer's; Ask the pts permission and then tell the pt about the importance of structured home environment and the precautions to be taken to avoid falls.
• Explain to the pt the necessity of being regular in taking her medication. See to it that the pt understands her problem ,
• Ask her about her social support and offer any help
D.D for this Case:
• Alzheimer's Disease
• Vascular dementia
• Normal pressure Hydrocephalus
• Vitamin B12 deficiency
• Hypothyroidism
• Masked depression
• Chronic Subdural Hematoma
Work Up:
• CBC with differential
• CT san of head
• T4,T3 TSH
• S.Creatinine and S. electrolytes
• Syphilis serology
4) 50 Yr. old diabetic male came for medication refill
Vitals
• BP-135/70
• Pulse- 73
• R.rate-16
• Temp- 98.7
History taking:
Please remember that you need to use appropriate transitions sentences. This is quick glance of questions how to proceed.
• When were you diagnosed with diabetes?
• Are you currently taking any medications for diabetes? (yes, glyburide)
• Are you taking your medications regularly?
• Do you think that your medicines are controlling diabetes effectively?
• Have you ever taken insulin?
• How often do you check your blood sugar? or Are you checking blood sugar regularly according to your previous physician advice?
• How has your blood sugars been lately? I mean can you please tell me how high / at what range were they?
• Do you have any problems that you would like to tell?
• How is your vision? Do you think is there any change in vision lately?
• Do you feel any abnormal sensations in legs like pins or needle prick sensations, any tingling or numbness?
• Have you ever had any chest pain?
• Do you have any breathing problems?
• Are you sexually active? Do you have any problems in sexual intercourse?
• How are your bowel habits?
• Do you have any problems with urination?
Past History
• Are you allergic to anything?
• Have you ever been hospitalized for diabetic complications or for any other reason?
• Are you taking any medications besides diabetic drugs?
• Do you have any other medical problems like high blood pressure?
• Do you smoke?
• Do you drink alcohol?
• Do you exercise regularly?
• How is your appetite? Have you lost or gained any weight lately?
Examination
• Look fundus for DM retinopathy.
• Test sensation in legs.
• Auscultate for carotid bruits.
• Palpate precordium for PMI. (Cardiomegaly)
• Auscultate heart.
• Check distal pulses in at least two places
Investigations
• CBC with differential count
• Blood glucose
• HbA1C
• BUN and Serum Creatinine
• Lipid Profile
Key point: Even if the SP is wearing shoe or socks, please don't forget to take them out to examine the feet!!
5) 20 Yr. O/F Complaining of vaginal bleeding
Vitals:
• B.P - 90/60
• Pulse - 90
• R.rate - 16
• Temp - 98.8
Make a Differential Diagnosis in your mind
• Regular menses
• Abortion
• Pregnancy
• Ectopic pregnancy
• H. mole
• Trauma.
Simulated encounter:
Please remember that you need to use appropriate transitions sentences. This is quick glance of questions how to proceed.
• When did the bleeding start?
• Was it all of sudden in onset or gradual?
• Can you describe more about the bleeding. I mean is it a bright red blood or clotted blood.
• Is it a pure blood or does it contain any tissue like substance (i.e. Molar pregnancy --> Grape like tissue)
• Has it been a continuous flow or spotting?
• What were you doing when it started? I mean were you sleeping or having sex?
• Do you have any other symptoms that you would like to tell besides bleeding, like abdominal pain, fever, vomiting.?
• Have you ever been pregnant?
• When was your LMP?
• Can you describe more about your menstrual cycles. I mean how was the flow? How many pads do you use per day? How many days? are they regular or irregular?
• Have you had any history of abortions?
• Have you ever been tested for STDs?
Past History
• Have you ever had any history of bleeding or hospitalizations for bleeding?
Sexual History
• Are you married ?
• If yes
• Do you have any other sexual partners? (yes)
• Do you use any means of contraception?
• If no
• Do you have any other sexual partners? (yes)
• Do you use any means of contraception?
• When was your last sexual contact?
Social history
• Do you smoke?
• Do you drink alcohol?
• Do you use illicit drugs? (cocaine may cause painless 1st trimester bleeding)
Family history
• Do you have family history of any bleeding disorders?
• Do you have any family history of multiple abortions.
Examination
• Look for other sites of bleeding. (nose, gums)
• Tell that you want to check for orthostatic hypotension.
• Auscultate abdomen .
• Percuss abdomen for liver span.
• Palpate abdomen superficially.
• Palpate abdomen deeply.
• Check for rebound tenderness.
• Ask to do pelvic exam.
D.D for this Case
• Regular menses
• Abortion
• Pregnancy
• Ectopic pregnancy
• H. mole
Work Up
• Pelvic examination
• Pregnancy test
• CBC and ESR
• Transvaginal ultrasound
• TSH.
• Serum ß-HCG levels
6) Case: 56 year old Scott comes with left sided shoulder pain, vitals were normal.
Simulated encounter
• Once you see the doorway information all you need to do is just note the name of the pt. Take 15-30 seconds at door way to make a mental checklist of differential diagnosis of shoulder pain. There is no point in spending more time.
• First knock the door
• Make comfortable eye contact - empathic
• Patient on the table will be in awkward position in pain. Don't change position of the patient, stand in front of the patient. Make two to three feet distance from patient; you adapt to his position.
• We advised to stand instead of sitting.
• Say hello Mr. xyz nice to meet you. I am here to ask you some question's and take your physical ( in a slow empathic tone)
• Don't shake his hand…because he will be supporting his painful hand with the opposite hand. (You will not get points of shaking and you will loose point of causing pain to patient)
• Patient says “ this pain, I cannot even sleep.”
• First ask an open ended question, Mr. Scott can you tell me something more about your pain. He will answer some aspects of pain like location, quality and some others of LIQOR AAA, make a note in the mind, and don’t ask them again. If you are caught asking again tell him that you were just checking.
• Ask all pain questions (LIQOR AAA) plus functional impairment (ask questions about, occupational impairment, sleep, help at home). Remember all three will be there in the check list.
• The patient will respond to all LIQOR AAA questions. Ask specifically whether he took any medications and any relief with them. He will say the pain was becoming better after he took Ibuprofen.
