| | 20 Case 20 scenario (leg pain bilateral)
Doorway information about patient
The patient is a 50-year-old man who comes to the office due to bilateral leg pain
Vital signs
. Temperature : 36.7”C(98F)
. Blood pressure : 140/80 mmHg
. Pulse : 78/min
. Respirations : 20 /min
Basic differential diagnosis
Bilateral pain
. Atherosclerotic vascular disease
. Lumber spinal stenosis
. Diabetic polyneuropathy
. Radiculopathy due to spinal disease
. Medications , such as statin
. Trauma
. Thromboangiitis obliterans
Unilateral pain
. Cellulitis / myofasciitis
. Deep vein thrombosis
. Rupture of baker cyst
. Osteomyelitis
. Radiculopathy /sciatica
. Pathological fracture of the bone
—————
Case 20 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 50 year-old-man with bilateral leg pain
History of present illness
. Onset 2 months ago
. Pain stated gradually and has become progressively worse
. Throbbing pain with 5-6 /10 severity
. Located in the calf muscles , no radiation
. Worse with walking , running , and prolonged standing
. Better while sitting and at rest
. No history of trauma
Review of systems
. No fever
. No back pain
. No weakness , numbness , or tingling in the leg
. No sexual or bladder symptoms
Past medical / Family / social history
. Diabetes for the past 3 years , controlled by diet
. High cholesterol
. No surgires
. Medications : Simvastain 40 mg daily at bedtime
. Allergies : No
. Father died at age 65 of a stroke ; mother and 2 sibling are healthy
. Occupation: Postal worker
. Married , live with wife
. Tobacco : 2 pack a day for past 30 years
. Alcohol : Occasional beer
. Recreational drugs : No
Physical examination
Abdomen:
. No bruits
Extremities
. Pulse 2+ and symmetrical in bilateral lower extremities
Musculoskeletal
. Negative Homans sign
. ,No calf tenderness to palpation bilaterally
Neurologic
. Motor strength 5/5 in both lower extremities
. Grossly intact sensation
. Deep tendon reflexes 2+ symmetrically
—————
Case 20 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 location and radiation of the pain
. Asked about the onset of pain
. Asked about whether it is continuous or intermittent pain
. Asked about the intensity of pain
. Asked about the quality of pain
. Asked about the course of pain over time
. Asked about any aggravating or relieving factors
. Asked about rest pain
. Asked about swelling of the legs
. Asked about sensory changes ( such as numbness ) and paresthesia
. Asked boy any weakness of the legs
. Asked about any history of back pain
. Asked about fever
. Asked about trauma to the legs
. Asked about other joint pain
. Asked about recent surgeries or prolonged immobilization
. Asked about impotence
Past medical /family/social history
. Asked about similar episodes in the past
. Asked about past medical issues (especially high blood pressure , diabetes , high cholesterol, disc prolapse)
. Asked about current medications
. Asked about family health (especially history of blood clots)
. Asked about tobacco , alcohol , and recreational drug use
. asked bout occupation
Examination
. Washed heads before examination
. Examined without gown , not through gown
. Examined calf tenderness
. Elicited Homans sign
. Checked pulses in both legs and arms
. Listened for bruits at the distal aorta , iliac , or femoral arteries
. Checked sensation in both legs
. Checked reflexes in bother legs
. Checked for vibration sense in both legs
Counseling
. Explained physical findings and possible diagnosis
. Explained further workup
. Discussed lifestyle modifications, including 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
. 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
. Thromboangiitis obliterans
. Atherosclerotic vascular disease
. Drug induced (statins)
. Diabetic polyneuropathy
Diagnostic study/studies
. Creatinine kinase
. Blood sugar and hemoglobin A1c
. Lipid profile
. Arterial doppler study coif the lower extremities
. Duplex venous ultrasound of power limbs
. CBC with differential
. Spine MRI
—————
Case 20 clinical summary
Clinical Skills Evaluation
Case 20 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).
. 50-yo man with 2 months of worsening bilateral leg pain
. Trolling pain mainly over the calf muscle made worse with walking , running, and prolonged standing.
. Symptom improvement with rest and sitting
ROS : No pain at rest , fever , trauma , swelling , back pain, weakness , sexual difficulties , numbness , or tingling in legs
PMHx : Diabetes for 3 years under diet control , hypercholesterolemia
PSHx : None
Meds: Simvasatin 40 mg daily at bedtime
Allergies : None
FHx : Father died at age 65 of stroke ; mother and 2 siblings are healthy
SHx : 2 PPD smoker for past 30 years , occasional alcohol use
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 , 140/80 mmHg; pulse , 78/min; and respirations ,20/min
. Abdomen : No bruits
. Extremities : Pulse 2+ and symmetrical in bilateral lower extremities
. Musculoskeletal : Negative Homans sign , no calf tenderness to palpation bilaterally
. Neurologic : bilateral lower extremities with 5/5 motor strength , intact vibratory sensation and proprioception, and DTR 2+
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 : Drug-induced (statin) myopathy
History finding(s)
. Proximal muscle pain
. History of statin use
Physical examination finding(s)
. Normal motor strength in legs
. No sensory deficits in legs
Diagnosis #2 : Atherosclerotic peripheral vascular disease
History finding(s)
. History of diabetes and high cholesterol
. History of smoking
. Family history of stroke
Physical examination finding(s)
. None
Diagnosis #3 : Diabetic polyneuropathy
History finding(s)
. Diet-controlled diabetes
. History of high cholesterol
Physical examination finding(s)
. None
Diagnostic studies
. Creatinine kinase
. Fasting blood sugar and hemoglobin A1c
. Lower-extremity arterial Doppler
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2018/08/15 03:37pm 
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