| | 9 Case 9 scenario (medication refill)
Doorway information about patient
The patient is a 56-year-old man who comes to the office for a blood pressure check and medication refill
Vital signs
. Temperature : 36.1’C (97F)
. Blood pressure ; 150/90 mmHg
. Pulse : 80 /min
. Respirations : 16/min
Basic differential diagnosis
When patient come for follow-up of known conditions , the primary diagnosis is known . However, you should be aware of complications and associated conditions.
. Congestive cardiac failure
. Coronary artery disease (angina)
. Peripheral vascular disease
. Retinopathy
. Side effects of the medications
—————
Case 9 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 56-year - old man who needs a blood pressure recheck and medication refill.
history of present illness
. Diagnosed with hypertension and high cholesterol 10 years ago
. Taking medications regularly
. Currently medications include hydrochlorothiazide and simvastatin
. DO not volunteer this information unless asked specifically abut past treatment:
You were initially treated with lisinopril , but that was stopped due to a dry cough ; You were then treated with atenolol but developed erectile dysfunction
. Not exercising regularly and not always following dietary recommendations
. Checking blood pressure at home ranges form 140-150 systolic and 80-90 diastolic
. No headaches , palpations , blurry vision , chest pain , shortness of breath , nosebleeds , dizziness , or leg swelling.
Past medical / family / social history
. Medical history otherwise negative
. No surgeries
. No other medications
. No medication allergies
. Father has hypertension and mother has diabetes
. Occupation : Accountant
. Smoking ; 1 pack /day for 30 years
. Alcohol ; 1 glass of wine on social occasions
. Recreational drugs : None
Physical examination
HEENT:
. Pupils are equally round and reactive to light and accommodation (PERRLA)
. Extra ocular movement are intact (EOMI)
. Funduscopic examination shows no papilledema , exudates or AV nicking
Neck:
. No enlarged lymph nodes
. No bruits
. Carotid pulse 2+ bilaterally
Chest/lungs:
. Clear to auscultation bilaterally
Heart :
. Regular rhythm without murmurs , gallops , or rubs
Extremities :
. No cyanosis , clubbing , or edema
. Radial and posterior tibial pulses 2+
—————
Case 9 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 when you diagnosed with high blood pressure
. Asked what medications you are taking and of you take them as prescribed
. Asked about any side effects or other issues with medications
. Asked about prior treatment and why it was changed
. Asked about symptoms that might indicate a problem , including:
- Headache
- Dizziness
- Nosebleeds
- Dyspnea , orthopnea, paroxysmal nocturnal dyspnea
- Palpations
- Chest pian
- Pedal edema
. Asked about home blood pressure checks
. Asked about diet and exercise habits
Past medical / family / social history
. Asked about otters medical issues , hospitalizations , and surgeries
. Asked about other medications
. Asked about medication allergies
. Asked about family health (especially cardiovascular daises)
. Asked about tobacco . alcohol , and recreational drugs use
. Asked about occupation
Examination
. Washed hands before examination
. Examined without gown , not through gown
. Measured blood pressure in both arms
. Examined eyes with ophthalmoscope
. Check carotid arteries (pulses and bruits)
. Checked jugular venous pressure
. Auscultated heart
. Auscultated lungs
. Palpated peripheral pulses
Counseling
. Complemented you for using medications as prescribed
. Complemented you for checking home blood pressure regularly
. Explained further workup
. Explained the importance of diet and regular exercise
. Explained likely complications of uncontrolled blood pressure
Communication skills and professional conduct
. Knocked beef entering the room
. Introduced self and greeted you warmly
. Used your name to address you
. Paid attention to what you said and maintain good eye contact
. Asked open-ended questions
. Asked non-leading 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
. Asked whether you have any concerns/questions
Differential diagnosis
. Essential hypertension
Diagnostic study/studies
. Urinalysis
. Lipid profile
. Electrolytes
. BUN and creatinine
. Glucose
. ECG
—————
Case 9 clinical summary
Clinical Skill evaluation
Case 9 Patient Notes
The following represent a typical notes 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 problems(s)
. 56-yo man here for BP check and medical refill.
. BP ranges form 140-150 systolic and 80-90 diastolic at home 3x/week in morning and evening
. Not compliant with low salt diet , no regular exercise
. Compliant with medications.
. Cough with ACE inhibitor , ED with beta blocker
ROS : no headache , palpations, blurry vision , chest pain , shortness of breath , nose bleeds, dizziness , or leg swelling
PMHx : Hypertension and hypercholesterolemia for past 10 years .
PSHx: None
Meds : Hydrochlorothiazide 50 mg daily , simvastatin 20 mg daily
Allergies ; None
FHx ; father has hypertension , mother has diabetes
SHx: Smokes 1 PPD for 30 years . drinks occasionally
Physical examination : Describe nay 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 , 37’C (98.6F) ; blood pressure , 150/90 mmHg in both arms ; pulse , 90/min; and respirations , 16/min
. HEENT : PERRLA , EOMI , fund without papilledema , exudates , or AV nicking
. Neck : No enlarged lymph nodes , no bruits
. Chest /lungs : Clear to auscultation bilaterally
. Heart : RRR without M/G/R
. Extremities : No cyanosis , clubbing , or edema ; pulse 2+ bilaterally in carotid , radial , and posterior tibialis
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 compliant(s) .List your diagnosis form most to least likely . For some cases , fewer than 3 diagnosis will be appropriate . then enter the positive or negative findings form 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 , laborite tests , imaging ECG)
Diagnosis #1 : essential hypertension , sub optimally controlled
history finding(s)
. Hypertension
. Poor dietary complicate
. No regular exercise
Physical examination finding(s)
. Elevated blood pressure to 150/90 mmHg
. No neck bruits
. Symmetrical peripheral pulses
. Normla funduscopic examination
Diagnostic studies
. Serum electrolytes and creatinine
. Lipid panel
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2018/08/15 03:26pm 
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