• Always ask the precipitating factor of pain: SP will say that he fell down on the stairway at night while going down to kitchen to drink water
• Then ask about deficits:
• Do you have tingling, ......(pause) or numbness (no)
• Did you notice any swelling/redness after the fall (no)
• Do you have pain in any other part of the body (Yes; little at the palm)
• Are you able to use your arm (No; because painful)
• Do you feel any weakness (No, only pain)
PMH:
The ask PAM HUGS FOSS -
Now I need to ask you a few questions about your health in the past. Is that ok with you (Yeah)
• Ask the second open ended question "How has your health been until now"
• Have you ever had any problems with your shoulder (Yes, Injury to left arm 3 yrs back and had a humerous fracture)
• Do you have any other medical problems ( Yes I did have acid peptic disease)
• Are you allergic to anything ( Yes; I am allergic to penicillin)
• Have you taken any medications ( Yes only Ibuprofen for pain)
• Do you have any problems with your digestion or your bowels (I have been constipated of late)
• Do you have any problems with your urination (no)
Now I need to ask you a few questions about your family health. Is that Ok with you? (Yes)
• Are your parents living (no. They died of old age)
• Has any one in your family members have medical problems (Pulmonary fibrosis to brother and father)
Now I need to ask you a few personal questions. Please do not feel embarrassed. Everything you say will be kept confidential.
• Are you sexually active (No)
Now I need to ask you a few questions about your lifestyle
• Do you use tobacco (no)
• Do you drink any type of alcoholic beverages? (Yeah. I have 2 shots of scotch on the rocks. Been doing so for the past 10 years.)
• Do you use any recreational drugs (no)
Here ask the another open ended question for social and occupational history.
• You can ask like this 'tell me something about your life at work and home' (Cannot go to party today because not able to drive)
Examination:
• After your history….ask him like " All right; thank you for being cooperative.. now I would like to take your physical; before going physical is there anything you want to tell me before I start your physical. I would be happy to answer" ( Remember he will tell you exactly like this ' Please be gentle with my arm doctor). This is the time to grab one more point for you. Right away console him like "I know that you are in pain, I will try to do my exam as gentle as I can, is that sounds good.' You will see the relief on face of the patient and an importance of an open ended question. This question will help you to ask and counsel the patient more efficiently.
• 'Please excuse me for a few seconds while I wash my hands';
• Always start with local examination i.e. painful shoulder
• Expose the joint properly while draping th other parts.
• Before inspection say that you are looking for redness and swelling, don’t just look…he should know that you are looking. Palpate and compare both joints.
• Palpate…for swelling, warmth, and crepitus gently…tell him first that you will be very gentle. Say sorry if he complains of tenderness during the examination.
• Most of the times SP will have tenderness on anterior part of shoulder joint.
• Check range of motion (ROM) in abduction, adduction, flexion, extension, internal and external rotation (Obviously SP will have restricted abduction beyond 60 degrees i.e. he will complain of pain after 60 degrees). Always adduct the patient's arm across the chest (crossover test).
• Check reflexes, pin prick sensations
• Check the opposite arm
• Check hand in detail
• Just see the legs very quickly
• Listen heart and lungs in 10 to 15 seconds.
Counseling:
• Explain the probable diagnosis, follow-up after investigations, and the availability of physiotherapy.
Diagnosis
• Shoulder dislocation
• Shoulder fracture
• Rotator cuff tear
• Subacromial bursitis
• Ligament sprain
Work up
• CBC
• X-ray of shoulder joint two views, including elbow
• X-ray hand two views
• MRI of shoulder
• ANA and Rheumatic factors
Note: You will get the case exactly similar to this in the real time exam. Please don't ask how come. The important thing that you need to remember from this case is "You have to ask all PAM HUGS FOSS for all the cases no matter what the complaint is because they will have those in the check list. They see whether you are asking all the aspects or not. 'Ask PAM HUGS FOSS for all the cases, you will pass.'
Doorway information
7) A 40 yr old white female (Mrs. Kelly) came for obesity evaluation
Her vitals are BP - 150/90 mm of Hg, HR - 68/min, RR - 16/min and temperature - Normal.
How do you approach this patient?
• Knock the door and enter the room with a smiling face.
• Hello Mrs. Kelly, this is Dr. Robert walker, good morning; nice to meet you. (nice to meet you doctor)
• How are you doing today? (Good)
• Excellent. So what brought you in today? ( You know doctor I am really worried about my weight; these days I am really gaining weight, it makes me worried)
• I am glad that you came here for evaluation. We will try to work together and try to fix it, ok? (yes doctor , thank you)
• I know you are concerned about your weight gain; could you please describe me little bit more about your problem? (I don't know anything specific doctor but I am concerned about my weight)
[Note: Remember they reveal only few things. They really don't tell you until you ask specific questions. So you have to start asking relevant questions. Before you ask, make a checklist of problems associated with obesity.]
Here are the common problems associated with obesity
1. Type II diabetes
2. Heart disease
3. Stroke
4. Hypertension
5. Osteoarthritis
6. Sleep apnea
7. Breathing problems
8. High blood cholesterol
9. Gall bladder disease
10. Increased incidence of cancer like endometrial, colon, postmenopausal breast cancer etc.
11. Increased surgical risk
12. Menstrual irregularities
13. Stress incontinence (due to weak pelvic floor muscles)
14. Psychological disorders like depression
15. Psychosocial difficulties like social stigmatization
• So how do you ask all these; start like this
• Ok Mrs. Kelly I am going to ask few specific questions about your present and past medical health. Just let me know if you have any problems. Ok (Oh! sure Doc)
• For how long have you really been concerned about your weight gain? ( May be from the past 6-7 months)
• What do you think is the major reason for your obesity? (I really don't know)
• How is your appetite? ( It's too much Doc; I want to stop eating junk food but I cannot control)
• Ok for how long have you been having this increased appetite? ( For the last 2-3 yrs)
• Do you have any problems with your breathing; especially in the nights? (No)
• How is your urination? (Pretty good), I mean did you notice any increased frequency (no); have you ever leaked without your knowledge (no)
• Do you have any problem with your bowel movements? (They are pretty regular)
[Note: You have to consider hypothyroidism and Cushing's syndrome as a differential diagnosis in a case of obesity. "Have you ever had problems adjusting to temperatures?"( No). "Have you been on any steroid medications for any reason?" (No). You already know that she did not have any problems with bowel movements (constipation in hypothyroidism)]
• Did you notice any joint pain especially at the level of hips or knees? ( Some pain in both knees)
• Have you ever been diagnosed with high blood pressure (no). When was your last visit with your primary care physician ( A couple of years ago )
• Have you ever had any heart problems? (no)
• Have you had any history of stroke? (no)
• Have you ever been tested for diabetes? (no)
• Ok Mrs. Kelly when did you check your cholesterol level last time? (I think 5 yrs ago and it was slightly elevated and after that I did some exercises, but it did not really help much)
• Have you had any surgeries in the past? (Yes Doc, cholecystectomy 9 months back)
• Are you allergic to any thing? (no)
Ok Mrs. Kelly now I would like to ask you few personal questions. Everything you say will be kept confidential. (Ok Doc sure)
• How has been your menstrual cycles? (They have become irregular these days, but they are not bothering me much.)
