| | 15 Case 15 scenario (shortness of breath)
Doorway information about patient
The patient is a 60-year-old man who comes to the emergency department due to acute shortness of breath.
Vital signs
. Temperature: 36.7’C(98F)
. Blood pressure : 110/70 mmHg
. Pulse : 90 /min
. Respirations : 26/min
Basic differential diagnosis
. Pulmonary embolism
. Congestive heart failure
. Chronic obstructive pulmonary disease exacerbation
. Pneumonia
. Spontaneous pneumothorax
. Asthma exacerbation
. Anxiety/panic attack
—————
Case 15 sim.pt. instruction
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 60-year-old man with acute shortness of breath.
History of present illness
. Onset 2 days ago
. Mild shortness of breath with strenuous work that has slowly worsened over the past year. but is now suddenly worse
. Not of breath with walking 1 block
. Occasional dry cough
. No fever , chills , or unusual fatigue
. No syncope or palpations
. No swelling in the legs
. Difficulty at night
. Worsen when lying down and better when sitting up
Do not volunteer this information unless asked :
You sleep on 2 pillows because you get short of breath when lying flat , also , you woke up in the middle of the night weigh shortness of breath and could not go back to sleep for 20 minutes.
Past medical history
. Spinal fusion surgeries 2 weeks ago for spinal stenosis that required 1 week in the hospital postoperatively
. Hypertension diagnosed 20 years ago
. Medications ; hydrochlorothiazide 25mg daily
. Medication allergies : None
. Father died of a heart attack at age 55; mother is alive and has hypertension ; no siblings
. Occupation : Computer software analyst
. Married , live with wife
. Tobacco ; 1 pack of cigarettes a day for 40 years
. Alcohol : 1-2 glasses of wine a day for 35 years
. Recreational drugs : None
Physical examination
HEENT :
. PERRLA , EOMI
Neck :
. Supple without lymphadenopathy
. No JVD
. No thyromegaly
Lungs :
. Clear to auscultation and percussion
Heart :
. Regular rate and rhythm
. No murmurs , gallops , or rubs
Extremities :
. No edema , cyanosis , or clubbing
. Pedal pulse 2+ bilaterally
. No calf tenderness to palpation
—————
Case 15 sim. pt. checklist
Following the encounter , check which of the following items were performed by the examinee
History of present illness/ review of systems
. Asked about the onset of symptoms
. Asked about the course over time
. Asked about associated symptoms :
- Chest pain
- Orthopnea and paroxysmal nocturnal dyspnea
- Wheezing
- Coughing
- Fever and chills
- Palpitations
- Syncope
- Leg pain and swelling
. Asked about recent travel or prolonged immobilization (recent surgery)
Past medical /family/social history
. Asked about similar episode in the past
. Asked about past medical issue (especially high blood pressure ,heart problems , asthma , and chronic obstructive pulmonary disease)
. Asked about surgeries and hospitalizations
. Asked about current medications
. Asked about medication allergies
. Asked about occupation
. Asked about tobacco , alcohol , and drug use
. Asked about family history of blood clots and heart problems
Examination
. Washed heads before examination
. Examined without gown , not through gown
. Examined neck for jugular venous pressure
. Examined heart : inspection , palpation , auscultation
. Examined lungs : inspection , palpation , auscultation , percussion
. Examined the extremities for pulses and edema
. Checked calf muscle tenderness
Counseling
. Explained physical findings and possible diagnosis
. Explained further workup
. Discussed quitting smoking
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 opened questions
. Asked non-leading questions
. Asked one question at a time
. Listened to what you said without interrupting me
. 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
. Asked whether you have any concerns/questions
Differential diagnosis
. Pulmonary embolism
. Pneumonia
. Congestive heart failure
. Chronic obstructive pulmonary disease
Diagnostic study/studies
. CBC with differential count
. Chest x-ray
. ECG
. Ventilation / perfusion (V/Q) scan or chest CT scan
. Echocardiogram
—————
Case 15 clinical summary
Clinical Skills Evaluation
Case Patient Note
The following represents a typical note for this patient encounter . the detail may vary depending on the information given by the simulated patient.
History : Describe the history you just obtained form this patient . Include only information (Pertinent positives and negatives) relevant to this patient’s problem(s).
. 60-yo man with 2 days of worsening shortness of breath.
. 1 years of gradually worsening shortness of breaths that acutely worsened 2 days ago.
. New 2 -pillow orthopnea , PND.
. Spinal fusion surgery 2 weeks ago.
. Occasional dry cough.
ROS: No chest pain , wheezing , fatigue , palpations , leg swelling , syncope , fever , or chills
PMHx : HTN
PSHx : Spinal fusion surgery
Meds : Hydrochlorothiazide 25 mg daily
Allergies : None
FHx: Father died of MI at age 55 , mother has HTN
SHx : 1 PPD smoker for 40 years , 1 or 2 glasses of wine /day for 35 years
Physical examinations : Describe any positive and negative findings relevant to this patient’s problem(s) . be careful to include only those parts of the examination performed in this encounter.
. Vital signs: Temperature , 36.7’C(98.1F) ; blood pressure , 110/70 mmHg; pulse , 90/min; and respiration , 26/min
. HEENT : PERRLA , EMOI , no jaundice
. Neck ; Supple without lymphadenopathy , no JVD , no thyromegaly
. Lungs ; clear to auscultation
. Heart : RRR without murmurs, gallops , or rubs
. Extremities ; No edema , pulse 2+ bilaterally , no cyanosis or clubbing , no lower extremities tenderness on palpation
Data interpretation : Based on what you have learned from the history and physical examination, list up to 3 diagnosis that might explain this patient’s complaint(s) . List your diagnoses from most to least likely . For some cases , fewer than 3 diagnosis will be appropriate . the , enter the positive and negative findings form the history and the physical examination (if present) that support each diagnosis . Finally , list initial diagnostic (if any) you would order for each listed diagnosis (eg,restricted physical examination maneuvers, laboratory tests , imaging ECG , etc).
Diagnosis #1 :Pulmonary embolism
History finding(s)
. Acute worsening of dyspnea
. Tecent spinal fusion surgery
Physical examination finding(s)
. None
Diagnosis #2 : Congestive heart failure
History finding(s)
. 1 year of gradually worsening dyspnea
. Dyspnea worse with exertion
. Orthopnea and PND
Physical examination finding(s)
. None
Diagnosis #3 : COPD
History finding(s)
. History of smoking
. 1 year of gradually worsening dyspnea
. Cough
Physical examination finding(s)
. None
Diagnostic studies
. Chest x-ray
. CT anagram of chest
. CBC with differential
. Basic metabolic panel
. ECG , echocardiogram
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2018/08/15 03:32pm 
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