Boston University School of Medicine EOTYA Sample Case Woman with Headaches

SAMPLE CASE
Boston University School of Medicine Clinical Skills Center
A thor!s "ame# $orraine Stanfield% M&'&% BUSM 'ate (((()*+, Cler-ship# EOTYA

Anticipated Time# ./ min tes for foc sed H 0 1

OUTLINE FO FOCUSE! P OBLEMS Short Case Title" #o$an %ith &eadaches (Students: Note this is the patients script. You would only see the Opening Scenario on page four, and the write-up for on page !".#
Laura Jackson% a )23year3old woman% presents to a primary care center for eval ation of headaches Ms& 4ac-son% who wor-s as an acco ntant% has 5een noticin6 worsenin6 headaches over the past month& At first she only noticed them late in the day after she had 5een wor-in6 on the comp ter for many ho rs& "ow she has diffic lty seein6 the comp ter screen earlier in her wor- day% and often has a headache late in the day& 'istancin6 herself from the screen seems to help the 5l rriness somewhat% 5 t then the n m5ers seem very small& 7n 6eneral the headache is felt as a press re across her forehead& Tylenol s ally helps resolve it& The typical pain is descri5ed as a 83/*.+ on the pain scale% lasts an ho r% and occ rs 93) days*wee-& Yesterday she had a more severe headache after wor- that went p to ,*.+ and lasted for several ho rs& She felt na seated 5 t did not vomit& The only thin6 that helped was 6oin6 to 5ed& "ow she has a mild headache& She has 6ood ener6y and denies chan6e in wei6ht% poly ria% polydyspia% vomitin6% m scle wea-ness or n m5ness& She felt a little warm yesterday d rin6 the headache% 5 t does not own a thermometer and did not ta-e her temperat re& Some collea6 es at worhave had colds and she is startin6 to 6et a st ffy nose and her nec- feels sore& She has not 5een to see an eye doctor in a5o t : years% and never wore 6lasses& She has 5een drin-in6 more coffee than s al& She denies floaters or vis al scotomata& She has had very heavy periods for the past si; months& Social &istory" Ms& 4ac-son has 5een nder some stress at wor- recently& She was promoted one year a6o and has had to wor- lon6er ho rs& The company has 5een downsi<in6 and several collea6 es have 5een laid off& While she do 5ts her =o5 is in =eopardy it has 5een psettin6% and has increased everyone!s wor- load& She never married% and is not involved with a se; al partner& She is involved in a local theater company and en=oys

Boston University School of Medicine EOTYA Sample Case Woman with Headaches doin6 comm nity prod ctions& Ms& 4amison lives with her elderly parents& Her mother s ffers from arthritis and dia5etes& Ms& 4ac-son does not smo-e% has a rare 6lass of wine >CA?E 3@ and never sed dr 6s& She drin-s three c ps of coffee per day >increased over 5aseline@& The patient!s concern% if as-ed% of a 5rain ane rysm& Her a nt died of a r pt red 5rain ane rysm& P&'" Menorrha6ia3 pelvic ltraso nd showed terine fi5roid last year Medication A OC1 >for menorrha6ia@ Aller6ies A Befle; ca ses rash &a(its" "on3smo-er Care 6lass of wine CA?E A "o recreational dr 6s Psychosocial" Sin6le% witho t se; al partner& Wor-s f ll time as an acco ntant& 'oes comm nity theater& F&'" Dather A alive and well Mother% a6e ,/% 'M Maternal a nt died of a r pt red 5rain ane rysm

!ESC IPTION OF PATIENT) PATIENT BE&A*IO ) AFFECT) MANNE ISMS

Attit de# Actively see-in6 help% appears worried a5o t her symptoms tho 6h it is not apparent why& Will not openly state her concern >of 5rain ane rysm@ nless as-ed& 7f the st dent tries to reass re her witho t -nowin6 what her concern is% she will say# EB t how do yo -now it is not somethin6 serio sFG Appearance# Well dressed% o5vio sly concerned&

Boston University School of Medicine EOTYA Sample Case Woman with Headaches

PATIENT !EMO+ AP&ICS

.@ 9@ )@ 8@ /@ A6e ran6e# )+3/+ ?ender# female Cace# any Socioeconomic level# middle class Ed cational level# two3year colle6e de6ree

AN, -UESTIONS PATIENT #ILL CONSISTENTL, AS. O C&ALLEN+ES T&AT PATIENT #ILL P ESENT TO E/AMINE
E7 have to do somethin6 a5o t these headaches&G ECan yo fi6 re o t what is wron6FG