• From how long have you been having these irregular periods? ( For the past 2-3 yrs, it seems everything started from the past 2-3 yrs)
• When was your last menstrual period? (20 days ago)
• Are you sexually active? ( This is one more problem for me doctor, these days I don't feel like having sex)
• How is your mood Mrs. Kelly? Are you feeling Ok? ( I am feeling a little bit down these days)
• Do you smoke Mrs. Kelly (No)
• Do you drink any type of alcoholic beverages ( occasionally 1-2 beers in the weekends)
• Are you taking any prescription medications? (no),
• Do you take any over the counter medications (no)
• Do you take any recreational type of drugs (no)
• Can you describe me more about you diet? I mean what is your diet usually consists of? (Pretty much cheese and junk food doctor, some times fruits)
• What do you do for your living? I mean do you work? ( yes doc I am working as a desk clerk)
Examination:
• Just do some focused lung, and heart examination.
• Check the thyroid gland.
• Check extremities for any edema.
Counseling:
• There is a possibility of thyroid problem (even Cushing's syndrome if the patient is on steroids) in your case even though very unlikely, first let me run some tests on you then we will sit together and go over the treatment options available.
• Mean while try to restrict fatty food and start regular exercise.
• Most people will not succeed if they radically change their current eating and cooking habits; however, you will probably have greater success if you try to modify only one aspect of your eating habits at a time. Eventually, you will find yourself eating a healthier diet.
• If you would like more specific advice for diet changes there are many excellent books available, or you may wish to ask for a formal consult with a dietitian.
Investigations:
• CBC with Differentials
• EKG
• Thyroid panel
• Urine cortisol levels
• Lipid profile
Diagnosis:
• Obesity
• Hypothyroidism
• Cushing's syndrome
Note: This is a quick glance of questions that you have to ask in a case of obesity. Don't forget to use appropriate transition sentences and open ended questions.
8) A 69 yr old male with terminal cancer requesting for pain medications
• If you get a case like this you really have to show empathy and care.
• Start with formal greeting and place a hand on the patient shoulder, make an eye contact then the ask an open ended question "Mr. XYZ please tell me what bothered you to come in here? (I am having pain in my epigastrium)
• I have been informed that you have been diagnosed with cancer. Is that correct? (yes)
• Could you please tell me more about your cancer? (I have pancreatic cancer, diagnosed 3 months back)
• I am very sorry to here that (Thank you doc). I know its very difficult, I can understand what you are going through. But I want you to know that I am there to help you if you need anything and make you feel comfortable. ( Thanks you very much)
• Can you please explain me little bit more about your pain? How severe is the pain in a scale of 1 to 10? Do you think there is anything that makes your pain less?
• Do you have pain anywhere else? (Some times my back hurts)
• Are you using any medications for your pain especially any narcotics or morphine? ( not much)
• Do you have any other complaints other than pain? ( I am feeling tired most of the time)
• How is you appetite? ( Its very much decreased), Have you lost any weight? (yes; around 1-12 pounds in 3 months)
• Do you have any fever? (no)
• How are your bowel movements? Do you have any problem urinating?
• How is your mood? ( not good doc, I feel depressed)
• Have you had any thoughts of ending your life? (not really so far)
• Can you please tell me about your home situation? ( I don't have anyone doc, I live alone)
• Do you have any one to help or support you like any friends or family members ( I have few close friends, yes they certainly help if I need)
My. xyz I will certainly help you in relieving your pain. I will prescribe some narcotics like morphine to relive your pain. I would also like you to be aware of certain things which will be necessary at some point in your life. I am very sorry to ask you these questions but I hope you understand the situation. (Thank you doc, don't worry ask me)
• Where do you want to live? Do you want to stay at your home or at nursing home? (I want to stay at home)
• Are you aware about "hospice"? (not much) Ok let me explain about hospice. Hospice care is a choice you can make to enhance your quality of life in a terminal stage. You can also choose to die at home with the support of family, friends, and caring professionals. Over 90% of hospice care is provided at your home. The advantage of Hospice care is that the providers have the skills and resources to permit you to live as pain-free, as comfortable, and as full a life as possible. In addition to providing pain relief Hospice care emphasizes comfort measures and counseling to provide social, spiritual and physical support to you and your family. All hospice care is under professional medical supervision. So I strongly advise you to take Hospice care. ( Thank you very much Doc, You relieved most of my tensions)
• Ok, are you aware of advance directives? (no not much doc). Ok, an "advance directive" or a "living will", will enable you to give your opinion on how you should be treated when you reach the terminal stage of the disease and not in a state to make a decision or you can give the right to take that decision to a loved one who you think will take a wise decision for you. Do you understand what I am saying? (yes doc)
• Do you have any other questions? (No not much doc)
Examination:
• Auscultate and palpate the abdomen.
• Quick auscultation of the heart and lungs.
• Look conjunctiva for pallor or jaundice
If you do this much this is more than enough for the exam.
• There is no single way to give counseling. This is an example for you to give counseling but bear in mind its not necessary that you follow this exactly word to word. This just gives you an idea to help you build up your own way in which YOU ARE COMFORTABLE. It is fine as long as you show that you are sensitive, supportive and conveying necessary information.
• You don't need to write investigations or differential diagnosis if the problem is purely cancer.
9) A 62 yr old male with confusion
• Evaluation of confusion has very broad differential diagnosis. So narrowing down to differential diagnosis depends on the SP's complaints.
• Start with formal greeting and ask, "What brought you in today?" (You know doc actually I don't think I have any problem but my wife says I am very confused these days)
• How long has she been concerned about this? (I think from the past 2-3 months)
• Is she saying that you are confused all the time or is there any specific time or related specific situation? (All the time Doc)
"I understand that you are not much concerned about this. But let me ask few more questions to find out what exactly is going on. Is that ok with you?" (Sounds great Doc)
• Do you have any problems with your memory? Or has she ever complained about your memory? (No)
• Do you feel any weakness in the extremities? (No)
• Do you feel abnormal sensations like tingling or numbness in the extremities? (No)
• Do you feel dizzy? (No)
• Have you ever had any fit like movements or seizures? (No)
• Do you have any history of head trauma? (No)
• Do you have any fever? (No)
• Do you have any headache? (No)
• Have you ever passed out? (No)
• Can you please describe me about your typical day, like your routine activities of daily living?
