First Aid for the USMLE Step 2 CS

Section 4. Practice Cases

Case 34. 32-Year-Old Woman with Fatigue

Doorway Information

Opening Scenario

Jessica Lee, a 32-year-old female, comes to the office complaining of fatigue.

Vital Signs

BP: 120/85 mm Hg Temp: 98.2°F (36.8°C)

RR: 13/minute HR: 80/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 32 yo F, married with 2 children.

Notes for the SP

 Look anxious and pale.

 Exhibit bruises on the face and arms that elicit pain when touched.

Challenging Questions to Ask

“I am drinking a lot of water, doctor. What do you think the reason is?”

Sample Examinee Response

“At this point I don’t know for sure, but I want to run some tests. Drinking a lot of water could be the first sign of diabetes, and we will need to check for that.”

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.

 Domestic violence counseling:

 “I care about your safety, and I am always available for help and support.”

 “Everything we discuss is confidential, but I must involve child protective services if your children are being harmed.”

 Support group information, including contact numbers or Web sites.

 Safety planning.

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

Sample Closure

Ms. Lee, I am concerned about your safety and your relationship with your husband. I would like you to know that I am available for help and support whenever you need it. Although everything we discuss is confidential, I must involve child protective services if I have reason to believe that your children are being abused. I will bring back some telephone numbers and contact information for you regarding where to go for help if you or your children are in a crisis or if you just want someone to talk to. I am also concerned about your frequent urination and thirst. I will run a simple blood test to see if you have any problems with your blood sugar or your hormones. Do you have any questions?

History

HPI: 32 yo F c/o fatigue and weakness x 5 months.

 Fatigue increases throughout the day.

 Loss of energy and concentration, which is affecting job as nurse.

 Patient admits that husband, who is an alcoholic, has beaten her.

 At least 1 episode of physical abuse directed at youngest son.

 Patient attempts to defend husband's actions.

 Feels guilty.

 Self-blame.

 Has not reported abuse. No head trauma or accidents due to husband.

 No emergency plan.

 Feels sad but denies suicidal ideation.

 Polyuria, polydipsia, nocturia x 5 months.

 LMP 2 weeks ago, menstrual period is regular, q28 days, lasting 7 days of heavy flow.

 No dysuria or change in color of urine.

 No constipation, cold intolerance, or change in appetite or weight.

 No sleep problems.

ROS: Negative except as above.

Allergies: NKDA.

Medications: None.

PMH/PSH: None.

SH: No smoking, no EtOH. Sexually active with her husband; decreased sexual desire.

FH: Diabetic father died from a heart attack; mother is in a nursing home with Alzheimer's disease

Physical Examination

Patient is obese, in no acute distress, looks anxious.

VS: WNL.

HEENT: Pale conjunctivae.

Neck: No lymphadenopathy, thyroid normal.

Chest: Clear breath sounds bilaterally.

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

Abdomen: Soft, nondistended, nontender,BS, no hepatosplenomegaly

Extremities: Muscle strength 5/5 throughout; DTRs 2+; symmetric, painful bruises on both arms.

CASE DISCUSSION

Patient Note Differential Diagnoses

 Domestic violence: The patient is clearly a victim of domestic violence and of her husband’s alcoholism. This can explain many of her symptoms but not the polyuria or polydipsia.

 Diabetes mellitus (DM): Aside from domestic violence issues, many of the patient’s symptoms can be explained by new-onset diabetes. Her obesity and positive family history put her at risk. She should also be asked about any recent vaginal yeast infections, which are a frequent complication of hyperglycemia (and may be its initial presenting symptom).

 Anemia: This may also help explain her fatigue and weakness. Menstruating females often have an iron deficiency anemia. Conjunctival pallor on exam has a high likelihood ratio for predicting a hematocrit < 30% (Hb < 10 g/dL).

Additional Differential Diagnoses

 Major depressive disorder (MDD): This patient does not currently meet the criteria for MDD. However, her history of intimate partner violence increases her risk of developing a mental disorder, with the degree of risk directly related to the frequency of violent episodes.

 Hypothyroidism: Nonspecific symptoms such as fatigue and weakness may suggest this common diagnosis. However, the patient denies constipation, weight/appetite changes, or cold intolerance. Hypothyroidism does not explain polyuria, polydipsia, or the admitted physical abuse.

 Diabetes insipidus (DI): This is an uncommon disease characterized by polyuria (of low specific gravity) and polydipsia. It has many etiologies and is caused by a deficiency of or resistance to vasopressin. Central diabetes can be idiopathic or acquired (eg, post-head trauma, benign tumors, or surgery). The patient’s obesity, family history of DM, and lack of acquired causes of DI support DM as a more probable explanation for her symptoms.

 Myasthenia gravis: Increasing fatigue as the day progresses is highly nonspecific. By contrast, this disease involves fluctuating muscle weakness and presents with ptosis, diplopia, difficulty chewing or swallowing, respiratory difficulties, and/or limb weakness—all of which the patient has denied.

Diagnostic Workup

 Serum glucose, HbA1c: To screen for DM.

 CBC: To investigate anemia. If the CBC is suggestive of iron deficiency anemia, the next step would be to order a serum iron level, ferritin, and TIBC. Serum B12 levels should also be ordered to check for B12 deficiency anemia.

 UA: Glucose or protein may be present in DM.

 Electrolytes: Hypernatremia may be seen in DI.

 MRI—brain (pituitary protocol): To look for mass lesions in central DI.

 DDAVP nasal spray test ("vasopressin challenge test"): To confirm a clinical suspicion of central DI.



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