P OPS NEE!E! FO CASE

His al ac ity testin6 card

Boston University School of Medicine EOTYA Sample Case Woman with Headaches

OPENIN+ SCENA IO Na$e" A0e" CC" $a ra 4ac-son )2 headache

Yo are wor-in6 with a primary care doctor at a nei6h5orhood health center& Yo r ne;t patient is $oretta 4amison% a )23year3old woman who presents for eval ation of headache& *ital Si0ns" B1 ..+*:+ Heart Cate ,9 5pm Temperat re 22&.ID You ha$e !% inutes to:

O5tain a foc sed and relevant history& 1erform a foc sed and relevant physical e;amination 1!O NOT EPEAT *ITAL SI+NS2& Co nsel the patient where appropriate& 'isc ss yo r findin6s and yo r dia6nostic impressions with the patient& 'isc ss yo r initial mana6ement plans with the patient& You ha$e !" inutes to: After seein6 the patient% complete the related paperwor-& You ha$e !" inutes to: Cet rn to the room to receive feed5ac- from the patient&

Boston University School of Medicine EOTYA Sample Case Woman with Headaches
&ISTO , CONTENT C&EC.LIST .& 9& )& 8& /& K& ,& :& 2& .+& ..& .9& .)& .8& ./& .K& .,& .:& .2& 9+& 9.& 99& 9)& 98& 9/& 9K& 9,& E;aminer introd ces self and e;plains his*her role or position& E;aminer as-s or ses patientJs name& Chief complaint# headache Onset A . month 1attern# worsenin6 Settin6# late in the day Associated symptoms# 5l rry vision L ality# frontal press re Yesterday ,*.+ ' ration 1ertinent positive# felt feverish yesterday 1ertinent positive# nec- soreness 1ertinent positive# na sea 1ertinent positives# increased coffee cons mption 1ertinent positives# =o5 stress 1ertinent ne6atives# no vis al a ra Alleviatin6 factors# Tylenol Alleviatin6 factors# rest 1H; A menorrha6ia Medication A OC1 Aller6ies# Befle; 3 rash "ot se; ally active Occ pational history A acco ntant DH; 'ia6nostic impression disc ssed with patient Elicited concern# ane rysm 7nitial mana6ement plans disc ssed with patient

Boston University School of Medicine EOTYA Sample Case Woman with Headaches

E'cer3ted fro$ the MASTE INTE *IE# ATIN+ SCALE

&'ass 'edical School Standardi(ed )atient )rogra
M/N The interviewer str ct res the interview with a clear 5e6innin6% a middle% and end& 7n the openin6% the interviewer identifies himself and his role and determines the a6enda for the interview& The 5ody of the inter3 view consists of a series of topics >chief complaint% past history% etc&@ p rs ed systematically& The interview is closed >O ality of clos re is = d6ed later@& M8N ITEM 4 5 O +ANI6ATION M)N The interviewer seems to follow systematically a series of topics or a6enda items most of the time& However% parts of the interview mi6ht 5e 5etter or6ani<ed& OC The 5ody of the interview is or6ani<ed 5 t there is no clear openin6 or no clos re& M9N M.N The interview seems dis=ointed and nor6ani<ed&

M/N The interviewer tili<es tran3 sitional statements when pro3 6ressin6 from one s 5section to another which ass re the patient that the information 5ein6 so 6ht is necessary and relevant% e&6&P"ow 7Jm 6oin6 to as- yo some O estions a5o t yo r family 5eca se we find that there are certain diseases that occ r amon6 5lood relatives% and it will help s to -now what health ris-s are in yo r family&P

ITEM 7 5 T ANSITIONAL STATEMENTS M8N M)N M9N The interviewer sometimes intro3 d ces s 5sections with effective transitional statements% 5 t fails to do so at other times& Some of the transitional statements sed are lac-in6 in O ality% e&6&% P"ow 7Jm 6oin6 to as- yo some O estions a5o t yo r family&P

M.N The interviewer pro6resses from one s 5section to another in s ch a manner that the patient is left with a feelin6 of ncertainty as to the p rpose of the O estions& >"o transitional statements are made&@

ITEM 8 5 -UESTIONIN+ S.ILLS 5 T,PE OF -UESTION M/N M8N M)N M9N M.N The interviewer 5e6ins information The interviewer often fails to The interviewer as-s many 6atherin6 with an open3ended 5e6in a line of inO iry with why O estions% m ltiple O estion& This is followed p 5y open3ended O estions 5 t rather O estions% or leadin6 more specific or direct O estions only employs specific or direct O estions% e&6&% PYo r which allow him to foc s in on the O estions to 6ather information& child has had diarrhea% pertinent positive and ne6ative OC hasnJt heFP& PYo want yo r points that need f rther ela5oration& The interviewer ses a few leadin6% child to have a tetan s shot% each ma=or line of O estionin6 is why% or m ltiple O estions& donJt yo FJ 5e6 n with an open3ended O estion& "o poor O estions are sed&

