Doorway information about patient
The patient is a 50-year-old man who comes to the office due to bilateral leg pain.
Vital signs
Temperature: 36.7 C (98 F)
Blood pressure: 140/80 mm Hg
Pulse: 78/min
Respirations: 20/min
Basic differential diagnosis
Bilateral pain
Atherosclerotic vascular disease
Lumbar spinal stenosis
Diabetic polyneuropathy
Radiculopathy due to spinal disease
Medications, such as statins
Trauma
Thromboangiitis obliterans
Unilateral pain
Cellulitis/myofasciitis
Deep vein thrombosis
Rupture of Baker cyst
Osteomyelitis
Radiculopathy/sciatica
Pathological fracture of the bone

Question

Doorway information about patient
The patient is a 50-year-old man who comes to the office due to bilateral leg pain.
Vital signs
Temperature: 36.7 C (98 F)
Blood pressure: 140/80 mm Hg
Pulse: 78/min
Respirations: 20/min
Basic differential diagnosis
Bilateral pain
Atherosclerotic vascular disease
Lumbar spinal stenosis
Diabetic polyneuropathy
Radiculopathy due to spinal disease
Medications, such as statins
Trauma
Thromboangiitis obliterans
Unilateral pain
Cellulitis/myofasciitis
Deep vein thrombosis
Rupture of Baker cyst
Osteomyelitis
Radiculopathy/sciatica
Pathological fracture of the bone

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 50-year-old man with bilateral leg pain.
History of present illness
Onset 2 months ago
Pain started gradually and has become progressively worse
Throbbing pain with 5-6/10 severity
Located in the calf muscles, no radiation
Worse with walking, running, and prolonged standing
Better while sitting and at rest
No history of trauma
Review of systems
No fever
No back pain
No weakness, numbness, or tingling in the legs
No sexual or bladder symptoms
Past medical/family/social history
Diabetes for the past 3 years, controlled by diet
High cholesterol
No surgeries
Medications: Simvastatin 40 mg daily at bedtime
Allergies: No
Father died at age 65 of a stroke; mother and 2 siblings are healthy
Occupation: Postal worker
Married, live with wife
Tobacco: 2 packs a day for past 30 years
Alcohol: Occasional beer
Recreational drugs: No
Physical examination
Abdomen:
No bruits
Extremities:
Pulses 2+ and symmetrical in bilateral lower extremities
Musculoskeletal:
Negative Homans sign
No calf tenderness to palpation bilaterally
Neurologic:
Motor strength 5/6 in both lower extremities
Grossly intact sensation
Deep tendon reflexes 2+ symmetrically
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 location and radiation of pain
Asked about the onset of pain
Asked about whether it is continuous or intermittent pain
Asked about the intensity of pain
Asked about the quality of pain
Asked about the course of pain over time
Asked about any aggravating or relieving factors
Asked about rest pain
Asked about swelling of the legs
Asked about sensory changes (such as numbness) and paresthesia
Asked about any weakness of the legs
Asked about any history of back pain
Asked about fever
Asked about trauma to the legs
Asked about other joint pain
Asked about recent surgeries or prolonged immobilization
Asked about impotence
Past medical/family/social history
Asked about similar episodes in the past
Asked about past medical issues (especially high blood pressure, diabetes, high cholesterol, disc prolapse)
Asked about current medications
Asked about medication allergies
Asked about family health (especially history of blood clots)
Asked about tobacco, alcohol, and recreational drug use
Asked about occupation
Examination
Washed hands before examination
Examined without gown, not through the gown
Examined calf tenderness
Elicited Homans sign
Checked pulses in both legs and arms
Listened for bruit at the distal aorta, iliac, or femoral arteries
Checked sensation in both legs
Checked reflexes in both legs
Checked for vibration sense in both legs
Counseling
Explained physical findings and possible diagnosis
Explained further workup
Discussed lifestyle modifications, including quitting smoking
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
Thromboangiitis obliterans
Atherosclerotic vascular disease
Drug induced (statins)
Diabetic polyneuropathy
Diagnostic study/studies
Creatinine kinase
Blood sugar and hemoglobin A1c
Lipid profile
Arterial doppler study of the lower extremities
Duplex venous ultrasound of lower limbs
CBC with differential
Spine MRI
Case 20 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).
50-yo man with 2 months of worsening bilateral leg pain.
Throbbing pain mainly over the calf muscles made worse with walking, running, and prolonged standing.
Symptom improvement with rest and sitting.
ROS: No pain at rest, fever, trauma, swelling, back pain, weakness, sexual difficulties, numbness, or tingling in legs
PMHx: Diabetes for 3 years under diet control, hypercholesterolemia
PSHx: None
Meds: Simvastatin 40 mg daily at bedtime
Allergies: None
FHx: Father died at age 65 of stroke; mother and 2 siblings are healthy
SHx: 2 PPD smoker for past 30 years, occasional 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 examination performed in this encounter.
Vital signs: Temperature, 36.7 C (98.1 F); blood pressure, 140/80 mm Hg; pulse, 78/min; and respirations, 20/min
Abdomen: No bruits
Extremities: Pulses 2+ and symmetrical in bilateral lower extremities
Musculoskeletal: Negative Homans sign, no calf tenderness to palpation bilaterally
Neurologic: Bilateral lower extremities with 5/5 motor strength, intact vibratory sensation and proprioception, and DTR 2+
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: Drug-induced (statin) myopathy

Diagnosis #2: Atherosclerotic peripheral vascular disease

Diagnosis #3: Diabetic polyneuropathy

Doorway Information About Patient