| | 36 Case 36 scenario ( insomnia )
Doorway information about patient
The patient is a 70-year-old man wth insomnia
Vital signs
. Temperature ; 36.7’C(98.1F)
. Blood pressure : 130/90 mmHg
. Pulse ; 58/min
. Respirations : 16/min
Basic differential diagnosis
. Depression
. Post-Traumatic stress disorder
. Anxiety disorder
. Chronic pan syndormes
. Adverse effect of medication
. Age-related sleep change
. Thyroid problems
. Sleep apnea
. Restless legs syndorme
—————
Case 36 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 70-year-old man who has insomnia
History of present illness
. Admitted to the hospital 3 months ago with chest pain and diagnosed with coronary artery disease . Coronary angioplasty was performed and several new medications were initiated . you were very anxious throughout the hospitalization and were given lorazepam for anxiety . A few weeks after discharge , you began having difficulty falling asleep and are able to stay asleep for only 2-3 hours before getting up and pacing.
. No unusual dreams or nightmares
. You do not wake refreshed and feel tired in the morning and throughout the day
. You do not drink alcohol or caffeine in the evening before you go to bed
. Decreased appetite an a 2.27-kg (5-lb) weight loss since the hospitalization
. Your son loves nearby and says that you have become more isolated and not interested in normal activities
Review of systems
. No chest pain
. No shortness of breath or swelling in the ankles /feet
. No tremors or change in strength or sensation
. No changes in hair or skin
. No nausea , vomiting , diarrhea , constipation , or abdominal pain
. No palpitations or dizziness
Past medical / family / social history
. Coronary artery disease
. no surgires
. Medications ; Aspiri , clopidogrel , metoprolol, atovastatin , lisinpril , nitroglycerin, sublingual as needed (have not used)
. No drug allergies
. After died at age 75 of heart attack , motor died at age 68 of breath cancer , 1 sister (healthy)
. Widowed for last 2 years , live alone
. Retired accountant
. Tobacco : 1 pack a day for last 50 years
. Alcohol : Occasional beer
. Recreational; drugs : No
Physical examination
General :
. Awake and alert but appear fatigued
. Grooming and hygiene normal
. No distress
HEENT :
. Oropharynx clear
Neck :
. Supple without lymphadenopathy
Lungs :
. Clear to auscultation bilaterally
Heart :
. Regular rate and rhythm
. no murmurs , gallops ,or rubs
Abdomen :
. Non-tender, non-distended
. Normative bowel sounds
. No hepatosplenomegaly
Neurologic :
. Oriented to person , place, and time
. Motor 5/5 throughout
. Reflexes 2+ throughout
—————
Case 36 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 bout the average duration and quality of sleep
. Asked if having difficulty falling asleep ,staying asleep , or both
. Asked about bedtime habits
. Asked if having nightmares
. Asked if having anxiety or depressive symptoms
. Asked if having any associated palpitations , sweating , or dizziness
. Asked if having any pain
. Asked about snoring / breathing problems
. Asked about daytime sleepiness and morning headaches
. Asked about appetite and changes in weight
. Asked about constipation and diarrhea
. Asked bout impact on personal relationship and daily activities
Past medical /family/social history
. Asked about similar episodes in the past
. Asked about past medical issues , hospitalizations ,and surgeries
. Asked about curent medications
. Asked about medication allergies
. Asked about family health
. Asked bout current living situation and family support
. Asked about occupation
Examination
. Washed heads before examination
. Examined without gown , not through gown
. Examined pharynx
. Examined neck/thyroid
. Performed neurologic examination including cranial nerves , motor strength , and reflexes
. Examined heart and lungs
Counseling
. Explained physical findings and possible diagnosis
. Explained further workup
. Discussed sleep habits/ sleep hygiene
. Discussed smoking cessation and readiness to quit
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
. Anxiety disorder
. Drug-induced insomnia
. Depression
. Sleep apnea
Diagnostic study/studies
. CBC
. Basic metabolic panal (Na, K , BUN , Cr, CO2 , Cl)
. TSH
. Nocturnal polysomnography
—————
Case 36 clinical summary
Clinical Skills Evaluation
Case 36 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).
. 70yo man with 2 months of insomnia after hospitalization for CAD with angioplasty
. Difficulty falling and staying asleep
. Decreased appetite and 2.27-kg (5-lb ) weight loss.
. Family thinks the patient feels isolated and has loss interest in activities
ROS : Fatigue , no chest pain , shortness of breath , tremor , hair loss diarrhea , constipation, palpitations , dizziness , or recent trauma
PMHx : CAD
PSHx : None
Meds : Aspirin , clopidogrel , metoprolol, lisinpril, atovastatin, nitroglycerin as needed
Allergies : None
FHx : Father died of MI ; mother died of breast cancer
SHx: 1 PPD smoker for 50 years , occasional alcohol use
. Vital signs : Temperature ,36.7’C(98.1F); blood pressure , 130/90 mmHg; pulse , 58/min; respirations , 16/min
. HEENT : Oropharynx clear
. Neck : Supple without lymphadenopathy
. Heart : RRR without murmurs , gallops , or rubs
. Abdomen ; Non-tender, non-distended, normative bowel sounds , no hepatosplenomegaly
. Neurologic : Motor 5/5 bilaterally ; alert and oriented to person , place , and time ; DTR 2+ bilaterally
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.
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 : Anxiety disorder
History finding(s)
. Recent hospitalization
. Difficulty falling and staying asleep
. Previous anxiety requiring medications
Physical examination finding(s)
. None
Diagnosis #2 : Depression
History finding(s)
. Decreased appetite and weight loss
. Decreased interest in activities
. Insomnia , fatigue
Physical examination finding(s)
. None
Diagnosis #3 : Drug induced insomnia
History finding(s)
. Recently started metoprolol
. Insomnia
Physical examination finding(s)
. Bradycardia
Diagnostic studies
. Basic metabolic panel
. CBC with differential
. TSH
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2018/09/13 08:00am 
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