Tuesday, October 18, 2011

CASE 8 LONG CASE 19mins Ray Smith presenting with multiple symptoms

PATIENT:  Ray Smith
AGE:  50
SEX:  Male
SOCIAL HISTORY:  Divorced 5yrs ago with 2young kids
OCCUPATION:  Truck driver

Appearance:  Obese, good rapport, flat mood, unshavened, tired, and pale

Presenting complaint:

Recent weight gain, tiredness, constipation, waking up unrefreshed, feeling down, lower back pain worse with sitting, intermittent chest tightness.

Things to think about......
???possible problem list
???how would you use your 3mins pre reading here
???in long cases, you will have to do a "system review"...how would you approach this?


  1. possible problem list:
    1. Presenting complaint – Hypothyroidism, OSA, obesity, IHD/angina, back problem/OA/ /sciatica, ???malignancy particularly bowel and prostate cancers
    2. Depression/anxiety
    3. Alcohol/drugs
    4. Relationship issue, relationship with children
    5. Diet/exercise/smoking
    6. Financial issue
    7. Safety of driving
    8. immunisation
    how would you use your 3mins pre reading - plan the topics need to be covered

    in long cases, you will have to do a "system review"...how would you approach this – pattern of symptoms, such as “do you have chest pain/SOB/palpitation?”

  2. 1 With waking up unrefreshed in the history, what other possible diagnosis would you include in the problem list?

    2 In your system review, what specific questions would you ask that might be relevant to your problem list?

    eg Have you have any loss of hair or thinning of your hair ???hypothyroidism

    3 With regards to chest tightness, what other differentials would you include as well?

    Dr Vin Tran
    MBBS FRACGP University of Qld

  3. DD,1. depression
    2. hypothyroid
    3. OSA
    4. malignancy
    start systemic review
    ask more about cardiovascular ,chest pain ,frequency associated SOB ,relieving and aggreviating factors
    ask about respiratory symptomes any SOB on rest or exertion,smoking history,cough
    digestive symptomes ask about bowel motion ,any Pr bleeding
    locomtor system ,nature back pain ,day and night ,any stiffness,any other joints pain ,any trauma to back,any radiation to lower limbs,endocrine system ask about any symptomes hypothyroid,cold intolerance,dry skin,putting weight,hair loss,tiredness

    ask about snoring at night and sleep apnoea
    ask about mental health and depression
    ask about alcohol drinking
    road safety if OSA
    sleep study
    blood tests

    1. Can you comment on your Ddx re lower back pain?

      What other differentials should you consider regarding the chest tightness?

    2. 1].Pneumonia 2]COPD. 3] GORD 4]IHD 5]CCF 6]PE 7]musculoskeletal pain

    3. Dear Dr Anonymous,

      That is a very thorough list.....

      However, is there another differential that you would like to consider as a possible explanation for the chest tightness in this particular case?