[Note: Please know the Katz Activities of Daily Living (ADLs) - "DEATH" i.e. Dressing, Eating, Ambulating, Toileting, Hygiene and Instrumental Activities of Daily Living (IADLs) - "SHAFT" i.e. Shopping, Housekeeping, Accounting, Food preparation, and Transportation.]
• How is your bowel habit? (They are pretty good)
• How is your bladder function? (Good)
• Did you notice any increased frequency of urination? (Yes, I have this problem from long time; I usually pee little bit more)
• Do you have any history of diabetes? (Yes), When were you diagnosed with diabetes? (About 25 years ago), Are you on any medication? (Yes I am on insulin), Do you know how much insulin you take daily? (Usually my wife or my daughter gives insulin shots), How often do you check your blood sugar? (Rarely like once or twice in a year), Is your blood sugar under control? (Some times), Have you ever been admitted in the hospital for diabetic related complications? (No) or for any other reason? (No, Never)
• Do you have any other medical problems? (Yes I do have high blood pressure), For how long? (Same as my diabetes), Are you taking any medications for that? (Yes; I am on atenolol 25 mg twice daily; I guess), For how long have you been on these medications? (Around 18 years), How often do you check your blood pressure? (Once or twice in a year), Is your high blood pressure under control? (Not always, only some times)
• Have you ever had any heart problems? (No) Have you ever had stroke? (No)
• Other than insulin and atenolol are you taking any other medications? (No)
• OK, Are you allergic to anything? (Yes; to penicillins)
[Note: Everyone will have allergic history, please ask about the allergic history, you don't have to get into details about the allergy if the case is not related to that, as in this case.]
• Ask about the family history?
• Are you sexually active? (No)
• Have you ever been diagnosed with sexually transmitted diseases especially like syphilis? (No, never)
• Do you smoke? (No)
• Do you drink any type of alcoholic beverages? (no)
• Do you take any recreational drugs? (no)
• Can you please describe about your dietary habits? ( I usually eat beef and some fruits, It's just a regular diet Doc)
If you ask this much in the history that is more than enough. You may not get enough positive history for any particular diagnosis. So don't worry.
Examination:
• You have to do Mini mental status exam (MMSE) - This kind of people usually have normal MMSE.
• You must do fundoscopy
• Check gait, muscle strength, reflexes, sensations, and very quick cranial nerve examination.
• If you have time auscultate heart and lungs.
Most of the times people wont get sufficient time because of the MMSE and CNS exam. Do as much as you can very fast. Once again practice repeatedly otherwise its very difficult to manage in the exam.
Investigations:
• CBC with differential
• Serum electrolytes or Basic metabolic profile (BMP)
• EKG and 24 hr Holter monitoring if there is any history of spells
• Carotid doppler
• CT head
• Urine toxicology screen if you suspect any drug abuse
Differential diagnosis:
• Insulin induced hypoglycemia
• TIA
• Multi infarct dementia
• Electrolyte abnormalities
• Substance abuse or Drug intoxication
• Alzheimer's dementia
We don't think you will have enough time to give counseling. But any way always ask "Do you have any questions?" and formal "closing the encounter". Explain about the importance of tight blood sugar and hypertension control.
"I am sorry to here that your blood sugar and blood pressure are not under good control. Controlling blood sugar requires determination. I will give you a treatment plan, which advises on right diet, exercise, and using the medication. High blood pressure could indicate that your blood vessels are having trouble. Hypertension/high blood pressure could complicate a diabetic’s problem. It could cause stroke, affect the functioning of the heart and even the kidneys. Again regular exercise, reduction of weight (if the patient appears over weight), limiting salt in your food could help in keeping hypertension in check. I would strongly advise you to take regular health maintenance examinations and tightly control your blood sugar and blood pressure. What do you say Mr. xyz?" (Sounds great, Doc)
10) A 25 yr old male for pre-employment check up
You may get this kind of cases as either "Pre-employment" checkups or as an "Insurance checkup". They will tell you everything what you have to do some may be asked to fill up a FORM (It will be provided to you). In case you were not provided with a form you will have to take a simple general history. Most of the times you will be asked to do physical examination only.
• If they want you to do any specific examination, do that and do all the things that are mentioned in the FORM first. You can fill the form after coming outside. In case if the SP asks about the form tell him that you will post it to his home. After you finish "filling"( examining ) the form ask "Do you have any questions?" If he asks for some thing then ask the relevant history. If they don't tell anything specifically you can start taking history in brief. Ask cardinal symptoms of each system.
• Do you have any cough? (No), Do you have any problems with breathing (No)
• Do you have any chest pain? (NO)
• Do you have any headache? (No) Do you have weakness in th extremities? (No)
• How is your bowel habit? (Pretty good)
• How is your bladder function? (Good)
Then you must ask PAM HUGS FOSS
• Please do not forget to ask about Allergic, smoking, alcohol and sexual history.
Here is the sample of the form that you might get. It may not be exactly like this its just to give you an idea. You may get some of the components of this form.
If they ask you to measure blood pressure (on the form/doorway information) you have to measure. This is different from all other cases where you need not to check blood pressure. After finishing the case you just have to fill out this form. You don't need to write any history (If they don't ask) or things that they have not asked you. All you have to do fill out the form.
Height
Weight
Blood pressure
Pulse rate
Lung auscultation
Heart auscultation
CNS reflexes
Abdomen
Spine examination
11) Case of Abuse:
• There are many ways to ask direct questions that elicit a response about domestic violence or abusive relationship. No single question is right as long as you are sensitive and supportive.
• In real life many battered women may hesitate to initiate information about abuse, but are relieved to answer when some one asks. That is why they (CSA exam) expect you to know this kind of cases and usually you may get a case like this. So know everything how to ask and elicit a proper history.
• If you are suspecting a domestic violence or a case of abuse ( Ex. Women with bruising or some pts with depression) you can start with a good screening qt like this
• "I don't know if this is a problem for you, but because so many people we see are dealing with abusive relationships, I have started asking about it routinely. Are you currently in a relationship where you are physically hurt, threatened or feel afraid?"
