Examinee instructions
Opening scenario
Steven Collins, a 45-year-old male, comes to the doctor's office because of weight gain.
Vital signs
- Temperature: 97.7°F (36.5°C)
- Blood pressure: 130/80 mm Hg
- Heart rate: 60/min
- Respirations: 14/min
Examinee tasks
- Take a focused history.
- Perform a relevant physical examination (do not perform corneal reflex, breast, pelvic/genitourinary, or rectal examinations).
- Explain the preliminary differential diagnoses and initial workup plan to the patient.
- Write the patient notes after leaving the room.
Patient encounter
Patient instructions
- Speak slowly and with a monotonous voice. Do not show any emotions (e.g., smile).
- You are not aware of the meanings of medical terms (e.g., polysomnography) and ask for clarification if the examinee uses them.
- Use the checklists below for history, physical examination, and communication and interpersonal skills.
Challenge: Ask “Why do I have to live?”
Focused history
Hovering over the speech bubbles in the lists below will reveal extra information about the adjacent term. However, clicking on links will cause you to navigate away from the current case, at which point your progress (i.e., your check marks) will be lost. If you do want more information on a subject, either open the link in a new tab or wait until you and your partner have finished the case and reviewed the check marks. Following the link to the patient note form will not interrupt your progress.
History of present illness
- Chief complaint
- I have gained at least 7–10 lbs.
- Onset
- It started about 2 months ago.
- Precipitating events
- I guess it started right after my wife left me. I am not sure if that has anything to do with it though?
- Previous episodes
- I was never skinny, but I have never gained this much weight in such a short amount of time. I think I weigh over 200 lbs now.
- Associated symptoms
- Well, now that you ask, I have also been feeling really tired – completely drained actually.
Review of systems specific to weight gain and fatigue
- Swelling of the ankles
- No.
- Fever/chills
- No.
- Rash/skin changes
- No.
- Chest pain
- No.
- Shortness of breath
- No.
- Bowel problems
- Yes, I have been constipated lately.
- Sleep problems
- Well, I wake up really early in the morning even though I am still tired. I just never feel refreshed. That is why I have been napping during the day lately.
- Appetite
- I have not had much of an appetite lately.
- Hair changes
- No.
- Voice changes
- No.
- Cold intolerance
- Now that you mention it, I have been feeling cold a lot lately.
- Mood
- I do not think I have really been happy since my wife left.
- Loss of interest
- I used to play poker with my friends but I do not go anymore. I would rather be by myself.
- Guilt/low self-esteem
- I am pretty sure it is my fault that my family fell apart. I just could not make my wife happy anymore.
- Low energy
- Yes, on top of always being tired, I also constantly feel exhausted. I do not even buy groceries anymore. Most days I just order take-out.
- Poor concentration
- Yes, I have a really hard time at work now, and my job was really the only thing that still kept me going.
- Psychomotor agitation or retardation
- No.
- Suicidality
- I have thought about it before. But I would not actually do it – at least not right now. I do not even have the energy. No, I have never tried to kill myself.
- Social support
- My sister watches out for me.
“SIG E CAPS”: Sleep (insomnia or hypersomnia), Interest loss (anhedonia), Guilt (low self-esteem), Energy (low energy or fatigue), Concentration (poor concentration or difficulty making decisions), Appetite (decreased appetite or overeating), Psychomotor agitation or retardation, and Suicidality!
Past medical history, family history, and social history
- Past medical history
- I have reflux.
- Allergies
- None.
- Medications
- None.
- Hospitalizations
- Never.
- Past surgical history
- None.
- Family history
- My family is really healthy even though we are all a little overweight.
- Work
- I am an insurance agent.
- Home
- I live by myself now. My wife moved out after the divorce, and we do not have any children.
- Alcohol
- Sometimes I have a beer or a glass of wine before going to bed. It makes it easier to fall asleep.
- Recreational drugs
- No, never.
