First Aid for the USMLE Step 2 CS

Section 4. Practice Cases

Case 27. 61-Year-Old Man with Fatigue

DOORWAY INFORMATION

Opening Scenario

William Jordan, a 61-year-old male, comes to the office complaining of fatigue.

Vital Signs

BP: 135/85 mm Hg Temp: 98.6°F (37°C)

RR: 13/minute HR: 70/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 61 yo M, married with 3 children.

Notes for the SP

 Look weak and sad, and lean forward while seated.

 Exhibit abdominal discomfort that increases when you lie on your back.

 Show pain on palpation of the epigastric area.

Challenging Questions to Ask

“I want to go on a trip with my wife. Can we do the tests after I come back?”

Sample Examinee Response

“It doesn’t sound as though you’re feeling well enough to be able to enjoy a trip. Let’s do some initial blood tests, and then we can see how you’re feeling and decide whether we’re comfortable letting you go away.”

Examinee Checklist

Building the Doctor-Patient Relationship 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.

 Examinee made eye contact with the SP.

Reflective Listening

 Examinee asked an open-ended question and actively listened to the response.

 Examinee asked the SP to list his/her concerns and listened to the response without interrupting.

 Examinee summarized the SP’s concerns, often using the SP’s own words.

Information Gathering

 Examinee elicited data efficiently and accurately.

Connecting with the Patient

 Examinee recognized the SP’s emotions and responded with PEARLS.

Physical Examination

 Examinee washed his/her hands.

 Examinee asked permission to start the exam.

 Examinee used respectful draping.

 Examinee did not repeat painful maneuvers.

Closure

 Examinee discussed initial diagnostic impressions.

 Examinee discussed initial management plans:

 Follow-up tests.

 Depression counseling:

 Support system at home (friends, family).

 Support systems in the hospital and community.

 Coping skills: Exercise, relaxation techniques, spending more time with family and friends.

 Examinee asked if the SP had any other questions or concerns.

Sample Closure

Mr. Jordan, your symptoms are consistent with a few different diagnoses. They may be caused by an ulcer that would resolve with a course of antibiotics and acid suppressors, or they may have a more serious cause, such as pancreatic cancer. I am going to schedule you for an abdominal CT scan that may reveal the source of your pain, and I will also run some blood tests. I know you are concerned about your upcoming vacation, but the results of your tests should be back within a few days, and they should give us a good idea what is wrong with you. In the meantime, our social worker can meet with you to help you find ways to cope with the stress you have been experiencing in your life. Do you have any questions for me?

History

HPI: 61 yo M c/o fatigue and weakness. The patient notes that the fatigue and weakness started 6 months ago. He feels tired all day. He has poor appetite and unintentionally lost 8 lbs in the past 6 months. He also complains of occasional nausea and of a vague, deep epigastric discomfort that radiates to the back. This discomfort started 4 months ago and has gradually increased to a severity of 4/10. The discomfort decreases when he leans forward and increases when he lies on his back. There is no relationship of the pain to food. No changes in bowel movement regularity, but he has recently noticed more foul-smelling, greasy-looking stools. He denies blood in the stool. He feels sad sometimes, has lost interest in things that he used to enjoy, wakes up unusually early in the morning, and complains of low energy and concentration that have affected his daily activities and work. The patient denies suicidal ideation or plans. No feelings of guilt or worthlessness.

ROS: Negative except as above.

Allergies: NKDA.

Medications: Tylenol.

PMH: None.

PSH: Appendectomy at age 16.

SH: 1 PPD for 30 years; stopped 6 months ago. Drinks 2 beers daily and 3-4 beers on weekends. Sexually active with his wife.

FH: Father with diabetes, died accidentally. Mother died from breast cancer.

Physical Examination

Patient is in no acute distress, looks sad.

VS: WNL.

HEENT: No conjunctival pallor, mouth and pharynx normal.

Neck: Supple, no JVD, no lymphadenopathy, thyroid normal.

Chest: Clear breath sounds bilaterally.

Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops.

Abdomen: Soft, nondistended, mild epigastric tenderness, no rebound tenderness,Murphys sign, BS, no hepatosplenomegaly

Extremities: No edema.

Differential Diagnosis

CASE DISCUSSION

Patient Note Differential Diagnoses

 Pancreatic cancer: The pattern and location of the patient’s pain are worrisome for pancreatic disease, and his weight loss raises concern for malignancy. Smoking is among the most significant risk factors for pancreatic cancer; others include chronic pancreatitis, diabetes mellitus, and a high-fat diet. Depression may be the initial manifestation of pancreatic cancer, and diarrhea—presumably due to malabsorption—is an occasional early finding. Malabsorption is suggested by the patient’s foul-smelling, greasy-looking stools.

 Depression: The patient has many classic symptoms of depression (SIG E CAPS; see Case 33). Although it may be a somatic symptom of depression, his abdominal pain is of significant concern and warrants a thorough medical evaluation.

 Chronic pancreatitis: The pattern and location of pain are consistent with this diagnosis, but usually there is a history of recurrent episodes of similar pain. The patient’s alcohol use should be explored further, as alcoholism accounts for 70-80% of cases of chronic pancreatitis (the patient consumes more than 14 drinks a week, which is considered the limit for males). Moreover, his history of foul-smelling, greasy-looking stools may suggest pancreatic insufficiency, which is a manifestation of chronic pancreatitis.

Additional Differential Diagnoses

 Peptic ulcer disease: Suspect this diagnosis in any patient with epigastric pain, although the complaint is neither sensitive nor specific enough to make a reliable diagnosis. It is important to note that many patients deny any relationship of the pain to meals. Weight loss, however, is unusual in uncomplicated ulcer disease and may suggest gastric malignancy.

 Hypothyroidism: Nonspecific symptoms such as fatigue and weakness may suggest this common diagnosis. Abdominal pain is unusual.

Diagnostic Workup

 CBC, stool for occult blood: A fecal occult blood test is a useful means of screening for potential blood loss. A CBC can determine hemoglobin levels, which, when compared to a known baseline level, can confirm the presence of significant blood loss.

 Glucose: To screen for pancreatic endocrine dysfunction (eg, diabetes mellitus, which is a risk factor for pancreatic cancer).

 Fecal fat studies: Ordered in suspected cases of pancreatic insufficiency. Fecal elastase and chymotrypsin would likely be decreased in the setting of pancreatic insufficiency.

 Amylase, lipase: Nonspecific, but can be elevated in chronic pancreatitis or malignancy.

 AST/ALT/bilirubin (direct, indirect, and total)/alkaline phosphatase: To look for evidence of obstructive jaundice (often seen in pancreatic cancer). Alkaline phosphatase and bilirubin levels would be elevated in obstruction, whereas AST and ALT are generally normal unless the liver is involved.

 CT—abdomen: To diagnose pancreatic cancer or other pathology and to look for pancreatic calcifications suggestive of chronic pancreatitis.

 TSH: Thyroid disease must be ruled out in a patient with symptoms of depression.

 U/S—abdomen: To diagnose gallstones as the underlying cause of pancreatitis. This test is particularly useful if acute pancreatitis is suspected. Ultrasound is routinely performed on patients with acute pancreatitis to help determine if gallstones are the cause.

 Upper endoscopy: To diagnose ulcer disease. 



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