• If the chief complaint itself is an abuse you can ask direct questions like
o "What happened? How were you hurt?
o "Were alcohol or drugs involved? How ? By whom? or Does your partner use drugs or abuse alcohol?"
o "Has a weapon ever been used in an attack on you?"
o "How long have you been in this abusive relationship? Has it happened ever before? Are you afraid it will happen again?"
o "Has your partner ever made you have sex when you didn't want to?"
o "You have mentioned your partner looses his temper with you. How are things between him and your children?"
o "Have you ever left home? When? if not, have you wished to leave? What has prevented it?"
o "Are you planning to leave/divorce your partner?"
o "Has your partner ever threatened or tried to commit suicide?"
o "Do you, yourself, think of suicide as a way out of the relationship?" If the answer is 'yes' ask "Do you have a plan or method by which you would kill yourself? or partner?"
o "Do you have an emergency plan if needed?"
o "Are your family or friends aware of your situation?"
• During the whole encounter tell her repeatedly that she does not deserve to be beaten. Battering is against the law.
• Examination is basically examining the injured (painted parts!!) parts and quick auscultation of heart, lungs (no percussion unless pt has a big bruise over the chest and having breathing problem) and abdomen (do palpation also).
Counseling:
• Counseling is a major part if you get a case in the exam.
• Create a safe space by assuring her that you will do everything possible to maintain her safety. Assure her that her medical condition will be treated appropriately, and that she will not be forced to do anything against her will.
• Tell her that children are cared for and safe (if present).
• Assure her confidentiality. Explain her that only with her signed consent will her medical records be released to any other source.
• Tell her that violence never ends on its own and that the violence almost always escalates in severity and frequency over time, and that the only way to end it is to get away from the batterer.
• Always be respectful and non-judgmental; Say "I believe you, it is not your fault, you are not crazy, you are not alone, help is available for you."
• Before she/you leaves ask "Do you think is it safe to go home? Do you have a safe place to stay? Would you like to speak with a domestic violence counselor?"
Note: If you notice multiple bruises (nice painting by CSA people) and the patient did not give any history of abuse, ask like this "I notice you have a number of bruises. Did some one do this to you? It looks like some one hurt you. Can you please tell me what happened to you?"
12) Patient with Insomnia:
Insomnia has numerous, often-concurrent etiologies, including medical conditions, medications, psychiatric disorders and poor sleep hygiene. Sleep apnea should be also considered in the differential diagnosis. So the evaluation usually requires detailed history taking. This is one of the most common problems in the USA and its good to know about this case for CSA.
Starting encounter with the SP:
• What brought you in today? (I have problem with sleep Doc)
• Can you please tell me more about your problem? (I use to work as truck driver during night and now I switched to day time work, since then I am having problems with sleep, I think this all is due to the shift of work. Please give me some sleeping pills Doc)
• I understands that your problem might be due to change of working schedule but there are some other common things and conditions that can cause sleep problems, which can be easily treatable if we can find. So I need to ask few more questions about your sleep patterns, your general condition and some other things. Is that ok with you? (Sure go ahead Doc)
• How long have you been having problem with sleep? (Around 3 - 4 weeks)
• Do you have problems with falling asleep? (Yah most of the times)
• Do you have any problems with staying asleep? (Yah some times)
• Do you have problems with waking from sleep? (No)
• You said that most of the times you are having problems with falling asleep. When do you usually go to bed? (between 8 to 9 PM), How much time do you take to fall into sleep?(1 to 2 hours). What do you do before you go to bed? I mean some people do exercise in late evening and drink alcohol before go to bed. Do you do any exercise like that? (No), Do you take any alcohol before you go to bed? (Yah), How much do you take? (A couple of beers usually), Do you smoke before you go to bed? (Yah mostly after having dinner), Do you take caffeine or excess coffee before go to bed? (Not really)
• Do you watch television while lying on the bed? (Yah usually)
• You said you also have some problems staying asleep. Do you wake up several times during night? (Not several but 2-3 times and if I wake up it takes awhile to go to sleep again). Ok you said you wake up 2-3 times in a night, do you have any idea what might be causing it? I mean do you wake up to urinate many times or any problems with breathing or coughing? (No) [If you are asking several question always give a pause to each question]
• Have you or any of your family members noticed frequent movement of legs during your sleep? (No, not that I know of)
• Do you have pain anywhere? (No)
• How is your mood? (Pretty good) [If the SP appears depressed you have to ask all depression questions. But it is very unlikely to get a case with 2-3 problems like depression, shifting of work etc, as it s very difficult to manage in 15 minutes]
• How are your bowel habits? (Pretty good)
• How is your bladder function? (Pretty good)
• Do you have any other medical problems? (No, I am pretty healthy)
• Have you ever been hospitalized for any reason? (No, never)
• Do you have any allergies? (No)
• Are you taking any prescription medications? (No), Any over-the-counter medications? (No), Are you using any recreation type drugs? (No)
• Are you sexually active? (Yes), Do you have any problems with sexual performance? (No)
• You said you have a habit of smoking and drinking alcohol? How long have you been smoking? (15 yrs). How many cigarettes do you smoke in a day? (5to10), How long have you been drinking alcohol? (Same like smoking), How much do you drink per day? (As I said 2-3 beers a day)
• Do you have any stress at your work? (No)
• Ask about family history.
[Note: Some times the major cause of sleep disturbance in middle-aged women is the menopause-related "hot flush." Recent studies indicate that nearly every hot flush promotes an arousal from sleep. So please keep this in mind if you get a female patient of menopausal age.]
Examination:
• Check thyroid
• Auscultate lungs and heart quickly
Diagnosis:
• Circadian rhythm sleep disorder
Counseling:
• "Based on your history I think your problem is most probably due to a combination of multiple factors. Obviously shift of work is a consideration but at the same time maintaining sleep hygiene is also very important and it will certainly help you in recovering from your problem. I would like you to maintain a sleep diary for two weeks to see the sleep patterns. Please keep regular bedtimes and wake times, even on weekends and days off from work. Limit or stop the use of nicotine, caffeine and alcohol. Exercise regularly, but no later than late afternoon or early evening. Do not use the bed as a place to worry especially about not sleeping. If you feel necessary, write down all your worries and concerns before you go to bed and place the list on your dresser to examine the next morning. Use the bedroom only for sleep. Don't read, watch television, eat or do other activities in bed. Try to avoid daytime naps. But if you must nap, do so in the early afternoon and for no longer than 30 minutes per day. Eat a light snack (but not a heavy meal) before bedtime if food is needed because of hunger. Get regular exposure to outdoor sunlight, especially in the late afternoon." If you follow all these you may no longer have problem with sleep. We usually don't recommend medications as this problem often resolves with these behavioral modifications. Ok
• Do you have any questions?