- Tobacco
- No.
- Exercise
- I do not really like exercising, but even if I did, I doubt I would have the energy right now.
- Diet
- Whatever the delivery services around my house offer. A lot of pizza.
Focused physical examination
- Washed hands
- Used respectful draping
- Head, eyes, ears, nose, and throat examination
- Neck examination
- Cardiovascular examination
- Chest examination
- Extremities
- Skin examination
- Neurologic examination
Communication and interpersonal skills
Patient interaction
- Examinee knocked on the door.
- Examinee introduced him- or herself and identified his/her role.
- Examinee correctly used the patient's name.
- Examinee asked open-ended questions.
- Examinee listened attentively (did not interrupt the patient).
- Examinee showed interest in the patient as a person (i.e., appeared caring and showed respect).
- Examinee demonstrated the ability to support the patient's emotions (i.e., offered words of support, asked for clarification).
- Examinee discussed initial diagnostic impressions with the patient.
- Examinee explained the management plan.
- Examinee used non-medical terms and provided reasons for planned steps in management.
- Examinee evaluated the patient's agreement with the next diagnostic steps.
- Examinee asked about concerns or questions.
Counseling and challenge
- Examinee offered counseling on support options for weight and diet changes.
- Examinee reacted appropriately to challenge.
Suggested response to challenge: ”Mr. Collins, because of your question and the symptoms you are telling me about, I am concerned that you may be suffering from depression. Are you thinking about ending your life at this time? If you ever consider hurting yourself or ending your life, I would like for you to come to the emergency room immediately. If you cannot come to the emergency room, please call 911. I would also like to get you in touch with one of our social workers today so that they can provide you with some valuable resources. My door is also always open.”
Patient note
Further discussion
Patient note
Differential diagnoses
- Major depressive disorder (MDD): To diagnose MDD, a patient needs to fulfill 5 or more out of 9 criteria (SIGECAPS), one of which must be anhedonia or depressed mood, for at least 2 weeks at a time. This patient meets the criteria because he has had 2 months of depressed mood, loss of interest, feelings of guilt, low energy, poor concentration, and decreased appetite. In order to diagnose MDD, other differential diagnoses that can also present with depressive symptoms should be ruled out with diagnostic tests, especially since this patient presents with weight gain despite decreased appetite and cold intolerance, which would not be typical in MDD.
- Hypothyroidism: This patient presents with recent weight gain despite decreased appetite, fatigue, cold intolerance, constipation, possible hypertension, and poor concentration, which are all classic symptoms of hypothyroidism. Hypothyroidism is a very important differential diagnosis for MDD and thyroid function should always be assessed as part of the work-up for patients with suspected MDD. Given his depressed mood and thoughts of suicide in the past, however, MDD is slightly more likely in this patient.
- Obstructive sleep apnea (OSA): Not waking up rested, fatigue, daytime naps, depressive symptoms, and impaired concentration are typical features of OSA. Risk factors for OSA include obesity and alcohol consumption before going to bed, which are both seen in this patient. Moreover, this patient presents with possible hypertension, and OSA is a frequent cause of secondary hypertension. However, weight gain despite decreased appetite and cold tolerance make this diagnosis less likely.
Diagnostic studies
- Blood pressure measurement (24 hours): to confirm arterial hypertension
- Polysomnography: first-line diagnostic test for suspected OSA
- CBC: It is important to assess for anemia in patients with fatigue. OSA, on the other hand, can manifest with polycythemia.
- Electrolytes, calcium, magnesium: Electrolyte abnormalities can manifest as depression.
- TSH: TSH is the best initial step in suspected hypothyroidism.
Major depressive disorder is a clinical diagnosis; there is no no diagnostic study to confirm the condition. However, several diseases (e.g., hypothyroidism, anemia, electrolyte abnormalities) can present with depressive symptoms and should be ruled out before forming a definitive diagnosis.
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