Boston University School of Medicine EOTYA Sample Case Woman with Headaches
ITEM 9 5 -UESTIONIN+ S.ILLS 5 SUMMA I6IN+ M/N The interviewer s mmari<es the data o5tained at the end of each ma=or line of inO iry or s 53 section >i&e&% History of 1resent 7llness% 1ast Medical History@% in an effort to verify 0*or clarify the information or as a preca tion to ass re that no important data are omitted& M8N M)N The interviewer sometimes s m3 mari<es the data at the end of some lines of inO iry 5 t fails to do it consistently or completely& M9N M.N The interviewer fails to s mmari<e any of the data o5tained&

ITEM : 5 -UESTIONIN+ S.ILLS 5 LAC. OF ;A +ON M/N The interviewer as-s O estions and provides information in lan6 a6e which is easily nderstoodQ content is free of diffic lt medical terms and =ar6on& 7f =ar6on is sed% the words are immediately defined for the patient& $an6 a6e is sed that is appropriate to the patientJs level of ed cation& M8N M)N The interviewer occasionally ses medical =ar6on d rin6 the inter3 view% failin6 to define the medical terms for the patient n3 less specifically reO ested to do so 5y the patient& M9N M.N The interviewer ses diffic lt medical terms and =ar6on thro 6ho t the interview&

ITEM 4< 5 APPO T5FACILITATI*E BE&A*IO M/N The interviewer p ts the patient at ease and facilitates com3 m nication 5y sin6 primarily non3 ver5al techniO es incl din6 6ood eye contact% rela;ed% open 5ody lan6 a6e% an appropriate facial e;pression and tone of voice% and 5y eliminatin6 physical 5arriers >s ch as sittin6 5ehind the des- or standin6 over a patientJs 5ed@& Her5al c ein6 > h3h h% yes% 6o on&&@ or echoin6 a few words of the patientJs last sentence is also sed& When appropriate% physical contact is made with the patient& M8N M)N The interviewer ma-es some se of facilitative techniO es 5 t co ld 5e more consistent& One or two techniO es are not sed effectively% e&6&% freO ency of eye contact co ld 5e increased or some physical 5arrier may 5e present& M9N M.N The interviewer ma-es no attempt at p ttin6 the patient at ease& Body lan6 a6e is ne6ative or closed or an annoyin6 mannerism >foot or pencil tappin6@ intr des on the interview& Eye contact is not attempted&

Boston University School of Medicine EOTYA Sample Case Woman with Headaches
ITEM 4= 5 PATIENT>S PE SPECTI*E M/N The interviewer elicits the patientJs perspective on his illness% in3 cl din6 his 5eliefs and concerns a5o t its etiolo6y and his nder3 standin6 a5o t its treatment and pro6nosis& The interviewer specifically O estions for hidden concerns& M8N M)N The interviewer elicits only some of the patientJs perspective on his illness or his hidden concerns& M9N M.N The interviewer fails to elicit the patientJs perspective% or to elicit any hidden concerns&

ITEM 4? 5 APPO T 5 ENCOU A+EMENT OF -UESTIONS M/N The interviewer enco ra6es the patient to as- O estions a5o t the topics disc ssed& He also 6ives the patient the opport nity to 5rin6 p additional topics or points not covered in the interview% e&6&% PWeJve disc ssed many thin6s& Are there any O estions yo mi6ht li-e to as- concernin6 yo r pro5lemF 7s there anythin6 else at all that yo wo ld li-e to 5rin6 pFP This is s ally done at the end of the interview& M8N M)N The interviewer provides the patient with the opport nity to disc ss any additional points or as- any additional O estions 5 t neither enco ra6es nor dis3 co ra6es him% e&6&% P'o yo have any O estionsFP& This is s ally done at the end of the interview& M9N M.N The interviewer fails to provide the patient with the opport nity to as- O estions or disc ss additional points& The interviewer may disco ra6e the patientJs O estions% e&6&% PWeJre o t of time&P

Boston University School of Medicine EOTYA Sample Case Woman with Headaches
P&,SICAL E/AMINATION C&EC.LIST .& 9& )& 8& /& K& ,& :& 2& .+& ..& .9& .)& Wash hands His al ac ity A near testin6 His al ac ity A proper techniO e E;amine e;ternal eyes >m st se li6ht so rce@ E;traoc lar movements D nd scopic e;am# performed D nd scopic e;am# proper techniO e Assess for sin s tenderness 5y palpation or perc ssion E;amine nasal m cosae >m st se li6ht so rce and ear spec l m@ E;amine teeth E;amine posterior pharyn; >say EahhhG@ "ec- A palpation >mild diff se tenderness@ "ec- A COM

