Doorway information about patient
The patient is a 40-year-old woman who comes to the office due to increased urination.
Vital signs
Temperature: 36.7 C (98 F)
Blood pressure: 110/70 mm Hg
Pulse: 86/min
Respirations: 16/min
Basic differential diagnosis
Increased urine volume
Diabetes mellitus
Diabetes insipidus (central, nephrogenic)
Psychogenic polydypsia
Diuretic use
Hypercalcemia
Increased urinary frequency
Urinary tract infection
Overactive bladder
Excess caffeine intake
Vaginitis, urethritis

Question

Quizplus · Accepted Answer

The Answer is Instructions:
If the doctor asks you about anything other than these, just say "no," or provide an answer that a normal patient might give.
You are a 40-year-old woman complaining of increased urinary frequency.
History of present illness
Onset 2 months ago
Urinating 8-10 times during the day and 2-3 times a night
Increased urinary volume
Increased feeling of thirst for last month
Associated symptoms: Fatigue
4.5-kg (10-lb) weight loss (despite increased appetite)
No dysuria or urgency
No fever or chills
Past medical/family/social history
Bipolar disorder diagnosed 20 years ago
Minor head injury after falling off bicycle 3 months ago; seen in emergency department and discharged without intervention
No surgeries or hospitalizations
Medications: Lithium 60 mg twice daily
Medication allergies: None
Married, live with husband
2 pregnancies with normal vaginal delivery; both children are healthy
Both parents have type 2 diabetes mellitus; no siblings
Tobacco: No
Alcohol: No
Recreational drugs: No
Physical examination
HEENT:
PERRLA, EOMI
Visual fields intact
Heart:
Regular rate and rhythm
No murmurs, gallops, or rubs
Abdomen:
Soft and nontender with normal bowel sounds
No suprapubic or CVA tenderness
Neurologic:
Muscle strength 5/5 throughout
Sensation in tact in all 4 extremities
Reflexes 2+ in all 4 extremities
Checklist:
Following the encounter, check which of the following items were performed by the examinee.
History of present illness/review of systems
Asked about the onset of problem
Asked about the frequency of urination
Asked about nocturia
Asked about urine volume
Asked about burning on urination
Asked about urgency and hesitancy of urination
Asked about increased thirst and fluid intake
Asked about appetite and changes in weight
Asked about the trauma to the head
Past medical/family/social history
Asked about similar problems in the past
Asked about past medical issues, hospitalizations, and surgeries
Asked about psychiatric problems (history of bipolar disorder, schizophrenia)
Asked about current medications
Asked about medication allergies
Asked about family health (especially diabetes)
Asked about tobacco, alcohol, and drug use
Asked about occupation
Examination
Washed hands before examination
Examined without gown, not through gown
Examined mucous membranes
Examined heart and lungs
Tested muscle power in both upper and lower limbs
Tested sensation in the lower extremities
Tested reflexes in the lower extremities
Tested visual fields and examined fundus
Tested for suprapubic and costovertebral angle tenderness
Counseling
Explained physical findings and possible diagnosis
Explained further workup
Communication skills and professional conduct
Knocked before entering the room
Introduced self and greeted you warmly
Used your name to address you
Paid attention to what you said and maintained good eye contact
Asked open-ended questions
Asked nonleading questions
Asked one question at a time
Listened to what you said without interrupting
Used plain English rather than technical jargon
Used appropriate transition sentences
Used appropriate draping techniques
Expressed empathy and gave appropriate reassurances
Asked whether you had any concerns/questions
Differential diagnosis
Diabetes mellitus
Central diabetes insipidus
Nephrogenic diabetes insipidus (lithium side effect)
Psychogenic polydypsia
Hypercalcemia
Diagnostic study/studies
Fasting blood sugar
Urinalysis
Serum electrolytes (Na, K, Cl, Co2, BUN, Cr, and calcium)
Urine and serum osmolality
Case 16 Patient Notes
The following represents a typical note for this patient encounter. The details may vary depending on the information given by the simulated patient.
History: Describe the history you just obtained from this patient. Include only information (pertinent positives and negatives) relevant to this patient's problem(s).
40-yo woman with 2 months of polyuria, polydipsia, nocturia, and polyphagia.
2-3 months of 4.5-kg (10-lb) weight loss with fatigue.
No dysuria or urinary urgency.
ROS: No fever or chills
PMHx: Bipolar disorder diagnosed 20 years ago; minor head trauma 3 months ago, seen in emergency department and discharged without intervention
PSHx: None
Meds: Lithium 600 mg 2 times daily
Allergies: None
FHx: Father and mother have diabetes
SHx: No history of tobacco or alcohol use
Physical examination: Describe any positive and negative findings relevant to this patient's problem(s). Be careful to include only those parts of the examination performed in this encounter.
Vital signs: Temperature, 36.7 C (98.1 F); blood pressure, 110/70 mm Hg; pulse, 86/min; and respirations,16/min
HEENT: PERRLA, EOMI, intact visual fields
Heart: RRR without murmurs, gallops, or rubs
Abdomen: Nontender without suprapubic tenderness, no CVA tenderness
Neurologic: Muscle strength 5/5 throughout, sensation grossly intact in bilateral lower extremities, DTR 2+ in bilateral lower extremities
Data interpretation: Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patient's complaint(s). List your diagnoses from most to least likely. For some cases, fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from the history and the physical examination (if present) that support each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis (eg, restricted physical examination maneuvers, laboratory tests, imaging, ECG).
Diagnosis #1: Diabetes mellitus

