| | 33 Case 33 scenario ( refill medication for HIV )
Doorway information about patient
The patient is a 30-year0-old man who comes to the office to refill medications for HIV
Vital signs
. Temperature : 37.1’C (98.8F)
. Blodpressure : 120/75 mmHg
. Pulse : 78/min
. Respirations : 16/min
Basic differential diagnosis
. HIV
—————
Case 33 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 30-year-old man requesting a refill for your HIV medications
History of present illness
. Diagnosed with HIV 1 year ago
. Your partner at the time terminated the relationship , and you were sad initially but have slowly recovered and currently have a positive outlook
. You have been compliant with your medications for the past 6 months
. Your CD4 count 3 months ago was 480 with an undetectable viral load
Do not volunteer this information unless asked :
Review of systems
. Normal appetite with no recent change in weight
. No fever , chills , or night sweats
. No weakness , numbness , or tingling in the extremities
. No chest pain , cough , or shortness of breath
. No abdominal pain , diarrhea , or constipation
. No genital lesion , urethral discharge , or ruining with urination
. No skin lesion or rashes
Past medical / family / social history
. HIV decided on screening 1 year ago
. No prior medical problems
. Medications : HARRT medications
. Allergies : None
. Surgeries : None
. Immediate family members (after , mother , sister ) are all healthy
. Occupation : Truck driver
. Single ; male partners in the past but none in the last year
. Tobacco : No
. Alcohol : No
. Recreational drugs : No
Physical examination
HEENT :
. Oropharynx clear
. Fund without papilledema or lesion
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
. No CVA tenderness
Extremities :
. No edema
. No skin rashes
—————
Case 33 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 current medication regimen and compliance
. Asked about side effects of drugs
. Asked about symptoms of possible HIV-related illness
- Systemic symptoms (eg , fever , changes in weight )
- Breathing problems (eg, cough , shortness of breath)
- Headaches
- Eye problems (eg , pain , redness , blurred vision)
- Oral ulcers or white patches
- Pain of difficulty with swallowing
- Skin lesion or rashes
- Weakness and sensory symptoms
- Abdominal /bowel problems (eg , pain , cause , vomiting , diarrhea)
- Urogenital problems (dysuria, lesion)
. Asked about symptoms of depression
Past medical /family/social history
. Asked about past medical issues
. Asked about concurrent medications
. Asked about medical allergies
. Asked about past hospitalizations and surgeries
. Asked about family health
. Asked about tobacco , alcohol , and recreational drug use
. Asked about sexual history
. Asked bout occupation
Examination
. Washed heads before examination
. Examined without gown , not through gown
. Examined eyes, ears, nose , and throat
. Examined lymph nodes
. Examined lungs and heart
. Examined sensation in hands and legs
. Examined abdomen
Counseling
. Explained physical findings and possible additional diagnosis(if any)
. Explained further workup
. Discussed safe sexual practices and use of condoms
. Discussed potential complications and how to deal with them
. Discussed recommended vaccinations
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
. HIV
.(if the simulated patient is instructed to report additional symptoms or signs , consider also: Pneumocytis infection , Candida infection, cytomegalovirus retinitis , esophagitis)
Diagnostic study/studies
. CBC with differential count
. Serum chemistry (including hepatic function markers)
. CD4 cell count
. Viral load (HIV , RNA , PCR)
. Chest x-ray
—————
Case 33 clinical summary
Clinical Skills Evaluation
Case 33 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).
. 30-yo man needing refill of HIV medications
. Diagnosed a year ago
. Initially felt sad but now has positive outlook
. Compliant with medications
. No weight loss , normal appetite
ROS : No numbness or tingling in the extremities , weakness , chest pain , shortness of breath , abdominal pain . rashes , cough , diarrhea , constipation , genital lesions , fever, chills , or night sweats
PMHx : HIV diagnosis a year ago ; 3 months ago , CD4 count was 480/mm3 with undectetable viral load
PSHx : None
Meds : HAART therapy
Allergis : None
FHx : Father , mother , and sister are healthy
SHx : No tobacco or 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 , 37.1’C (98.8F) ; blood pressure , 120/75mmHg; pulse , 78/min; and respirations, 16/min
. HEENT : Oropharynx clear , fund without papilledema or lesions
. Necks ; Supple without lymphadenopathy
. Lungs ; Clear to auscultation bilaterally
. Heart : Regular rate and rhythm without murmurs , gallops, or rubs
. Abdomen ; Non-tender, non-distended , normative bowel sounds , no hepatosplenomegaly, no CVA tenderness
. Extremities ; No rash or edema
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 : Chronic HIV
History finding(s)
. HIV diagnosis a year ago
. Recent stable CD4 count and viral load
. Complaints with medications
Physical examination finding(s)
. Normal examination findings
Diagnostic studies
. CD4 count and viral load
. CBC with differential
. Liver function tests
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