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-=-=-=-=-=> 3 Case 3 Scenario (arm and leg weakness) Doorway information about patient The patient is a 65-year-old woman who comes to the emergency department due to are and leg weakness. Vital signs . Temperature . Blood pressure : 160/90 mmHg . Pulse : 78/min . Respirations : 22 /min Basic differential diagnosis Neurologic . Stroke . Transient ischemic attack (TIA) . Subarachnoid hemorrhage , Subdural hematoma . Intracranial mass . Guillain -Barre syndrome . Spinal cord lesion . Complex migraine Metabolic . Hypoglycemia . Hypothyroidism . Adrenal insufficiency . Electrolyte disorders Musculoskeletal . Myopathy Miscellaneous . Conversion disorder . Heart-Reflated illness ————— Case 3 sim. pt. instructions If the doctor asks you about anything other than these , just say “ no “ , or provide an answer that a normal patient might give . You are a 65-year-old woman who comes to the emergency department with 1 hour of right arm and leg weakness. History of illness . The symptoms started an hour ago with weakness in the right arm and leg . Gradually increasing numbness . Moderate (5/10 in severity) headache that felt”all over “ the head . Nausea but no vomiting . No slurred speech or difficulty swallowing . No blurred or double vision. . No recent fall or loss consciousness . no symptoms like this in the past. Review of systems . No fever . No chest pain or palpitations . No diarrhea . No urinary symptoms . No seizures Past medical/family/social history . High blood pressure for 25 years . High cholesterol . Heart attack 6 years ago; heart bypass surgery at that time . Medications : Simvastatin 20 mg daily, aspirin 81mg daily, atenolol 50 mg daily . Medication allergies : None . Both parents had hypertension and died in their 60s of heart attacks . Widow (husband died 8 years ago); lives alone . Bought to the hospital by neighbor (“Steve”) who si closet contact and is “Like a son to me” . Tobacco: 2 pack of cigarettes a day for 35 years and quit 6 years ago . Alcohol : 1-2 drinks , once a month . Recreational drugs : None Physical examination Neurological: . Weaker on the right side of the body . Unable to lift right leg or arm without assistance . Unable to stand . Cranial nerves are normal . Reflexes are slightly exaggerated on the right . Babinski: Upping on right and downgoing on the left . Sensation is normal on both sides of body The rest of the examination is normal Ask this question : If the examinee dose not discuss the possibility of a stroke , ask , “Doctor , is it a stroke?” ————— Cases3 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 weakness . Asked where the weakness is felt . Asked if the weakness is changing over time . Asked how you felt prior to onset of the weakness . Asked about associated symptoms - Sensory changes or numbness - Loss of consciousness - Seizures/jerky movements - Fever - Nausea/vomiting - Chest pain, palpations - Problems with speech or swallowing - Visual changes (eg , blurred vision, double vision) - Incontinence / Bowel or bladder dysfunction . Asked about a history of frequent fall/spells . Asked about any history if recent head trauma Past / family/ social history . Asked about similar symptoms in the past . Asked about past/other medical issues (especially hypertension, diabetes mellitus , hypercholesterolemia, myocardial infarction, strokes ,migraine headaches) . Asked about previous hospitalizations and surgeries . Asked about current medications . Asked about medication allergies . Asked about any family history of stoke , heart attacks , or aneurysms . Asked about alcohol intake . Asked about living situation Examination . Examinee washed hands before examination . Examined without gown , not though gown . Checked cranial nerves II-XII . Tested muscle power bilaterally . Checked deep-tendon reflexes in bother the upper / lower extremities . Checked for sensory modalities proximally and distally . Checked coordination and gait . Listened for carotid bruits . Checked for neck stiffness . Auscultated heart Counseling . Explained the physical findings and possible diagnosis . Explained further workup Communication skills and professional conduct . Knocked before entering the room . Introduced self and greeted you warmly . Used your name to address you . Paid attention to what you said and maintained good eye contact . Asked open-ended questions . Asked non-leading questions . Asked one question at a time . Listened to what you said without interrupting . Used plain English rather than technical jargon . Used appropriated transition sentences . Used appropriate draping techniques . Expressed empathy and made appropriate reassurances . Asked whether you had any concerns./questions Differential diagnosis . Stroke . Transient ischemic attack . Subarachnoid hemorrhage Diagnosis study . CBC with differential . Basic metabolic panel (or glucose and electrolytes) . CT scan of the head without contrast . Doppler ultrasound of the carotid arteries . ECG . Transesophageal echocardiogram ————— Clinical Skill Evaluation Case 3 Patient Note The following represents a typical note for this patient encounter . the details may vary depending on the information given by the simulated patient. History: Describe the history you just obtained from this patient. Include only information (patent positives and negatives) relevant to this patient’s problem(s) . 65-yo female with an hour of acute-onset , right -sided weakness and headache. . Gradually progressing symptoms over the pats hour. . Nausea without vomiting. . No history of fall or syncope. ROS: no fever , chest pain , shortness of breath , vision changes , dysarthria , seizures Max : HTN , hypercholesterolemia , CAD PSHx : CABG 6 years ago Meds : Aspirin , simvastatin , atenolol Allergies : None FHx : Mother and father had HTN and died of MI , Brother has HTN and hypercholesterolemia SHx : Smoked 2 PPD for 35 years but quit 6 years ago Physical examination : 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 : 36.8’C (98.2 F) , Blood pressure : 160/90 mmHg , pulse : 78 /min , respirations : 16/min. . Lungs : CTA bilaterally . Heart : RRR without M/G/R . Neurological ; A&Ox3 , CN 2-12 intact , motor 5/5on LUE and LLE but 3/5 in RUE and RLE , sensory grossly intact , DTR 2+ on left but 3+ in RUE and RLE , upping toes on right and downing on left , gait unable to be assessed. Data interpretation: Based on what you have learned from the history and physical examination ., .lsit up to 3 diagnosis that might explain this patients complaint(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 physical examination (if present) that support each diagnosis . lastly ,list initial diagnostic studies (if any ) you would order for each listed diagnosis (eg , restricted physical examination maneuvers , laboratory tests , imaging , ECG , etc.). Diagnosis #1 ; Evolving stroke History finding(S) . Acute -onset weakness . Gradually progressing symptoms Physical Exam finding(s) . Right hemiparesis . Eight-side hyperflexia . Right Babinski rifles present Diagnosis #2: TIA or reversible ischemic neurological deficit History finding(s) . Acute-onset weakness Physical Exam finding(S) . Right hemiparesis . Right-sided hyperreflexia . Right Babinski reflex present Diagnosis #3 : Subarachnoid hemorrhage History finding(s) . Headache . Nausea . Acute-onset weakness Physical Exam finding(s) . Right hemiparesis . Right-sided hyperreflexia . Right Babinski reflex present Diagnosis Studies . CT scan of head without contrast . Transesphageal echocardiogram . Carotid Doppler . CBC with differential -=-=-=-=-=>
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