Case-8: Tired All the Time
Case-8: Tired all the time
Patient Brief Record / Brief Scenario:
(Information for student about the case)
ü Patient Name: Nabeel
ü Age: 30 years
ü Occupation: Salesman at a computer shop
ü Not known to have any chronic illness
ü Today:
o BP: 120/78 mm Hg
o Pulse: 102 beat/minute
o Temperature 36.5 0C
Mr. Nabeel is a 30-year old, presented today with the complaint of feeling tired all the time.
TASK: (What is expected from a student?)
ü Take a focus history from this patient, to arrive at the most likely diagnosis.
ü Perform the relevant clinical examination
ü Inform the patient about the possible diagnosis.
ü Explain to the patient the management plan.
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Case-8: Tired all the time
Patient Brief Record / Brief Scenario:
(Information for the simulated patient)
ü Patient Name: Nabeel
ü Age: 30 years
ü Occupation: Salesman at a computer shop
ü Married but lives alone as the wife and two children 3 and five year old are in Philippine.
You are a 30-year-old man, who works as a salesman. Since few weeks you feel tired all the time.
Opening scenario: I feel tired all the time, doctor (You will admit only this information).
Tell your doctor about the following information only if specifically asked about:
ü Since few weeks you feel tired all the time.
ü When you clime staircase you feel slightly shortness of breath.
ü You live with your friends in a shared house.
ü Your family is in Philippine as you could not get them here, due to visa problem.
ü Usually, you do not cook at home, but you take milk and milk product in your food at home or some fast food stuff.
ü You usually take Brufen (Analgesic tablets) for aches and body pain on and off, as you have long standing duty at the shop.
ü No history of fever, coughing or vomiting blood.
ü No history of blood in stool or black stool.
ü No history of constipation, the bowel movement is normal
ü Not known to have any chronic disease.
ü No history of feeling low or chest tightness.
ü Your appetite and sleep pattern is normal.
ü Slight worried as family is abroad.
ü No history of specific diseases in family.
ü Non-smoker.
ü Your idea: it is something serious going on.
ü Your concern: You are worried that you may lose your job.
ü Your expectation: to get medication to treat your problem.
Doctor will perform a general examination for you.
Case-8: Tired all the time
1. Professional behavior
ü Introduces himself, and get the permission to take history and do examination
ü Starts with open ended question.
ü Develops the rapport with patient.
ü Do not interrupt the patient during history taking.
2. History Taking Skills:
ü Explore about the problem, by exploring different symptoms to differentiate, possibly, between different causes of tiredness including; nutritional (IDA) anemia, hypothyroidism, depression, and so forth.
ü Specially, screen about depression and hypothyroidism.
ü Dietary habit inquiry
ü Family history
ü Smoking
ü Medications (NSAID)
ü Social history (home or work stress…)
ü Ongoing problem/past history
ü Summarizes to the patient about the history taken from him.
ü Explored well Patient idea, concern and expectation
3. Clinical examination:
ü General Examination:
ü Vital signs
ü Looking for pallor in different sites; conjunctivae, mucous membrane, palms of the hands and finger nails.
Ø When the student examine the patient, look at the technique, and tell him that the findings are as follow:
Pallor all over the mentioned sites above, and tachycardia, otherwise OK
4. Management
ü Explored the patient understanding about the problem.
ü Explain the possibility of Nutritional Anemia and drug induced (NSAID) anemia.
ü Explains the role of dietary stuff in Anemia
ü Adding supplemental iron, should write the prescription.
ü Lab investigation: CBC, Ferritin level, possibility of Hb electrophoresis to exclude hemoglobinopaties.
ü Arrive at shared understanding.
ü Invite questions from patient
ü Summarize at the end of consultation
ü Follow up arranged.