d*********n
发帖数: 18 | 1 this one of my CS protocols, hope can help whoever going to take the test, I
don’t need any more.
not perfect, but good to figure out diagnosis, should not miss the diagnosis
,
do not need to ask all questions , must adjust base the case,
if better ideas, pleas modify to make easier for people who may need
Amenorrhea
Mental check list:
Pregnancy,
hyperprolatinemia,
hypothyroidism,
PCOS,
premature menopause,
depression
asheman syndrome,
anorexia nervosa,
strenuous exercise
Patricia Garrison, a 36-year-old female, comes to the office complaining of
not having menstrual periods recently.
Vital Signs BP:120/85 mmHg Temp:98.0°F (36.7°C) RR:13/minute HR:65/minute,
regular
Examinee Tasks
1. Take a focused history.
2. Perform a focused physical exam (do not perform rectal, genitourinary, or
female breast exam).
3. Explain your clinical impression and workup plan to the patient.
4. Write the patient note after leaving the room.
CHALLENGING QUESTIONS TO ASK
“Am I going through menopause?”
SAMPLEEXAMINEERESPONSE
I understand you concern, I hope not.
“I doubt it. It would be extremely unusual at your age. I need to learn
more by asking you about other symptoms and examining you, and then we can
discuss possible reasons you are not having periods.”
Examinee Checklist
ENTRANCE:
Examinee knocked on the door before entering.
Examinee introduced self by name.
Examinee identified his/her role or position.
Examine correctly used patient’s name.
Examinee made eye contact with the SP.
HISTORY:
Examinee showed compassion for your illness.
Onset OB/GYN/pregnancy/menopause/ hyperprolectinemia/ hypothyroidism/
anxiety, depression/anorexia nervosa/ strenuous exercise/ PAM HUGA FOSS
(Knock 3 times)
Mrs. Garrasion?
Hi, Mrs. Garraddion. I am Dr. xxx, nice to meet you. (with a smile and firm
handshake). I am a physician here and I will be taking care of you today. (
eye contact)
(Look around the room) Is everything alright for you in this room?
Ok, Let me first cover you up. (apply the drape over the legs) Do you feel
comfortable now?
May I sit down and take the note?
Mrs. Garraasion, tell me what brings you in today?
I haven’t had a period in three months.
Can you tell me more about your menstrual periods?
Obstetric and GYN history(PCOS):
When was your last menstrual period?
Are your cycles regular? I used to have regular periods every month lasting
for 4–5 days, but over the last year I started having them less frequently
every 5–6 weeks lasting for seven days
How often do you have your period?
How long does your menstrual period last?
How many pads do you use per day? It was 2–3 Pads/tampons changed a day,
but the blood flow is becoming less, and I use only one a day now.
Do you have any vaginal spotting now?
When was your very first menstrual period?
Age at menarche Age 14.
Have you ever pregnant?
Pregnancies: I have one child; he is 10 years old.
How many times had you been pregnant? Have you ever had miscarriages /
abortions(Asherman syndrome)? No.(don’t ask miscarriages directly, will
cause cry. )
Did you have any problems during your pregnancy or delivery? No, it was a
normal delivery, and my child is healthy.
When was your last Pap smear? Last Pap smear Ten months ago. It was normal.
Did you have abnormal Pap smear? History of abnormal Pap smears No.
Pregnancy symptoms question:
Do you have a fever?
Do you have any rash?
Are you feeling short of breath?
Do you feel morning sickness?
Are you nauseated?
Did you vomit?
Do you have any belly pain?
Do you notice any vaginal bleeding or discharge?
Do you notice any swelling in your feet?
Do you notice any increase urinary frequency?
Menopause symyptoms
Are you feeling any hot flashes? No.
Are you feeling any vaginal dryness/itching? No.
Do you have any sleeping problems (falling asleep, No. staying asleep, early
waking, snoring)
Hyperprolactinemia:
Do you have any headache? No.
Have you noticed any visual changes? No.
Have you noticed any nipple discharge? Yes, just last week I noticed some
milky discharge from my left breast.
Hypothyroidism:
Have you ever had any problems adjusting temperatures? Cold intolerance No.
Have you noticed any skin/hair changes? Actually, I noticed some facial hair
recently that I am plucking.
Have you noticed any voice change? No.
Have you noticed any change in bowel habits? No.
Depression:
Are you feeling fatigued? No.
Do you have any depression?
Are you feeling anxious?
Are you feeling stress about anything?/ No.
Anorexia nervosa:
How is your appetite? I have a good appetite.