Boston University School of Medicine EOTYA Sample Case Woman with Headaches You now have ten minutes to complete the write-up. .& S ccinctly s mmari<e the patient!s H7STOCY incl din6 pertinent positives and ne6atives relatin6 to the presentin6 complaint&

9& S mmari<e yo r 1HYS7CA$ ERAM findin6s incl din6 pertinent positives and ne6atives relatin6 to the presentin6 complaint&

)& Create a '7DDECE"T7A$ '7A?"OS7S of p to >5 t not more than@ five items& .(((((((((((((((((((((( 9(((((((((((((((((((((( )(((((((((((((((((((((( 8(((((((((((((((((((((( /(((((((((((((((((((((( 8& What wo ld yo do ne;t to EHA$UATE this patientF $ist p to% 5 t not more than% five recommendations& These may incl de la5oratory wor-% dia6nostic tests% ima6in6 st dies% or any test that yo mi6ht ordinarily do in the co rse of a physical e;amination& .(((((((((((((((((((((( 9(((((((((((((((((((((( )(((((((((((((((((((((( 8(((((((((((((((((((((( /((((((((((((((((((((((

Boston University School of Medicine EOTYA Sample Case Woman with Headaches LAU A ;AC.SON" PEP SCO ES&EET
.& 9& )& 8& /& K& ,& :& 2& .+& ..& .9& .)& .8& ./& .K& .,& .:& .2& 9+& 9.& 99& 9)& 98&

9/& 9K& 9,& 9:& 92& )+& ).& )9& ))& )8&

*istory CC# frontal headache Onset# . month 1ro6ression# worsenin6 $ocation# frontal Associated symptom# na sea Associated symptom# 5l rry vision Associated symptom# nec- soreness Associated symptom# low 6rade fever Alleviatin6 factor# Tylenol 1ertinent positives# cold symptoms 1ertinent positives# =o5 stress 1ertinent positives# increased coffee cons mption 1ertinent ne6atives# no ne rolo6ical or vis al symptoms 1H;# Menorrha6ia Aller6ies A Befle; ca ses rash Meds A OC1 DH; A 5rain ane rysm )+ findings: ?eneral description His al ac ity 1 pillary e;am D nd scopic e;am "o sin s tenderness 'ental e;am "ec- s pple ,ifferential ,iagnosis Tension headache >) points@ Caffeine withdrawal headache >) points@ Eye strain >9 points@ Mi6raine >9 points@ Sin s >9 points@ Brain t mor >. points@ Brain ane rysm >. points@ 1se dot mor cere5ri >9 point@ Menin6itis >. point@ Anemia >. point@ ,iagnostic -or.-up Dormal Ophthalmolo6y eval ation >accept 'DE@ CBC Head CT MC7 5rain $ m5ar p nct re ?l cose

Boston University School of Medicine EOTYA Sample Case Woman with Headaches

La@ra ;ackson5 EOT,A Sa$3le Case #rite5@3

.& S ccinctly s mmari<e the patient!s H7STOCY incl din6 pertinent positives and ne6atives relatin6 to the presentin6 complaint& )2 year old woman c*o headache H17# 7ntermittent press re type headache worsenin6 over two months% 93);* wee-% 83/*.+ on pain scale% lastin6 an ho r& Most severe HA yesterday assoc with na sea% and mild pain persists today& Sna sea S5l rry vision Afever 1t concern# ane rysm& 1H;# Menorrha6ia Meds# OC1 Aller6ies# Befle;3T rash Ha5its# no ci6s% CA?E3 DH;# maternal a nt with h; cere5ral ane rysm 1sychosocial# sin6le% not se; ally active% wor-s as acco ntant 9& S mmari<e yo r 1HYS7CA$ ERAM findin6s incl din6 pertinent positives and ne6atives relatin6 to the presentin6 complaint& Well dressed% in mild distress from headache Eyes# His al ac ity 9+*9+ at .: inches OU% 1ECC$% no scleral in=ection f nd scopic e;am with normal veno s p lsations notes% no AH nic-in6 "ose# no sin s tenderness% no dischar6e noted Oropharyn;# post pharyn; witho t erythema "ec-# s pple )& Create a '7DDECE"T7A$ '7A?"OS7S of p to >5 t not more than@ five items& .((((Mi6raine 9((((Tension3type HA )((((Brain T mor 8((((Anemia /((((7ncreased CSD press re d e to OC1 se 8& What wo ld yo do ne;t to EHA$UATE this patientF $ist p to% 5 t not more than% five recommendations& These may incl de la5oratory wor-% dia6nostic tests% ima6in6 st dies% or any test that yo mi6ht ordinarily do in the co rse of a physical e;amination& .(((((((Hct 9(((((((Head CT )((((((($ m5ar 1 nct re 8((((((($1 to meas re CSD press re /(((((((formal vis al ac ity testin6