Basic Case Instructions

For each of the following cases, pick a student to elicit from you as the facilitator patient the non-ROS
portions of the history (i.e. CC, HPI, PMH, SH and FH) that they were to memorize for this week. The
patient scripts are outlined below and will all represent VERY basic CV concepts because these students
should have just recently reviewed VERY basic CV anatomy. Change student clinicians with each case.
After the student who obtains the basic history from the facilitator please do the following after each
case:

Ask the student clinician to provide a brief oral report about the information they just collected
to mimic an oral staffing procedure like they will experience on rotations.
Ask the student clinician and other students in the room whether or not any component of the
history was missed and/or if any information was reported incorrectly in the oral report.
Ask the students to explain why certain questions in the history are asked (i.e. why do clinicians
want/need to elicit these answers). Choose the questions about which you will ask at your
discretion. For example, you may ask, Why is it helpful to ask about associated symptoms? or
Why do you care what the rate of progression of the disease process is? Ask the students to
provide feedback regarding the professional demeanor of the student clinician. What did they
do well? What could they have done better? Did they speak too quickly or too slowly? Did they
appear unsure of what to ask or how? Did they look the patient in the eye and display empathy?
Ask the case-specific questions listed for each case. See below for details.

Case #1
Case Specific Questions
1) What causes pain?
2) Of what diagnostic value is it to know that the pain started suddenly?
3) What is pallor? The students should look this up if they dont know. Given the answer to the
above question does this help narrow diagnostic possibilities? Explain?
4) What do paresthesia and paralysis mean? The students should look this up if they dont know.
Given the answer to the above question does this help narrow diagnostic possibilities? Explain?
5) What is atrial fibrillation? The students should look this up if they dont know. Given the answer
to the above questions does this help narrow diagnostic possibilities? Explain?
6) What is a pack year? Of what significance is this information?
Case #2
See Basic Case Instructions
Case Specific Questions
1) Assuming this patients symptoms are from a local vascular compromise, do the symptoms
suggest impaired venous or arterial circulation? Explain.
2) Why does the discoloration have a bluish tint?
Repeat for Group #2
Case #3

See Basic Case Instructions

Case Specific Questions
1)
2)
3)
4)

What is the medical term for uncomfortable breathing? Why does this sensation arise?
What is a differential diagnosis? What is the differential diagnosis for acute dyspnea?
Explain why a blood clot in a peripheral vein tends to end up in the lungs and not the brain.
What happens to blood while it travels through the lungs? If this process is impeded, what will
the consequence be to blood leaving the lungs and how will that result in dyspnea?
Discussion Topic
Discussion Topic: Cardiovascular and Peripheral Vascular Review of Systems
Heart and blood vessels:
Do you have any chest pain or distress?
If yes, ask the questions OLD CARTS AP questions just like you would for the HPI.
Do you have any palpitations, i.e. irregular heartbeats?
Do you have any shortness of breath or uncomfortable breathing?
How many pillow do you sleep on at night?
Do you have any swelling?
Do you have a history of high blood pressure or previous myocardial infarction?
How much exercise can you do before you feel too fatigued to go on?
Have you ever had an EKG or other heart tests? When? Where?
Peripheral vasculature:
Do you have any pain in your legs with walking or activity?
If yes ask about frequency and severity.
Do you seem to bleed or bruise more easily than your family or friends?
Have you ever suffered from blood clots?
Depending on time, discuss the rationale for asking the above ROS questions.
Homework Assignment
Memorize the CV and Peripheral Vascular components of the ROS. Be prepared for a comprehensive
history quiz next week potentially including all of the history components reviewed so far.

Case 1
CC: Arm Pain

History:
Onset: Sudden onset
Location Arm: Whole right Arm
Duration: 2 hours

Characteristic: Throbbing/Boring
Aggravating Factors: None
Relieving Factors: None
Timing: Continuous

Associated Symptoms: Hand has changed color, less pink

Progression: Started out with a little bit of pain but has gotten worse over time