Have you noticed any weight changes? I have gained 15 pounds over the past
year.
Are you on diet?
Fad diet or diet pills No, I’ve been a vegetarian for 10 years. Food fad is
a term originally used to describe simple, catchy diets that often focused
on a single element such as cabbage, grapefruit or cottage cheese. In 1974,
the term was defined as three categories of food fads. 1. A particular food
or food group is exaggerated and purported to cure specific diseases. 2.
Foods are eliminated from an individual’s diet because they are viewed as
harmful. 3. An emphasis is placed on eating certain foods to express a
particular lifestyle.
Are you taking strenuous exercise?
Exercise I run two miles three times a week.
Is there anything special you want tell me?
Past medical history (Transition): Now, I need to ask some questions about
your past medical history.
Have you had similar problems before?
Have you had any other medical illnesses in the past?
Allergies: Are you allergic to any medications? no
Medications: Are you currently taking any prescribed medications? Can you
show me the prescription?
Are you taking any over-the-counter medications?
Hospitalization (PSH):
Have you ever been hospitalized before?
Had you ever had any surgeries?
Family history (Transition): Now let me ask some questions about your family
history.
Does anyone in your family have any medical illnesses?
My father and mother are healthy.
Do you know the ago of menopause of your other family members?
My mother began menopause at age 55.
Sexual history (Transition): let me ask some personal questions. I want to
assure you what you tell me will be kept confidential, OK?
Are you currently sexually active?
Sexual activity Once a week on average with my husband.
Do you use any form of contraception? Contraceptives The same pills for
eight years.
Have you ever been test for STD?
Social life: (Transition) Now, let me ask you some question about your
social life and personal habits.
Smoking: Do you smoke? How many packs a day? How long have you been smoking?
Paraphrase and counsel briefly (1 pack per day for 30 years. Since smoking
can put you at high risk of developing lung cancer and Heart attack, I
highly suggest you to cut down your smoking and eventually quit it. If you
are interested, we have many ways to help you, Okay? )
Alcohol: Do you drink any alcohol? What do you drink? How much do you drink
per week/day?
Ask cage question. Counsel then and there briefly as above
Drugs: Do you use any recreational drugs? Which one? How often? Counsel then
and there so that you won’t forget it.
Occupation: What type of work do you do?
Physical Examination:
Examinee washed his/her hands.
Examinee asked permission to start the exam.
Examinee used respectful draping.
Examinee did not repeat painful maneuvers.
Exam Component Maneuver
Neck exam Examined thyroid gland
CV exam Auscultation
Pulmonary exam Auscultation
Abdominal exam Auscultation, palpation, percussion
Extremities Inspection
Neurologic exam Visual fields, extraocular movements, checked DTRs
Closure:
Examinee discussed initial diagnostic impressions.
Examinee discussed initial management plans:
Diagnostic tests.
Follow-up tests: Examinee mentioned the need for a pelvic and breast exam.
Examinee asked if the patient has any other questions or concerns.
Sample Closure:
Ms. Garrison, there are a few reasons you may not be having regular periods.
The first thing we need to do is determine whether you are pregnant. We can
do that with a simple urine test.
The other thing we need to do is conduct a breast and pelvic exam,
especially since you have had some nipple discharge, and look for any signs
of menopause. Menopause is highly unlikely in your age group, but on rare
occasions it may occur.
A blood test to measure your hormone levels will also help us determine if
you are menopausal or have a hormonal imbalance.
This will give us a good start in figuring out why you haven’t had your
period, and we will go from there if we don’t find anything. Do you have
any questions for me?
I will follow you up
case 25 amenorrhea case
30 yo F c/o amenorrhea for 3 mo,
with left nipple milky discharge and facial hair growth, oligomenorrhea and
hypomenorrhea, 20 lb weigh gain for last year.
denies headache, visual change,
no cold intolerance, constipation, voice change,
no morning sickness, belly pain , frequency of urine,
no vaginal dryness, itching or hot flashes,
no diet change or vigorous exercise,
no depression.