Explanation about insomnia:
• Certain medical conditions, such as COPD, GERD, peptic ulcer disease, BPH (resulting in overflow incontinence) and congestive heart failure with associated paroxysmal nocturnal dyspnea, frequently disturb sleep and may be interpreted by the patient as insomnia.
• Patients with chronic pain, such as that resulting from chronic pain syndromes, fibromyalgia, cancer pain may have insomnia and early-morning awakening. They (SP) wont tell unless you ask specifically about the pain.
• A psychiatric disorder, such as depression, is frequently a cause of chronic insomnia, especially in the elderly.
• Periodic leg movements during sleep are common in persons over 65 years of age. Although these limb movements are often associated with brief arousals, many patients have no sleep symptoms.
• Regardless of the cause of insomnia, most patients benefit from behavioral approaches that focus on good sleep habits. Exposure to bright light at appropriate times can help realign the circadian rhythm in patients whose sleep-wake cycle has shifted to undesirable times.
• Chronic insomnia may reflect a disturbance in the normal circadian sleep-wake rhythm as in this patient.
13) A 65 yr old lady with Dizziness:
Not only in CSA exam, even in real life dizziness is both challenging and frustrating for the clinician. Dizziness is a nonspecific term. Vertigo, non-specific "dizziness", disequilibrium, presyncope or near syncope can all be complained as a simple word "Dizziness" by the patients. Obtaining an extensive history is most important to put the patient into one of these more specific categories.
Encounter with the SP:
• "What brought you in today?" (I feel dizzy)
• "Can you please explain me little bit more about your dizziness?" (I always feel dizzy, I don't know what you want me to explain)
• Make a good eye contact and say, "Well..., It looks like you are not in a good mood. I am here to help you. Are you comfortable madam? Is there anyway that I can help you?" (My mood is ok just help me from this dizziness)
• "Ok, I do understand that most people with dizziness are not happy. But I want you to help you. To clearly understand your problem I need to ask few questions very quickly is that Ok with you?" Note that she wont be happy all the time during this encounter. She could be an uncooperative Patient
• "Tell me what do you mean by dizzy?" (Dizzy means dizzy)
• "Well, Many people describe their problems as dizzy though its not real dizziness. Anyway when you get dizzy do you feel like room is spinning around you?" (No) or "do you think that you are spinning inside?" (Yah)
• "Is your dizziness constant at all the time or does it just comes and goes" (Comes and goes)
• "When did dizziness first occur?" (2 weeks ago), "How often do you get?" (Once or twice in a day), "How long do they last?" (1 to 5 minutes)
• "Do you have any warning signs that the attack is about to start?" (No not really), "Do they occur at any particular time of the day or night?" (I am not sure).
• "Does change of motion make you dizzy?" (I don't know)
• "Do you know of any possible cause of your dizziness?" (I don't know)
• "Do you know anything that will stop your dizziness or make it better?" (No)
• "Do you know anything that will make your dizziness worse?" (No)
• "When you get dizzy do you have a tendency to fall?" (Yes) "To which side? Is it to right? Or Left?" (I don't remember)
• "Have you ever lost consciousness?" (No)
• "Do you have loss of balance when walking?" (Yah sometimes)
• "Have you had any headache when you get dizzy?" (yah light headedness) "Do you have it now?" (No), "Have you had any vomitings when you get dizzy?" (No), "Have you had any palpitations or shortness of breath or a feeling of panic when you get dizzy?" (No)
• "Have you noticed any difficulty in hearing?" (No).
• "Do you hear any ringing in the ears?" (No)
• "Do you have any problems like double vision or blurry vision?" (No)
• "Have you ever noticed any weakness in the arms or legs?" (No)
• "Do you have any numbness on face or arms or legs?" (No)
• "Do you have any other medical problems other than dizziness?" (I have low blood pressure), "Have you had any heart problems?" (No)
• "Have you ever been hospitalized?" (Yes for stroke few years ago)
• "Have you ever had history of trauma to your head or neck?" (No)
• "Are you allergic to anything?" (No)
• "Are you taking any prescription medications now?" (Yes aspirin), "Any over the counter medications?" (No)
• "Do you smoke?" (no), "Do you take alcohol?" (Yah social drinking, 1 to 2 beers in the weekend)
• "Do you have any problems with your bowel movements?" (No)
• "How is your bladder function?" (Good)
• "How has your appetite been lately?" (Good)
• Ask about family health.
Examination:
• Do complete quick CNS exam, which must include nystagmus, gait, Romberg's test, and cerebellar function tests.
Note: Not only in the CSA exam people with dizziness are often reluctant to move because of the fear of fall, though they are able to walk. Before you test gait or Romberg's test you have to say "I can imagine how uncomfortable it is, but I am here to assist you, I will help you in every aspect of the examination. This wont take more than a couple of minutes."
• Auscultate for "carotid bruit"
• Auscultate heart
• Hearing tests - If you get a positive history of hearing loss
• Do otoscopic examination if you get any positive history like ear discharge, pain in the ears, ringing in the ears and aural fullness.
• As long as memory is intact you don't need to do MMSE and obviously you don't get time. So always do most important things first.
Differential diagnosis in general for dizziness case:
• Benign positional vertigo
• TIA
• Stroke
• Postural hypotension/Orthostatic hypotension
• Arrhythmias
• CNS tumors Meniere's disease
• Drug induced/Polypharmacy
• Nonspecific dizziness
• Peripheral neuropathy
• Thyroid abnormalities
• Anemia
• Metabolic disturbances like hypoglycemia
Investigations:
• Check orthostatic hypotension
• CBC with differential
• Basic metabolic profile (Na, K, Cl, CO2, BUN, Cr, Calcium and blood sugar).
• Thyroid function tests
• Carotid Doppler - If you get a relevant history for stroke/TIA
• MRI of brain - For suspected acoustic neuroma or any CNS tumor
• 24 hr Holter monitoring - In patients with H/O palpitations and cardiac disease
Note: If you get an uncooperative patient it is very difficult to get everything in 15 min as they don't cooperate and don't do all the tests properly. So don't get panic, try to do as much as you can and remember that they are told to act like that. This problem is for all the CSA takers. So again the key to pass this exam is practice, practice and practice.
