CASE 23

DOORWAY INFORMATION

Opening Scenario
Jay Keller, a 49-year-old male, comes to the ER complaining of passing out a few hours earlier.

Vital Signs

BP: 135/90 mmHg

Temp: 98.0°F (36.7°C)
RR: 16/minute
HR: 76/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.

Checklist/SP Sheet

PATIENT DESCRIPTION
Patient is a 49 yo M, married with three children.

NOTES FOR THE SP

None.

CHALLENGING QUESTIONS TO ASK

“Do you think I have a brain tumor?”

SAMPLE EXAMINEE RESPONSE

“I think it’s unlikely. To make absolutely sure, however, we will do a CT scan, which is a special x-ray test of
the brain. That will help us see the structure of the brain and rule out any bleeding or tumor.”

Examinee Checklist
ENTRANCE:
Examinee knocked on the door before entering.
Examinee introduced self by name.
Examinee identified his/her role or position.
Examinee correctly used patient’s name.
PRACTIC E CASES

Examinee made eye contact with the SP.

HISTORY:
Examinee showed compassion for your illness.

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 嘼 Question Patient Response

□ Chief complaint I passed out.

□ Describe what happened This morning I was taking the groceries to the car with my wife
when I suddenly fell down and blacked out.
□ Loss of consciousness before, during, I think I lost consciousness and then fell down on the ground.
or after the fall
□ Duration of loss of consciousness My wife told me that I did not respond to her for several
minutes.
□ Palpitations before the fall Yes, just before I fell down, my heart started racing.
□ Sensing something unusual before No.
losing consciousness (sounds, lights,
smells, etc.)
□ Spinning/lightheadedness I felt lightheaded right before the fall.
□ Shaking (seizure) Yes, my wife told me that my arms and legs started shaking after
I fell down.
□ Duration of shaking Maybe 30 seconds.
□ Bit tongue No.
□ Lost control of the bladder No.
□ Weakness/numbness No.
□ Speech difficulties No.
□ Confusion after regaining consciousness No.
□ Headaches No.
□ Chest pain, shortness of breath No.
□ Abdominal pain, nausea/vomiting, No.
diarrhea/constipation
□ Head trauma No.
□ Similar falls, lightheadedness, or No.
passing out before
□ Gait abnormality No.
□ Weight changes No.
□ Appetite changes No.
□ Current medications Hydrochlorothiazide, captopril, aspirin, atenolol.
□ Past medical history High blood pressure for the last 15 years; heart attack one year
ago.
PRACTIC E CASES

□ Past surgical history Appendectomy.

□ Family history My father died from a heart attack at age 55, and my mother
died in good health.

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 Question Patient Response

□ Occupation Clerk in a video store.

□ Alcohol use Yes, I drink 3–4 beers a week.
□ CAGE questions No (to all four).
□ Illicit drug use No.
□ Tobacco No, I stopped a year ago. I had smoked one pack a day for the
previous 25 years.
□ Sexual activity Yes, with my wife.
□ Drug allergies No.

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

□ Head and neck exam Inspection (head, mouth), carotid auscultation and palpation,
thyroid exam
□ CV exam Palpation, auscultation, orthostatic vital signs
□ Pulmonary exam Auscultation
□ Extremities Palpated peripheral pulses
□ Neurologic exam Mental status, cranial nerves (including funduscopic exam),
motor exam, DTRs, cerebellar, Romberg test, gait, sensory
exam

Closure:

Examinee discussed initial diagnostic impressions.

Examinee discussed initial management plans:
Follow-up tests.
Examinee asked if the patient has any other questions or concerns.

Sample Closure:
Mr. Keller, I need to run some tests on you in order to determine the reason you passed out this morning, so I am
PRACTIC E CASES

going to get a CT scan of your head to look for bleeding or masses, and I will then order some blood tests to look
for infections or electrolyte abnormalities. You mentioned that your heart was racing just before you passed out,
so I will also ask you to wear a heart monitor for 24 hours. Doing so is just like having a constant ECG, and it will
allow us to detect any abnormal heartbeats you might have. We will start with these tests and then go from there.
Do you have any questions for me?

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 USMLE PATIENT NOTE
STEP 2 CS
History

Physical Examination

Differential Diagnosis Diagnostic Workup

1. 1.

2. 2.

3. 3.

4. 4.
PRACTIC E CASES

5. 5.

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 USMLE PATIENT NOTE
STEP 2 CS

History
HPI: 49 yo M c/o 1 episode of syncope that occurred a few hours ago. He was taking the groceries to the car with
his wife when he suddenly felt lightheaded, had palpitations, lost consciousness, and fell down. He was uncon-
scious for several minutes. His wife recalls that his arms and legs started shaking for 30 seconds after he fell
down. He denies subsequent confusion, weakness or numbness, speech difficulties, tongue biting, or inconti-
nence.
ROS: Negative except as above.
Allergies: NKDA.
Medications: HCTZ, captopril, aspirin, atenolol.
PMH: Hypertension for the last 15 years; MI 1 year ago.
PSH: Appendectomy.
SH: One PPD for 25 years; quit 1 year ago. Drinks 2–3 beers/week, CAGE 0/4, no illicit drugs.
FH: Father died from an MI at age 55.