ROS : negative except as above. ALL:NKA, MED:none, PSH: none, SH: no smoking
, no ETOH, no rec drugs, SXH: sexual active with husband only,on OTP, denies
STD.OB/GYN: LMP 3 mo ago, 28d/4-5d, G1P1, LPS 9 mo ago, was normal, FH:
mother menopause at 55
PE
Pt in no acute distress, facial hair, no conjunctivae pale, PERRLA, EOMI
without diplopia or lidlag, visual field intact, no thyromegaly, chest : CTA
BL , heart: RRR, no M,R,G. abdomen: NT/ND/+BS. No mass. DTRs: 2+ symmetric
hyperprolatinemia, 30 yo F c/o amenorrhea for 3 months, facial hair growth,
oligomenorrhea and hypomenorrhea, 20 lb weigh gain for last year
PCOS: 30 yo F c/o amenorrhea for 3 months, with left nipple milky discharge
and facial hair growth, oligomenorrhea and hypomenorrhea, 20 lb weigh gain
for last year
Pregnancy, 30 yo F c/o amenorrhea for 3 months, sexual active | f**********r
发帖数: 816 | | E****3
发帖数: 151 | 3 thanks you so much for sharing!!!!!!!! | v******2
发帖数: 41 | | d***i
发帖数: 93 | | d********o
发帖数: 98 | | l*****c
发帖数: 51 | 7 Thanks a lot. Have you passed? | d*********n
发帖数: 18 | 8 Confusion case: O CFDP P ADL, IADL, TIA/stroke, depression, DM, thyroid,
normal pressure hydrocephalus, PAMHUGSFOSS
insulin induced hypoglycemia
Electrolyte abnormalities
Vitamin B12 deficiency
Medications
TIA
Multi-infarct dementia
Chronic subdural hematoma
Alzheimer’s dementia
Normal pressure hydrocephalus
Intracranial tumor
Neurosyphilis
Depression
Hypyothyriodism
DDx Confusion
DEMENTIA
D-Diabetes /Dementia/ Drugs
E-Epilepsy
M-Migraine/Mult Infarct Dementia
E-Ethanol (withdrawl / Toxicity)
N-Neurological Deficit diseases= BETA (Bleeds,Encephalitis,Tumors,Abscess,
Meningitis)
T-TIA/ Trauma
I-Insulin/ Infections
A-Alzheimers/Abscess
63 M c/o confusion
Hello Mr. Green, how are you doing today, I am Dr. Sun, I am going to ask
your few questions and do the physical examination, is that ok with you?
What brought you in today?
I don’t think I have any problem, but my wife says I am very confused these
days.
Onset, duration,progression, constant,
How long she has been concerned about this? I think for past two to three
months.
Does she think you are confused all the time or at any special time or at
special situation? All the time, Doc
Does she think your confusing getting better or getting worse?
I understand that you are not much concerned about this, but let me ask a
few more questions to find out what exactly is going on, is that ok with you?
Sound great, Doc
Current status
ADLs- activities if daily living--DEATH:
How about you dressing, eating, ambulating, toileting and hygiene
Do you need any help with dressing?
Do you need help with eating?
Do you need any help with transferring from bed to the chair?
Do you need any help using toilet?
Do you need help with bathing?
IADLs- instrumental activities of daily living-SHAFT
Shoping, housekeeping, accounting, food preparation and transportation/
using telephone/shopping/preparing food/doing house laundry/managing money?
Do you need any help taking your medication?
Do you need help with shopping?
Do you need help with preparing food?
Do you need help with cleaning your house?
Do you need help managing your money?
Can you describe me a typical day of you? What are your daily routine
activities?
Depression
How is your mood?
Do you feel sad? Upset?
Do you have any problems with you memory? No
CNS
Do you have any fever? No
Do you have headache? No
Do you have any jerk movement or seizures?
Do you have slur speech?
Do you feel any weakness in your extremities? No
Do you have lightheadedness when stand up?
Diabetes, hypoglycemia
Do you feel dizzy? No
Have you ever pass out? No
Have you noticed any increased urination?
Yes, I had this problem for a long time, I usually pee a little bit more
Normal pressure hydrocephalus
Have you ever lost control of your urination?
Do you have any difficulty to keep you balance? Frequent falls.
hypothyroidism
Do you have problem adjusting to cold temperature?
Do you notice any change in your shin or hair?
How are your bowel movements? They are pretty good.
PM:
Past medical history (Transition): Now I need to ask some questions about
your past medical history
Do you have history of diabetes? Yes
When were you diagnosed with diabetes? About 25 yrs ago
Are you on any medication? Yes, I am on insulin
Do you know how much insulin you take daily? Usually my wife or my daughter
gives me my insulin shots.
How often do you check your blood sugar? Rarely, like once or twice a year.
Is your blood sugar under control? Sometimes
Do you have any other medical problems?
How about your blood pressure?
