Author: Tim Milligan

Case 1 – Productive Cough

Tim Milligan Respirology

You are seeing Mr. Smith, a 60 year old man, in your outpatient clinic today for a worsening productive cough. Take a focused history of his complaint.

History

  • Onset of cough
  • Worsening cough
  • Sputum production and volume
  • Change in sputum color
  • Presence of blood in sputum
  • Associated shortness of breath
  • Fever
  • Chest pain
  • Recent respiratory illnesses
  • Smoking history (quantity in pack-years)
  • Other drug use
  • Personal history of lung disease
  • Occupational history to airborne toxins/irritants
  • Infectious contacts
  • Exposure to environmental allergens
  • Recent travel
  • TB exposure history

Physical

Inspection

  • Comments on presence of central/peripheral cyanosis (frenulum, lips, fingernails)
  • Comments on respiratory status – tachypnea /intercostal indrawing/accessory muscle use, etc.
  • Examines for thoracic deformities

Percussion/Palpation

  • Percusses all anterior and posterior fields and comments on findings
  • Uses percussion to estimate diaphragmatic excursion on the posterior chest
  • Assesses fremitus in all anterior and posterior fields and comments on findings
  • Evaluates chest expansion using palpation

Auscultation

  • Instructs patient to breathe while auscultating; listens for at least one full breath at each location of auscultation
  • Auscultates both lung fields in at least 5 different locations
  • Auscultates posterior fields, and asks patient to cross arms in order to shift scapulae away from the lung fields
  • Comments on of breath sounds and presence of adventitious sounds, e.g. crackles and wheezes

Case 4 – Breaking Bad News

Tim Milligan Psychiatry

You are seeing Mr. Ozuka, a patient undergoing chemotherapy for advanced prostate cancer. You have recently performed tests which show that his tumor has progressed to an incurable stage. You estimate his life expectancy to be approximately 6 months. You have called him into your office today in order to disclose the results of these tests.

History

  • Determines current state of patient’s illness.
  • Determines whether patient wants to hear the test results (patient would like to know results)
  • Asks whether patient would like a family member or friend to be present
  • Prepares patient before disclosing the results
  • Provides diagnosis in a straightforward manner
  • Conveys information with brevity and simplicity, avoids using medical jargon
  • Establishes the impact of the news on the patient
  • Asks about patient’s goals of care
  • Asks patient about need for home support
  • Asks patient about need for spiritual support
  • Asks patient about need for financial support
  • Inquires about patient’s end-of-life goals
  • Uses appropriate tone of voice
  • Uses appropriate level of language
  • Uses appropriate body language
  • Respects patient’s personal space
  • Ensures patient’s privacy
  • Displays empathy and provides emotional support to patient
  • Handles patient’s questions well
  • Ensures patient’s understanding of the information
  • Allows patient to express concerns
  • Summarizes interview

Case 3 – Uncooperative Patient

Tim Milligan Psychiatry

You are seeing Mr. Simmons, a patient of yours and the father of one your female patients, aged 16, from your general practice. He states that he recently found an empty pregnancy test container in his daughter’s trash can and wants speak to you about it. Take a focused history of his complaint.

History

  • Inquires about the father’s concerns (father wants to know if his daughter is pregnant)
  • Establishes context for the father’s concerns
  • Acknowledges father’s concerns and reiterates his complaint
  • Asserts that daughter’s autonomy supersedes father’s concerns
  • Does not disclose details of daughter’s medical information
  • Behaves calmly with patient
  • Uses appropriate tone of voice
  • Uses appropriate language with patient
  • Uses appropriate body language
  • Respects patient’s personal space
  • Displays empathy
  • Summarizes interview
  • Handles patient’s questions well
  • Ensures patient’s understanding of the situation
  • Allows patient to express concerns
  • Copes with patient’s interruptions
  • Copes with patient’s aggressive tone and language
  • Avoids overreacting

Case 2 – Forgetfulness

Tim Milligan Psychiatry

You are about to see Mrs. Chambers, a 71 year old woman, in your outpatient clinic. She was brought in today by her husband who is concerned that she’s becoming increasingly forgetful. Take a focused history related to her husband’s complaint and perform the MMSE on Mrs. Chambers.