Short explanation about dizziness:
Vertigo: Unless it is a mildest form, it is usually associated with nausea, vomiting, and perspiration, indicating excessive autonomic activity. Typically there is no loss of consciousness. Because the only objective sign of vertigo is nystagmus, examination of eyes is extremely important and they expect you to check the eyes. You have to tell the patient that you are checking the eyes. If you just examine without informing you don't get point for that.
Presyncope: Its a perception that he or she is about to faint. Patients may have associated symptoms like constriction of the visual fields, diaphoresis, and nausea but there is no actual loss of consciousness.
Disequilibrium: These patients typically do not have problems when sitting or lying down but notice unsteadiness when standing or especially during walking. These patients also do not loose consciousness.
14) Heel pain (Or) Foot pain:
• Ask about the location of pain
• Ask about the intensity of pain
• Ask about the quality of pain
• Ask about the origin and duration of pain
• Ask about the radiation of pain
• Ask about the aggravating factors in detail ( walking, standing, "After standing, how long does it take for the pain to start?" etc.)
• Ask about the alleviating factors
• Ask about the prior episodes and frequency
• Ask about any trauma to foot
• Ask about the associated factors like fever, and other joint pains
• Ask about the morning stiffness
• Ask about the prior H/O diarrhea or any acute illness (For possible reactive arthritis)
• Ask about the urethral discharge and conjunctivitis ( For possible Reiter's syndrome)
• Ask about the H/O rash (For psoriatic arthritis)
• Ask about the occupation and type of work in detail ("What type of work do you do? Does your work involve any prolonged standing? Do you have to walk a lot at you work?")
• Ask about the family H/O rheumatoid arthritis or any other joint diseases
• Ask about any other medical problems
• Ask about medications
• Ask about allergies
• Ask about sexual history
• Ask about social history
Examination:
• Inspection of the foot (Let the SP know that you are inspecting).
• Palpation of the entire foot (not just the heel) for any point tenderness.
• Check for the range of motion at the ankle & forefoot joints. Note the pain & restriction of movements.
• Ask the patient to do active dorsiflexion and plantar flexion and see for any tendon tenderness (For tendinitis).
• Check the eyes for possible conjunctivitis (If you suspect Reiter's syndrome).
Investigations:
• CBC with diff
• X-ray of foot and ankle 3 views
• Rheumatoid factor assay
Differential diagnosis:
• Plantar fasciitis
• Calcaneal periostitis
• Calcaneal spurs
• Painful heel pad syndrome
• Bone tumors
• Rheumatoid arthritis
• Reiter's syndrome
Counseling:
• After the appropriate closing you can counsel like this "I have to order X ray of foot, ankle and some basic blood tests before we come to a proper diagnosis. Mean while I will try to help you to relive your pain. Give 2-3 days of rest to your foot, apply icing for 30 minutes for every 4hours, and use soft heel pads. At the same time take over the counter ibuprofen 400 mg 3 times a day. You can also try resting padded foot splint; these splints are available in pharmacies that feature orthopedic supplies. Wearing slippers or going barefoot may result in a recurrence of your symptoms. So your first step out of bed should be made with a supportive shoe or sandal on. You have to avoid excessive heel impact from jumping, walking. Most of the times people will get better with these measures. If you don't getter better or if your tests shows abnormal results we will sit together and will discuss the other possible options." Is that ok with you? (Sounds great Doc)
• Good thank you. Do you have any other questions?
Short explanation:
• Disorders of the ankle and foot, including ankle sprains, tendinitis, plantar fasciitis, and bursitis usually occur in association with movement and result from trauma.
• The common underlying problems include osteoporosis, spondyloarthritis and enthesitis (inflammation at muscle insertions) of lower limb structures, improper footwear, moving from a home with wood flooring to one with a slab foundation, prolonged standing on concrete floors, and structural disorders such as joint laxity or malalignment of the lower limbs.
Plantar fasciitis:
• Plantar fasciitis is one of the most common causes of foot pain in adults. Heel spurs often coexist and may represent a secondary response to an inflammatory reaction. The predominant symptom of plantar fasciitis is pain in the plantar region of the foot that is worse when initiating walking. A hallmark for diagnosis of plantar fasciitis is local point tenderness. This is best elicited by the examiner dorsiflexing the patient's toes with one hand in order to pull the plantar fascia taut, and then palpating with the thumb or index finger of the other hand along the fascia from the heel to the forefoot.
• In addition to soft tissue pain or fasciitis, plantar heel pain may be induced by a number of other disorders. These include nerve pain due to entrapment, bone pain, tendinitis of the posterior tibia or flexor digitorum longus tendons, or the presence of tumor or infection. Reiter's syndrome and other spondyloarthropathies, Lofgren's syndrome, and sarcoidosis should also be considered in the differential diagnosis.
• Radiographic studies are usually recommended in patients with persistent plantar pain after a trial of conservative therapy. Lateral and axial radiographs are the appropriate views due to the myriad of diagnostic possibilities. The primary goal of radiography is to rule out other disorders.
• The soft tissue may be evaluated with MR imaging in cases that are resistant to treatment. Technetium scintigraphy has also been successful in localizing the inflammatory focus and ruling out stress fracture.
Calcaneal periostitis
• Calcaneal periostitis may result from trauma, Reiter's syndrome, ankylosing spondylitis, psoriatic arthritis, or rheumatoid arthritis. Pain is usually bilateral, along the lateral and plantar aspect of the heels, worse in the morning upon arising, and often accompanied by morning stiffness. Tenderness is diffusely present along the plantar aspect of the heel and midfoot, and along the lateral border of the heels.
• Bilateral involvement should alert to the possibility of a coexistent systemic rheumatic disease.
Calcaneal spurs
• Calcaneal spurs can develop on the plantar tuberosity and extend across the entire width of the calcaneus.
• Heel spurs are typically asymptomatic; pain occurs when the apex is angled downward by depression of the long arch. An acutely painful heel spur may also be seen in certain systemic diseases, such as ankylosing spondylitis, Reiter's syndrome, or rheumatoid arthritis.
Painful heel pad syndrome
• The painful heel pad syndrome most often occurs in marathon runners. It is thought to result from disruption of the fibrous septae that compartmentalize the fat in the heel pad. Pain is localized to the heel pad; the plantar fascia is not tender and pain is not accentuated as the examiner dorsiflexes the toes.