Yes , I have high blood pressure
For how long? Same as my diabetes
Are you taking any medication for that? Yes, I am taking atenolol , 25 mg
twice a day, I guess
How long have you been on this medication? Around 18 years
How often do you check your blood pressure? Once or twice a year.
Is your blood pressure under control? Not always, only some times
Did you any heart problem?No
Did you have a stroke? No
All:
Are you allergic to anything?
Yes , to penicillin—do not get a detailed history if not seemed related to
Med:
Other than insulin and atenolol, are you taking any other medication?
No
Hospitalized: Have you ever been hospitalized for any diabetic- related
complications? no
Have you been hospitalized for any other reason? No never
Surgery: Have you ever had any surgeries?
Injury accident: Have you had any head trauma or injury? No
Urinary
G
Sleeping: how is your sleep?
FH:
Does any family member have similar symptoms? Alzheimer’s
Does anybody in your family have a high blood pressure? Diabetes, a heart
attack? Stroke?
Sexual history (Transition): let me ask some personal questions. I want to
assure you what you tell me will be kept confidential, OK?
Are you currently sexually active?
Have you ever been diagnosed with any sexually transmitted disease,
especially syphilis.
SH:
Do you smoke?
Do you drink any type of alcoholic beverages?
How about your diet? vitamin B12
Do you have anybody at home who is taking care of you and providing support?
Support systems
If you asked this much in the history, it is more than enough, because of
the limited time, you may not get enough from your history for any
particular diagnosis, don’t worry
PE:
Wash hand
Perform proper draping technique
Perform mini mental status exam, the patient usually have normal MMSE
Do an ophthalmoscopes examination
Do a quick cranial nerve examination
Check gait, muscle, strength, reflexes, and sensations,
Auscultatte the heart and lungs
Exam without gown
Examinees usually run out of time because of the MMSE and CNS exam,
therefore practice performing these exams quickly and efficientaly, practice
repeatedly, so that you wont have any difficulty in managing your time
during the exam
Counseling:
Usually will not have enough time to give counseling, however , it is very
important to formally close or conclude the encounter
Ask: do your have any questions?
I am sorry to hear that your blood sugar and blood pressure are not under
good control, controlling blood sugar requires determination, let’s discuss
your treatment plan, which involves having a proper diet, exercising, and
using medication regularly.
High blood pressure could indicate your blood vessels are having trouble.
Hypertension-high blood pressure could complicate a diabetic problem, it
could cause stroke, affect function of heart, and even kidneys,.
Again regular exercise, reduction of weight, and limiting salt in your food
could help in your hypertension in check.
I strongly advise you to take regular health maintenance examinations to
help control your blood sugar and blood pressure, what do you say, Mr, XYZ
Sound great , Doc
DD:
insulin induced hypoglycemia
TIA
Multi-infarct dementia
Electrolyte abnormalities
Medications
Alzheimer’s dementia
Investigation
CBC with differential
Urinalysis
Serum electrolytes or basic metabolic profile
EKG and 24hr holter monitor
Carotid Doppler
CT scan –head
MRI –brain
CXR
63 yo M c/o confusion for past 3 mo,
gradually onset, getting worse. affect his daily activities(bathing,
dressing , eating, transferring into and out of chairs and bed, shopping,
cooking, managing money , using telephone, cleaning the house ).
feels upset about his difficulty.
also notes orthostatic lightheadedness and at least one fall with head
injury without seeking medical attention.
has weigh loss and no appetite.
denies headache, seizure,visual change,slur speech, weakness or numbness
no cold intolerance skin or hair change, constipation,
no difficulty with balance or urinary incontinence,.
ROS: negative as above. ALL: NKA. MED:HCTZ, aspirin, transdermal
nitroglycerin. PMH: HTN, stroke, MI, the patient can not remember when he
had. PSH:partial bowel resection many yrs ago.SH:no smoking, no ETOH, no rec
drugs. Retired ,lives with wife, good family support system. normal diet.
denies STD. FH: noncontributory.
pt in no acute distress, VS:WNL,NC, AT, PERRLA, no funduscopic abnormal.
NECK: no JVD, no bruits, no thyromegaly.
Chest: CTA BL.heart RRR, s1 s2, no M,R,G. ABD:S/NT/ND/no mass,
NEURO:A &Ox3,, CN 2-12 intact. motor: strength 5/5 throughout except 3/5 in
left arm. DTRs asymmetric, 3+ in left upper and lower extremities. 1+ in the
right.
- Babinshi bilaterally,
- Romberg, normal gait,
normal finger to nose. sensation: intact to pinprick and soft touch |
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