History

  • Asks patient if she concurs with husband’s concerns (she reluctantly agrees)
  • Asks patient about forgetfulness in daily context (e.g. misplace keys, forgets to turn off stove)
  • Asks about forgetfulness with dangerous house appliances (has previously left stove on)
  • Asks about forgetfulness with medications
  • Asks patient to personally assess her current daily function
  • Ambulation (uses cane)
  • Hygiene and dressing (independent)
  • Eating, cooking
  • Banking and shopping
  • Housework
  • Driving and transportation (still drives)
  • Assesses for polypharmacy
  • Visual acuity, dizziness
  • Continence
  • Falls (has fallen once)
  • Arthritis
  • Other past medical history
  • Mood changes (patient’s mood is ‘so-so’)
  • Alcohol use
  • Social support outside of husband (has 2 adult children)
  • Addresses patient’s reluctance to address her husband’s concerns

Mini Mental Status Examination

Introduces exam to patient and explains why they are performing the test

  • (/5) Orientation to Place: Country, Province/State, City, building, floor
  • (/5) Orientation to Time: year, season, month, day of the week, day
  • (/3) Registration: Three naming prompts, asks to repeat back
  • (/5) Attention: Asks to calculate serial 7s or spell WORLD backwards
  • (/3) Recall: Repeating previously remembered words
  • (/2) Language: Asks to name two objects of minimal difficulty
  • (/1) Repetition: Asks patient to repeat a phrase back
  • (/1) Complex Task: Draw intersecting pentagons for patient to copy
  • (/3) Comprehension: Patient to follow three step command
  • (/1) Writing: Patient writes sentences with proper syntax
  • (/1) Reading: Patient obeys simple written command

Compiles total score, correctly interprets results, and conveys results to patients

Case 1 – The Fearful Patient

Tim Milligan Psychiatry

You are about to see Mr. Oberman, a 23 year old male, in your outpatient clinic. He is a long time patient of yours. He comes to your office today because he’s becoming increasingly afraid to leave his house and he wants your help. He is very agitated. Please take a focused history of his complaint.

History

  • Asks patient about content of fears (feels he’s being persecuted)
  • Asks why he believes he’s persecuted
  • Onset of beliefs
  • How beliefs have changed his life, and what he has done about them
  • Other delusions (denies delusions of grandeur, somatic, parasitosis, etc.)
  • Visual hallucinations
  • Auditory hallucinations
  • Tactile hallucinations
  • Ideas of reference
  • Asks if patient has been harmed by anyone, or has harmed anyone
  • Homicidal ideation
  • Suicidal ideation
  • Symptoms of depression
  • Symptoms of mania
  • Symptoms of anxiety
  • Alcohol and Smoking history (quantity in pack-years)
  • Other drug use, especially marijuana and hallucinogens
  • Current medications and Allergies
  • Occupational history
  • Legal history
  • Current social supports
  • Family history of schizophrenia
  • Family history of other psychiatric illnesses

Case 3 – Pain in Legs

Tim Milligan Peripheral Vascular

You are seeing Mr. Perera, a 68 year old male, in an outpatient clinic. He’s coming in today because he’s been getting pain in his legs for the last few months, and it’s getting worse. Please take a focused history of his complaint.

History

  • Onset and duration of pain
  • Quality of pain
  • Aggravating factors (pain is elicited by walking)
  • Distance travelled that elicits pain (2 blocks)
  • Alleviating factors
  • Intensity of pain
  • Radiation of pain
  • Pain at night
  • Neurologic symptoms, such as numbness or parasthesias
  • Leg trauma
  • Asks if both legs are affected (yes)
  • Foot ulceration
  • Lower limb infection
  • Shortness of breath
  • Recurrent chest pain
  • Personal history of myocardial infarction and stroke
  • Peripheral vascular disease
  • Diabetes
  • Dyslipidemia
  • Hypertension
  • Smoking history (quantity in pack-years)
  • Family history of cardiac or cerebrovascular events
  • Effect on daily activities

Case 2 – Limb Pain

Tim Milligan Peripheral Vascular

You are seeing Ms. Richards, a 45 year old female, in the ER for a two day history of right leg pain. Please perform a focused history and physical examination.

History

  • Onset and duration of pain
  • Severity of pain
  • Location of pain
  • Alleviating and aggravating factors
  • History of trauma to leg
  • Leg swelling
  • Neurologic symptoms in affected limb
  • Association with shortness of breath
  • Fever
  • Diaphoresis
  • Chest pain
  • Hemoptysis
  • Personal history of clotting disorders
  • Personal history of malignancy
  • Pregnancy history
  • Use of hormone replacement or oral contraceptive pill (patient uses OCP)
  • History of immobilization
  • Recent leg trauma
  • Medications/Allergies
  • Smoking history (quantity in pack-years)
  • Family history of thromboembolic disease (DVTs, PEs)

Physical Examination

Inspection

  • Inspects for swelling, edema
  • Inspects for erythema and varicosity in affected limb
  • Inspects for venous ulcers in lower limbs
  • Inspects for joint effusions in affected limb

Palpation

  • Palpates affected lower limb for tenderness
  • Compares limbs for warmth
  • Measures and compares calf circumference for each limb
  • Assesses sensation in affected limb

Case 1 – Acute Paralysis

Tim Milligan Peripheral Vascular

You are seeing Ms. Richards, a 75 year old female, in the ER. She is distraught because she is presenting with a two hour history of complete left leg paralysis. Please perform a focused history and physical examination.