15) Low back pain:
If you get a case of low back pain consider these things:
• Ankylosing spondylitis
• Herniated lumbar disc
• Spinal stenosis
• Osteoporosis with vertebral crush fractures
• Metastatic bone cancers
• Primary bone tumors like multiple myeloma
• Rheumatoid arthritis
Examination:
• Check spinal tenderness
• Check paraspinal tenderness
• Check lower extremity pulses
• Check sensations of the both lower extremities
• Do complete motor and reflex testing of the both lower extremities
• Do straight leg raising test
• Check lumbosacral spine range of motion
• Check the gait
Investigations:
• CBC with diff, ESR
• HLA-B27
• Rheumatoid factor levels
• X-ray of the lumbosacral spine
• MRI of the spine
Upper extremity pain:
If you get a case of upper extremity pain consider these issues:
• Carpal tunnel syndrome (ask about the occupation)
• Cervical spondylitis
• Herniated cervical disc
• Thoracic outlet syndrome (ask whether the symptoms worsen with the above head activities like combing)
• Tenosynovitis
• Trauma
• Referred pain from coronary ischemia
In the history just follow LIQOR AAA and PAM HUGS FOSS.
Examination:
• Check the thyroid gland
• Check the neck movements and the range of motion
• Do thoracic outlet test ( Adson's test) - Ask him to take the deep breath, extend the neck and turn the chin towards the opposite side and repeat the test with the chin opposite side. In the presence of thoracic outlet syndrome the radial pulse will disappear.
• Do Phalen's test (for carpal tunnel syndrome) - Hold the patients wrists in acute flexion for 30- 60 seconds. Patient will complain of pain, numbness and tingling over the distribution of medial nerve if the test is positive.
• You can also elicit Tinel's sign also if you want. With your finger percuss over the course of medial nerve in the carpal tunnel. Patient will complain of pain, numbness and tingling over the distribution of medial nerve if the test is positive.
• Check sensations, do motor and check reflexes of the upper extremities both sides.
Investigations:
• CBC with differential, ESR
• EMG and nerve conduction studies
• X-ray of the cervical and thoracic spine
• EKG
• MRI of the spine
16) A 25 yr old female with nausea and vomiting
• First think about the common causes of nausea and vomiting in this age group
• Gastroenteritis (food poisoning) - Ask about having food out side / travel history/ any other members being ill/ associated symptoms like abdominal cramps and diarrhea
• Obstructing disorders - pyloric obstruction (classically vomiting within 1 hr after having food), intestinal obstruction (vomiting late post prandial period)/ constipation/ is she passing gas (don't ask flatus; if you ask flatus SP will say 'what is that?'*). Relief of the pain with emesis is very characteristic of small bowel obstruction. Vomiting has no effect on acute pancreatitis or cholecystitis.
• Inflammatory diseases (cholecystitis - pain in the right hypochondriac region, acute pancreatitis - severe epigastric pain radiating to back, appendicitis - initially periumbilical pain later to right lower quadrant pain)
• Impaired motor function - Diabetic gastro paresis, GERD ( So ask about any history of diabetes may be type I in this female)
• Intracebral disorders like malignancy, infections - So ask about fever, headache and the quality of vomiting (projectile or not).
• Drugs (diogxin, cancer chemotherapy) - Just ask are you taking any medications.
• The 2 most common conditions and you will be likely to be tested in the CSA are pregnancy and anorexia nervosa. You should not forget to ask about the LMP because if you get a case of nausea and vomiting in the CSA it is most likely a pregnancy and in fact the SP may ask you "Doc is it a pregnancy?"
• Always follow the PAM HUGS FOSS because post operative vomiting, ethanol intake, drugs, diabetes, OBGYN history (LMP) will cover automatically and you don't need to remember what to ask.
• Don't worry about the rare causes (labyrnthitis, uremia, adrenal insufficiency) of vomiting for this exam.
Please follow the history taking section of the site for complete description of vomiting.
Examination:
• Auscultation of the abdomen (decreased bowel sounds indicates ileus, increased bowel sounds indicates bowel obstruction)
• Abdominal palpation both superficial and deep
• Fundoscopy if you are suspecting intracranial causes
• Explain about the need of rectal examination and pelvic examination (pregnancy)
• Quick lungs and heart exam
• Finally if you have some time look at the oropharynx
Investigations:
• CBC with diff
• Pregnancy test (must for this female)
• FOBT
• Serum amylase and lipase (if you are suspecting) acute pancreatitis
• Ultrasonogram (acute cholecystitis)
• Blood sugar for DM
• EKG should be obtained if patient has risk factors for MI (some times inferior wall MI presents only with vomitings especially in diabetics) but do not order for this female unless patient has intractable vomitings and you are worried about hypokalemia.
17) A 34 Yr O/F came for Bronchial asthma drug refill
• This case is not that much important but always there is a possibility, so just have a look
• The things that you need to ask specifically for this case are
• Start with formal greeting, ask open ended question like "What brought you in today?"
• "Can you please tell me more about your asthma?" Like "When were you diagnosed for the first time?" and "How have you been doing since then?"
• "Can you please tell me about your current medications?" or " What medications are you on?"
• "Did you notice any problems or side effects with your medications?"
• "Do you have any trouble breathing during the day or night with regular activity?" (yes)
• "How often does this occur on a weekly basis?"
• "Do you have any trouble breathing with exercise?" (yes)
• "How often does this occur on a weekly basis?"
• "Do you have episodes of excessive coughing during the day or night time?" (yes)
• "How often does this occur on a weekly basis?"
• "Have you ever been admitted in the hospital for an acute or severe attack?"
• "Tell me what do you think about the severity of your asthma ? Do you think is it getting better or worse? Do you know what precipitates your asthma?"
• "Are you taking any precautions to avoid those?"
After this you will just have to follow PAM HUGS FOSS. Make sure you ask smoking history and tell about the importance of smoking cessation.
Examination basically requires HEENT to look for any sinus tenderness (sinusitis), signs of upper respiratory tract infection, which can aggravate or precipitate asthma. You have to do complete lung examination. Look for JVD and pedal edema for signs of cor pulmonale even though it's a very rare complication of asthma.
Spirometry or pulmonary function tests are usually not required unless the patient is elderly and having persistent asthma. CBC with differential, Aspergillus serology, Chest X ray, X-ray of Para nasal sinuses, 24 hr pH for GERD and skin tests are required in chronic persistent and refractory asthma.
Differential diagnosis for chronic persistent asthma in a smoker includes
1. Bronchial asthma
2. COPD
3. Broncho pulmonary aspergillosis
4. Sinusitis
5. Atypical GERD