Physical Examination
Patient is in no acute distress.
VS: WNL, no orthostatic changes.
HEENT: NC/AT, PERRLA, no funduscopic abnormalities, no tongue trauma.
Neck: Supple, no carotid bruits, 2+ carotid pulses with good upstroke bilaterally, thyroid normal.
Chest: Clear breath sounds bilaterally.
Heart: Apical impulse not displaced; RRR; normal S1/S2; no murmurs, rubs, or gallops.
Extremities: Symmetric 2+ brachial, radial, and dorsalis pedis pulses bilaterally.
Neuro: Cranial nerves: 2–12 grossly intact. Motor: Strength 5/5 throughout. Sensation: Intact to pinprick and
soft touch bilaterally. DTRs: Symmetric 2+ in upper and lower extremities, Babinski bilaterally. Cerebellar:
Romberg, finger to nose normal. Gait: Normal.

Differential Diagnosis Diagnostic Workup

1. Convulsive syncope 1. CBC, electrolytes
2. Vasovagal syncope 2. CXR
3. Cardiac arrhythmia 3. CT—head or MRI—brain
4. Drug-induced orthostatic hypotension 4. ECG and Holter monitor
5. Seizure 5. Echocardiography
6. Aortic stenosis 6. Prolactin
7. EEG
PRACTIC E CASES

277
 CASE DISCUSSION
Differential Diagnosis
• Convulsive syncope: Seizure-like activity often occurs after syncope and is due to global cerebral hypoperfusion.
There is no EEG correlate, and a seizure workup is not required.
• Vasovagal syncope: This often occurs in the setting of emotional stress or pain and may be due to excessive vagal
tone with resulting hypotension. Syncope is often heralded by nausea, sweating, tachycardia, pallor, and feeling
“faint.” This is also the mechanism of syncope in postmicturition syncope.
• Cardiac arrhythmia: Cardiac syncope typically occurs without warning, although a history of palpitations may in-
dicate the presence of an underlying arrhythmia. This patient’s history of MI increases his risk of developing
ventricular tachycardia, and β-blocker therapy may contribute to bradyarrhythmia.
• Drug-induced orthostatic hypotension: The patient’s antihypertensive medications increase his risk for orthostatic
hypotension and syncope. However, lightheadedness and syncope in this condition is usually postural (i.e., oc-
curs when getting up from a lying or seated position), and this patient’s orthostatic vital signs were normal.
• Seizure: Seizures usually occur unpredictably in a manner unrelated to posture or exertion. They may stem from
a variety of causes, including metabolic factors, trauma, vascular factors, and brain tumors. Tonic-clonic seizures
are often accompanied by tongue biting, incontinence, and prolonged confusion or drowsiness postictally.
• Aortic stenosis: This and other mechanical causes (e.g., hypertrophic obstructive cardiomyopathy, atrial myx-
oma) are commonly exertional or postexertional and occur without warning. The lack of a murmur and other
physical findings makes this unlikely in this case.

Diagnostic Workup
• CBC, electrolytes: To rule out anemia, evidence of hyperviscosity, or electrolyte imbalance that could lead to ar-
rhythmia or other causes of syncope.
• CXR: To rule out lung mass, cardiomyopathy, or other pathology.
• CT—head: The test of choice to exclude intracranial hemorrhage. Also rules out tumor, trauma, prior stroke, or
abscess.
• MRI—brain: Provides better anatomic detail than CT. Indicated when focal neurologic signs and symptoms are
present. MRA is helpful when vertebrobasilar insufficiency is suspected (i.e., when syncope is accompanied by
other brain stem signs).
• ECG and Holter or event monitor: To evaluate possible arrhythmia.
• Echocardiography: To rule out mechanical causes of syncope (e.g., severe aortic stenosis, atrial myxoma, severe
LVH with small residual cavity size, and hypertrophic obstructive cardiomyopathy).
• Prolactin: Often elevated within 30–60 minutes following a generalized seizure (it is useless after that time inter-
val). Must be compared to baseline prolactin levels.
• EEG: To evaluate suspected seizure activity.
PRACTIC E CASES

278
 CASE 24
DOORWAY INFORMATION

Opening Scenario
Kristin Grant, a 30-year-old female, comes to the office complaining of weight gain.

Vital Signs

BP: 120/85 mmHg

Temp: 98.0°F (36.7°C)
RR: 13/minute
HR: 65/minute, regular
BMI: 30

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.

Checklist/SP Sheet

PATIENT DESCRIPTION
Patient is a 30 yo F.

NOTES FOR THE SP

None.

CHALLENGING QUESTIONS TO ASK

“I want to go back to smoking because I believe that I have started gaining weight since I quit.”

SAMPLE EXAMINEE RESPONSE

“I understand that your weight is very important to you, but it’s clear that the health consequences of smoking
far outweigh those associated with weight gain. We also need to determine what else might be contributing to
your weight gain and then discuss strategies to deal with it.”

Examinee Checklist
ENTRANCE:
Examinee knocked on the door before entering.
Examinee introduced self by name.
Examinee identified his/her role or position.
PRACTIC E CASES

Examinee correctly used patient’s name.

Examinee made eye contact with the SP.

HISTORY:
Examinee showed compassion for your illness.

279