Instructions: <strong>If the doctor asks you about anything other than these, just say no, or provide an answer that a normal patient might give.</strong> You are a 40-year-old woman complaining of increased urinary frequency. <strong>History of present illness</strong> Onset 2 months ago Urinating 8-10 times during the day and 2-3 times a night Increased urinary volume Increased feeling of thirst for last month Associated symptoms: Fatigue 4.5-kg (10-lb) weight loss (despite increased appetite) No dysuria or urgency No fever or chills <strong>Past medical/family/social history</strong> Bipolar disorder diagnosed 20 years ago Minor head injury after falling off bicycle 3 months ago; seen in emergency department and discharged without intervention No surgeries or hospitalizations Medications: Lithium 60 mg twice daily Medication allergies: None Married, live with husband 2 pregnancies with normal vaginal delivery; both children are healthy Both parents have type 2 diabetes mellitus; no siblings Tobacco: No Alcohol: No Recreational drugs: No <strong>Physical examination</strong> HEENT: PERRLA, EOMI Visual fields intact Heart: Regular rate and rhythm No murmurs, gallops, or rubs Abdomen: Soft and nontender with normal bowel sounds No suprapubic or CVA tenderness Neurologic: Muscle strength 5/5 throughout Sensation in tact in all 4 extremities Reflexes 2+ in all 4 extremities Checklist: Following the encounter, check which of the following items were performed by the examinee. <strong>History of present illness/review of systems</strong> Asked about the onset of problem Asked about the frequency of urination Asked about nocturia Asked about urine volume Asked about burning on urination Asked about urgency and hesitancy of urination Asked about increased thirst and fluid intake Asked about appetite and changes in weight Asked about the trauma to the head <strong>Past medical/family/social history</strong> Asked about similar problems in the past Asked about past medical issues, hospitalizations, and surgeries Asked about psychiatric problems (history of bipolar disorder, schizophrenia) Asked about current medications Asked about medication allergies Asked about family health (especially diabetes) Asked about tobacco, alcohol, and drug use Asked about occupation <strong>Examination</strong> Washed hands before examination Examined without gown, not through gown Examined mucous membranes Examined heart and lungs Tested muscle power in both upper and lower limbs Tested sensation in the lower extremities Tested reflexes in the lower extremities Tested visual fields and examined fundus Tested for suprapubic and costovertebral angle tenderness <strong>Counseling</strong> Explained physical findings and possible diagnosis Explained further workup <strong>Communication skills and professional conduct</strong> Knocked before entering the room Introduced self and greeted you warmly Used your name to address you Paid attention to what you said and maintained good eye contact Asked open-ended questions Asked nonleading questions Asked one question at a time Listened to what you said without interrupting Used plain English rather than technical jargon Used appropriate transition sentences Used appropriate draping techniques Expressed empathy and gave appropriate reassurances Asked whether you had any concerns/questions <strong>Differential diagnosis</strong> Diabetes mellitus Central diabetes insipidus Nephrogenic diabetes insipidus (lithium side effect) Psychogenic polydypsia Hypercalcemia <strong>Diagnostic study/studies</strong> Fasting blood sugar Urinalysis Serum electrolytes (Na, K, Cl, Co2, BUN, Cr, and calcium) Urine and serum osmolality <strong>Case 16 Patient Notes</strong> <strong>The following represents a typical note for this patient encounter. The details may vary depending on the information given by the simulated patient.</strong> <strong>History:</strong> Describe the history you just obtained from this patient. Include only information (pertinent positives and negatives) relevant to this patient's problem(s). 40-yo woman with 2 months of polyuria, polydipsia, nocturia, and polyphagia. 2-3 months of 4.5-kg (10-lb) weight loss with fatigue. No dysuria or urinary urgency. ROS: No fever or chills PMHx: Bipolar disorder diagnosed 20 years ago; minor head trauma 3 months ago, seen in emergency department and discharged without intervention PSHx: None Meds: Lithium 600 mg 2 times daily Allergies: None FHx: Father and mother have diabetes SHx: No history of tobacco or alcohol use <strong>Physical examination:</strong> Describe any positive and negative findings relevant to this patient's problem(s). Be careful to include only those parts of the examination performed in this encounter. Vital signs: Temperature, 36.7 C (98.1 F); blood pressure, 110/70 mm Hg; pulse, 86/min; and respirations,16/min HEENT: PERRLA, EOMI, intact visual fields Heart: RRR without murmurs, gallops, or rubs Abdomen: Nontender without suprapubic tenderness, no CVA tenderness Neurologic: Muscle strength 5/5 throughout, sensation grossly intact in bilateral lower extremities, DTR 2+ in bilateral lower extremities <strong>Data interpretation:</strong> Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patient's complaint(s). List your diagnoses from most to least likely. For some cases, fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from the history and the physical examination (if present) that support each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis (eg, restricted physical examination maneuvers, laboratory tests, imaging, ECG). <strong>Diagnosis #1: Diabetes mellitus</strong> <strong>Diagnosis #2: Diabetes insipidus</strong> <strong>Diagnosis #3: Psychogenic polydipsia</strong>

Diagnosis #2: Diabetes insipidus

Diagnosis #3: Psychogenic polydipsia

Doorway Information About Patient