History

  • Onset and duration of paralysis
  • Associated sensory loss
  • History of trauma to leg
  • Leg swelling
  • Pain in leg
  • Parasthesias in leg
  • Numbness in leg
  • Shortness of breath
  • Chest pain
  • Head trauma
  • Weakness elsewhere in the body
  • Sensory loss elsewhere in the body
  • Vision or speech changes
  • Personal history of myocardial infarction and stroke
  • Peripheral vascular disease
  • Diabetes
  • Dyslipidemia
  • Hypertension
  • Smoking history (quantity in pack-years)
  • Medications/Allergies
  • Family history of cardiac or cerebrovascular events

Physical Examination

Inspection

  • Comments on color of affected limb (pale)
  • Inspects for hair loss/lack of oil on affected limb
  • Inspects for arterial and diabetic ulcers on feet bilaterally (small ulcer on bottom of 1st toe)
  • Inspects for leg swelling

Palpation

  • Palpates affected limb for tenderness
  • Compares temperature in lower limbs
  • Assesses sensation in both lower limbs
  • Assesses power in both lower limbs
  • Assesses capillary refill in affected limb

Auscultation

  • Auscultates bilaterally for femoral and popliteal bruits
  • Auscultates abdomen for aortic aneurysm

Case 4 – The Sick Child

Tim Milligan Pediatrics

You are about to see 7 year old boy named Bobby. His father has brought him in and tells you that he’s been significantly less active in the last two days, and that he’s been running a high fever. Perform a focused physical examination for a child with a fever.

Physical Examination

  • Explains the nature and purpose of the examination to the child and parent
  • Asks parent for assistance while examining the child when needed

Inspection

  • Comments on overall appearance (looks unwell, diaphoretic)
  • Examines for rashes
  • Examines joints for effusion, erythema

Vitals/Hypovolemia

  • Measures heart and respiratory rate
  • Assesses volume status by examining mucus membranes, skin temperature/turgor, capillary refill
  • Takes temperature of patient (hyperthermic)
  • States that orthostatic vitals should be measured
  • States that the weight of the child should be measured as part of the volume assessment

Head and Neck exam

  • Comments on the presence of erythema and exudates in oropharynx
  • Palpates all lymph nodes of the head and neck
  • Comments on the size, texture, mobility, and location of any identified nodes
  • Asks patient/assesses child for tenderness during examination
  • Examines patient’s ears using otoscope, comments on auditory canal and tympanic membrane
  • Checks for neck stiffness

Respiratory

  • Comments on respiratory status: accessory muscle use, nasal flaring, central/peripheral cyanosis
  • Auscultates in all lung fields
  • Comments on findings

Abdominal Exam

  • Examines for abdominal tenderness in all four quadrants
  • Assesses for splenomegaly
  • Assesses for masses in the abdomen

Case 3 – Tired Teenager

Tim Milligan Pediatrics

You are seeing Haley Schilling, a 15 year old female, who’s coming to your office today at the behest of her mother. She has recently become more tired and her mom is concerned that she has ‘low blood.’ Take a focused history from Haley.

History

  • Determines chief complaint is fatigue
  • Inquires about onset and duration of fatigue
  • Asks patient what she believes is causing her fatigue
  • Inquires about patient’s mood (“I often feel low”)
  • Inquires about association with other systemic symptoms – fever, chills, nausea (none)
  • Symptoms suggestive of thyroid disease (cold intolerance, skin/hair changes)
  • Excessive sleep (yes)
  • Increasing weight, increasing appetite (yes)
  • Feelings of worthlessness/guilt/isolation
  • Pre-occupation with self image
  • Poor concentration
  • Psychomotor activation or retardation (activation)
  • Suicidal ideation
  • Suicide attempts
  • History of self-harm behavior
  • Symptoms of mania
  • Symptoms of anxiety
  • Symptoms of psychosis
  • Establishes social context of child’s home-life and relationship with family
  • Inquires about how the patient is adapting in school
  • Relationship/sexual history
  • Activities outside of school
  • Past medical history
  • Past history of depression and other psychiatric illnesses
  • Current medications
  • Alcohol, smoking, and drug history
  • Legal history
  • Current social supports
  • Family history of psychiatric illnesses