Mini-CPX 6

Part 1: Approaching the History

CC: “exhaustion”

HPI: The patient is a 38 year-old female who presents for evaluation of “exhaustion.” She describes its onset as starting very gradually, first noticing something was wrong about 6 months ago (the exact time of onset is difficult to pinpoint, but it was definitely less than a year ago). Her symptoms have started to get worse, particularly in the past 2 to 3 months, prompting her to schedule this appointment with her physician. She doesn’t remember any events that immediately preceded the onset of her “exhaustion,” as far as she can recall.

She describes her symptoms as feeling “exhausted” and “not having the energy to do things” like she used to be able to do. “I’ll start doing something, and then I just feel too exhausted and weak to finish.” Exertion makes this “exhaustion” more intense, and she reports feeling easily “winded” (short of breath) when doing activities that normally wouldn’t cause her to do so (e.g., climbing 6 to 8 stairs). She points out that, even when she’s not exerting herself, the “exhaustion” is still present. Rest, including a full night’s sleep or a long nap, doesn’t seem to make the “exhaustion” go away or improve at all. This feeling is constant in intensity, other than being worse with exertion, and it isn’t any worse at any particular time of day. When asked to rate the severity of her “exhaustion,” she states it is a 7 out of 10 (and up to 9 or 10, with exertion). She denies feeling sleepy or nodding off during the day.

When asked how this has affected her life, the patient reports that she’s not able to do a lot of things as easily as she once could, but she is able to follow through with most simple tasks that don’t require much physical effort. This inability to follow through with tasks has been very stressful to her.

When asked about previous experience with this “exhaustion,” she denies any prior episodes.

Instructions:

Based on the information given in this patient’s HPI and chart, use the template below (starting on page 3) to create a list of questions you would ask for each of the following segments of the history:

Past Medical History

Medications

Family History

Social History

Review of Systems

For each question on your list, indicate the specific reason you would ask this question in the right column, in terms of how it is relevant to your revised differential diagnosis for this patient. You must include this for every history question, to receive credit.

Note:

It is important that you avoid including unnecessary questions that are no longer needed based on what you know so far, focusing your interview content using your revised differential diagnosis after reading the HPI. QUALITY is much more important than QUANTITY, in this regard. That said, do not short cut areas of the history, if more exploration is needed.

The number of rows included in this template in no way indicates the number of questions expected to be included in any part of this assignment—they are simply here to provide a structure for creating your planned history, however long or short you make it.

Questions about the patient’s past medical history/medical problems/health maintenance:

Reason(s) why this question is relevant to the history for this patient

Add additional rows to any section, if needed.

Questions about the patient’s medications/allergies:Reason(s) why this question is

relevant to the history for this patient

Add additional rows to any section, if needed.

Questions about the patient’s family history:Reason(s) why this question is

relevant to the history for this patient

Add additional rows to any section, if needed.

Questions about the patient’s social history:Reason(s) why this question is

relevant to the history for this patient

Add additional rows to any section, if needed.

Questions about the patient’s review of systems:Reason(s) why this question is

relevant to the history for this patient

Add additional rows to any section, if needed.