case 1

Case 1 - History taking (MSK)

This is the history taking script. You may memorize this and ask your friends to take the history in 5 mins.

·         

      24 yearold

·         Male

·         Presenting Illness

o   Lower back pain - been there for 6 months

·         HPI

o   It’s a dull pain

o   started as a slight ache in the back

o   Its worse in the night

o   When I wake up, it takes effort to get up from bed

o   Requires a lot of bending and stretching before it gets better

o   Pain radiates from the back to the buttocks

o   It gets better as day progresses

o   have a slight hunch on the back (cervical kyphosis)

·         systemic review

o   no weight loss

o   no change in eating habits

o   no dizziness

o   hearing okay

o   my eyes seems to be red - for 1 year

o   diarrhea is a normality for me. Got used to it already - 3 years

·         family history

o   mother is well at 52

o   father 55, has DM2.

o   Brother is 20, healthy

·         Social history

o   Nonsmoker

o   Does not drink

o   Swimmer - national squad

o   Also does badminton once a week with friends

·         Worries

o   Might not be able to continue his swimming career

o   (because it is getting worse and worse)

o   He is a backstroker - but his coach keeps commenting on his form - said his back is too bent and is creating water resistance.

o   He is afraid his younger brother might get the same condition

Question variation 1 -

1.       Take…

a.       PC

b.      HPC

c.       Social history

2.       Questions

a.       What is his Presenting Complaint? (2m)

b.      Elaborate on his History of Presenting Complaint (6m)

c.       Will Rheumatoid factor aid in his diagnosis and state the reason why. (2m)

d.      What is his probable diagnosis? (2m)

e.      What are the other possible manifestations of this illness? Give 3. (3m)

f.        Elaborate on his social history. (3m)

g.       Are his hobbies helpful to the prognosis of this disease? State why. (2m)

(full marks 20)

Question variation 2 -

1.       Take…

a.       PC

b.      HPC

c.       Systemic review

2.       Questions

a.       What is his Presenting Complaint? (2m)

b.      Elaborate on his History of Presenting Complaint (6m)

c.       Elaborate on his systemic review. Give 2 positive findings. (4m)

d.      What is the probable diagnosis? (2m)

e.      What are the 3 manifestations of the disease is the patient having? (3m)

f.        State 2 diagnostic procedures you would like to use on this patient.(2m)

g.       State 1 other possible associated conditions with this illness. (1m)

(full marks 20)

Question variation 3 (BS station)

1.       Take…

a.       PC

b.      HPC

c.       Social history

2.       Questions

a.       What is his Presenting Complaint? (2m)

b.      Elaborate on his History of Presenting Complaint (6m)

c.       What is the probable diagnosis? (2m)

d.      What are his worries? (4m)

e.      What advice would you give to his worries? (4m)

(full marks 16)

Possible PE stations related to this case

1.       Examine his spine. - patient know case of Ankylosing spondylitis

a.       Inspection

                                                               i.      Special attention to kyphosis

b.      Palpation

                                                               i.      Special attention to sacroiliac joint - tenderness?

c.       Movement (passive)

2.       Viva - what special test would you perform on this patient, and what would you expect?

3.       Viva - what other places would you be interested in?

a.       Peripheral joints - for enthesitis

b.      Eye - for uveitis

c.       Heart- for aortitis, fibrosis, heartblock.

d.      Signs of IBD (aphtous ulcers etc)