DOORWAY INFORMATION
Opening Scenario
Kristin Grant, a 30-year-old female, comes to the office complaining of weight gain.
Vital Signs
BP: 120/85 mm Hg Temp: 98.0°F (36.7°C)
RR: 13/minute HR: 65/minute, regular BMI: 30
Examinee Tasks
1. Take a focused history.
2. Perform a focused physical exam (do not perform rectal, genitourinary, or female breast exam).
3. Explain your clinical impression and workup plan to the patient.
4. Write the patient note after leaving the room.
Checklist/SP Sheet
Patient Description
Patient is a 30 yo F.
Notes for the SP
None.
Challenging Questions to Ask
“I want to go back to smoking because I have started gaining weight since I quit.”
Sample Examinee Response
“I understand that controlling your weight is important to you, but the health risks of smoking far outweigh those associated with weight gain. We also need to determine if something else is contributing to your weight gain and, if so, discuss strategies to deal with it.”
Examinee Checklist
Building the Doctor-Patient Relationship Entrance
□ Examinee knocked on the door before entering.
□ Examinee introduced self by name.
□ Examinee identified his/her role or position.
□ Examinee correctly used patient’s name.
□ Examinee made eye contact with the SP.
Reflective Listening
□ Examinee asked an open-ended question and actively listened to the response.
□ Examinee asked the SP to list his/her concerns and listened to the response without interrupting.
□ Examinee summarized the SP’s concerns, often using the SP’s own words.
Information Gathering
□ Examinee elicited data efficiently and accurately.
Connecting with the Patient
□ Examinee recognized the SP’s emotions and responded with PEARLS.
Physical Examination
□ Examinee washed his/her hands.
□ Examinee asked permission to start the exam.
□ Examinee used respectful draping.
□ Examinee did not repeat painful maneuvers.
Closure
□ Examinee discussed initial diagnostic impressions.
□ Examinee discussed initial management plans:
□ Follow-up tests.
□ Lifestyle modification (diet, exercise, relaxation techniques, smoking cessation support).
□ Examinee asked if the SP had any other questions or concerns.
Sample Closure
Mrs. Grant, most smokers gain an average of 5 pounds when they quit. You have gained 20 pounds over 3 months. This may have resulted from your smoking cessation, but bear in mind that the health risk posed by smoking is far worse than the risk you might incur from excessive weight gain. In addition, there may be other reasons for your weight gain; for example, it may be related to your thyroid gland, or it may be a side effect of the lithium you’re taking. I would like to draw some blood to measure your thyroid function and lithium levels. In the meantime, in addition to stopping smoking, you should continue to pursue a healthier lifestyle. Try to decrease the fatty foods you eat and increase the healthy ones, such as fruits and vegetables. Exercising only 30 minutes 3 times a week can also improve your health. Do you have any questions for me?
History
HPI: 30 yo F c/o weight gain of 20 lbs over the past 3 months after she stopped smoking. She has a good appetite and reports no change in her diet. For 6 months she has experienced oligomenorrhea and hypomenorrhea, dry skin, and cold intolerance. The patient denies voice change, constipation, hirsutism, depression, fatigue, or sleep problems.
OB/GYN: Last menstrual period last week. See HPI for other.
ROS: Negative except as above.
Allergies: NKDA.
Medications: Lithium, started 6 months ago.
PMH: Bipolar disorder, diagnosed 6 months ago.
PSH: None.
SH: 2 PPD for 10 years; stopped 3 months ago. No alcohol, no illicit drugs. Sexually active with husband only. Doesn't exercise.
FH: Mother and sister are obese.
Diet: Consists mainly of lots of coffee during the day, chicken, steak, and Chinese food.
Physical Examination
Patient is in no acute distress.
VS: WNL.
HEENT: No conjunctival pallor, mouth and pharynx WNL.
Neck: No lymphadenopathy, thyroid normal.
Chest: Clear breath sounds bilaterally.
Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops.
Abdomen: Soft, nontender, nondistended,
BS, no hepatosplenomegaly
Extremities: No edema, normal DTRs in lower extremities bilaterally.
Differential Diagnosis
CASE DISCUSSION
Patient Note Differential Diagnoses
■ Hypothyroidism: This patient has classic early symptoms of hypothyroidism, which include weight gain, dry skin, cold intolerance, elevated serum cholesterol, and changes in menstruation patterns. Deepening of the voice, constipation, depression, and fatigue are also symptoms of hypothyroidism. It needs to be ruled out as a cause of her weight gain.
■ Smoking cessation: Weight gain occurs in most patients following smoking cessation but usually averages only 4.5 lbs (2 kg). However, major weight gain such as that seen in this case may occur. Patients generally report increased appetite and calorie consumption.
■ Lithium-related weight gain: Weight gain is a common side effect of lithium therapy and may contribute in this case. Other symptoms include cold intolerance, dry skin, confusion, dizziness, headache, lethargy, hair loss, and fatigue.
Additional Differential Diagnoses
■ Familial obesity: There are strong genetic influences on the development of obesity, but a positive family history does not account for acute weight gain.
■ Pregnancy: Regardless of the menstrual history given by the patient, pregnancy should be suspected in a woman of childbearing age who has unexplained weight gain.
■ Cushing's syndrome: This is a rare cause of unexplained weight gain and can usually be diagnosed by physical exam (eg, exam may reveal hypertension, moon facies, plethora, supraclavicular fat pads, truncal obesity with thin limbs, and abdominal striae).
Diagnostic Workup
■ TSH: To diagnose suspected hypothyroidism.
■ Serum lithium level: To check if the patient’s lithium dosage is appropriate. Lithium has a narrow therapeutic index, and serum levels should be checked every 3-6 months.
■ Fasting glucose, cholesterol, triglycerides: To screen for medical complications of obesity such as diabetes or hyperlipidemia.
■ Urine hCG: To rule out pregnancy.
■ Dexamethasone suppression test: To screen for hypercortisolism. A suppressed morning cortisol following bedtime dexamethasone administration excludes Cushing’s syndrome with 98% certainty.
■ 24-hour urine free cortisol: Performed if the dexamethasone suppression test is abnormal. Helps confirm hypercortisolism.