DDx/Exploring History:
Given the sudden onset of the pain its not cancer
Possible Trauma: Ask about what was happening at this time
o Pt states that she was working on her journal at the time of onset
o Emotional states during the time she was writing journal:
Pt did not answer the question the first time
Pt did not answer when asked how hard she was writing in her journal
She states she is left handed
MI radiation (referred pain): blockage of coronary ateries
o Ask pt if they have chest pain
Pt states no but reports tachycardia
She states that the tachycardia is something that happens regularly
Asked pt if she did anything that required her to exert herself and she says no
Ask pt if she has had any family history of cardiac issues
Pt's father died of aortic aneurysm
Pt's mother died of MI
Pinched nerve: The pain should be shooting pain
o Given that the pt stated that it was throbbing pain we can rule it out
o Ask about impaired movement given the function of nerves:
Pt states she can move her fingers but not her arm
o Ask about numbness and tingling:
Pt states she has loss of sensation in her fingers (whole fingers): Assess which
dermatomes are involved
Arterial Clot:
o EKG: negative for infarction but shows AFib
o Troponin blood test: released in blood when the cardiac cells die: negative
o Stress test: Test heart function at rest/under stress (treadmill or pharmaceutical): negative
o Check the pt's pulse: if there is a clot blocking the artery there will be no pulse
Case 1 Questions:
3. What is pallor? Loss of color; sign of arterial insufficiency; not having oxygenated blood getting to
the tissue
4. Paresthesia: Numbness; due to muscles not being fed oxygen from clot

5. Atrial fibrillation: Irregular firing of the Atria; quivering of the heart; effects atrial output and
ventricular output
a. Body produces clotting factors naturally but if there is limited flow this could result in a
blood clot
b. Can form in the atria and travel to arteries in the body
c. Coumadin is something that ppl take for Afib; its a anti-coagulant
6. Pack-year: How many packs you smoke per day times how many years
a. Can lead to plaque in the arteries

Case 2:
CC: Left leg pain
History:
Onset: One week ago
Location: Left leg pain from knee down
Duration: One week ago
Characteristic: Achey pain
Aggravating Factors: Running makes the pain and swelling worse; having it hang down making it
worse
Relieving Factors: Better when he wakes up in the morning
Timing: Constant pain
Associated Symptoms: None
Progression: Gradually worsened overtime
DDx/Exploring History:
Venous oriented given that there has been edema (leg swelling)
o Capillary beds: between arteries and veins; perforations allow for the fluid to travel into the
interstitial space
o Swelling shows its venous because arteries are delivering blood and fluid but cant leave area
due to blockage in veins leaving area
o Any recent long travel:
Car for 4 days
MVA
Hospitalized after and did not move for a long time
Trauma:
o No recent trauma to the leg
Allergic Reaction:
o No environmental allergies
o No over the counter med allergies
o Penicillin allergy
o No itchiness
o No erythema
o Can rule out allergic reaction
Infection:
o Fever: pt states no
o Red streaks that run from site of infection is lymphangitis

Final Diagnosis: Venous Clot

Case 3:
CC: Swelling in the left leg/swollen ankle/SOB
History:
Onset: 2 weeks
Location: Left calf
Duration: 2 weeks but SOB this morning when she woke up
Characteristic: (DIDNT SAY)
Aggravating Factors: Walking
Reliving Factors: (DIDN'T SAY)
Timing: Constant pain
Associated symptoms: SOB gives some chest pain
Progression: (DIDNT' SAY)
SHx:

Pt smokes 2 packs a day for 10 years

DDx/Exploring History:
SOB:
o Impaired flow beyond pulmonary capillaries
o COPD: No because its acute-on-chronic
Barrel chested
Pursed lip breathing
Look at scalene muscles
o Physical exertion
o Asthma
o Do spirometry to test the pt: test to see the pt's functional lung capacity
Key feature of emphysema: lower expiration volume than normal
DVT:
o Blood clot in the veins; it breaks off from the veins and travels through the heart and then to
the lungs
PE: Pulmonary Embolism
o The blood clot from DVT having traveled to the lungs

HOMEWORK: MEMORIZE THE FOLLOWING

Heart and blood vessels:
Do you have any chest pain or distress?
If yes, ask the questions OLD CARTS AP questions just like you would for the HPI.
Do you have any palpitations, i.e. irregular heartbeats?

Do you have any shortness of breath or uncomfortable breathing?

How many pillow do you sleep on at night?
Do you have any swelling?
Do you have a history of high blood pressure or previous myocardial infarction?
How much exercise can you do before you feel too fatigued to go on?
Have you ever had an EKG or other heart tests? When? Where?
Peripheral vasculature:
Do you have any pain in your legs with walking or activity?
If yes ask about frequency and severity.
Do you seem to bleed or bruise more easily than your family or friends?
Have you ever suffered from blood clots?
Depending on time, discuss the rationale for asking the above ROS questions.