DocCom Module 8
Mrs. P. is a 25 year old, 5 months post-partum with her first child, who is in neurology clinic because of a severe headache, and says that she's had painful peri-menstrual right and left sided headaches since age 15. Last night an unusually severe headache associated with nausea, vomiting and some difficulty pronouncing words occurred; subsiding after several hours and multiple doses of Ibuprofen. She says she was very frightened, as she was home alone with the baby. Mrs. P has not experienced palpitations or other neurological symptoms, takes no other medications and does not drink alcohol, smoke tobacco, or use other drugs. On exam her BP is 120/80 and P is regular at 72. Her fundi are normal, and she has no carotid bruits, cardiac murmurs, or neurological deficits. Mrs. P says, "There's been a lot going on lately. It's been tough at home. Maybe this was just a bad migraine. I've had headaches for a long time." Which of the following do you prefer? A. "Migraine is definitely possible You mentioned there's been a lot going on at home lately. Can you tell me more about that?" B. "Migraine is definitely possible. In the past, have you ever had problems speaking during your headaches?" C. "Was this the worst headache you've ever had in your life?" D. "Migraine is definitely possible, and I think we need to be certain nothing new is happening and I'm sending you for an MRI scan of your head." E. "Migraine is definitely possible. Did you take any medications other than the Ibuprofen?"
A is correct. Your clarifying question functions as an invitation to share additional psychosocial or contextual information, which may be important in its own right, and your preface to the question responds directly to the patient's concerns and emotions at the time of their expression. B, C, D and E respond to important biomedical issues, but fail to respond to the patient as a person, and do not seek additional contextual information. They miss the "window of opportunity" Mrs. P has presented.
Your patient, Dr. Singh, a 28 year old internal medicine resident, comes in 3 weeks after a trip home to India. She opens by complaining of rigors and fever to 103 degrees F, and then says, "This is exactly how I felt the last time I had malaria!" What is the recommended next statement? A. I understand you're having chills and fever. Have you noticed anything else? B. Were you taking malaria prophylaxis? C. Have you noticed a sore throat, cough, skin abscesses or problems when you urinate? D. How long ago did you have malaria? E. Has anyone else in your family been ill?
A is recommended, as it keeps the exploration open and avoids premature narrowing of hypothesis generation. B, C, D, and E are all closed questions, each of which probes for important details, but are best delayed until the patient tells her story.
"What did you notice experiencing when this first began?" Which of the following correctly names the question/ statement above? a) Open question b) Clarification c) Closed question d) Verbalize transitions e) Summarization
A. open question.
Ms. Dole, 25, an executive assistant, is in Urgent Care with left ankle pain and swelling following a fall 10 days ago. She says she simply lost her footing going downstairs from her apartment, and has not felt dizzy or blacked out. The clinic notes show that she had a right wrist injury following another fall at home a few months ago. Otherwise, she is healthy; takes only an oral contraceptive And her x-rays show no fracture. The waiting room is packed with patients waiting. Which option is recommended as your next action? A. I'm going to give you an air cast, crutches, and Ibuprofen. Elevate your leg as much as possible, and come back for more evaluation if you do not improve in this coming week. B. I'm concerned that you've had two recent falls and I'm wondering if you have any ideas about why this is happening. C. How much alcohol do you drink? D. I'd like to do a more complete physical exam. E. Do you have other symptoms, problems or concerns we have not yet discussed?
B is preferred. An open invitation to speak more about her life is helpful here. A ignores the two-fall fact; C is relevant, but too abrupt and if she has a substance abuse problem may lie or respond defensively; D is important but not yet, and E asks several questions at once, a poor strategy.
Dr. Singh (from prior Question) says she had shaking chills and fever without any other focal symptoms. She had malaria a year ago that was successfully treated and has been asymptomatic since that time. Her trip to India was for a month and she took appropriate chemoprophylaxis before, during and after the trip. She says she is quite concerned about P. falciparum infection, because she knows P. falciparum may carry drug resistance. What is the recommended action now? A. Say, "I'd like to send you to the lab for a malaria smear, as well as blood cultures and other appropriate blood and urine tests." B. Say, "I can understand your concern about P. falciparum infection, given your past history and recent travel." C. Say, "Even though P. falciparum may be resistant, its prevalence is low and you were so conscientious in taking the prophylaxis that it is unlikely you have malaria." D. Say, "Let's complete an appropriate physical, checking carefully for splenomegaly, then decide on next steps." E. Say, "I'm eager to work with you until we get to the bottom of this."
B is recommended at this choice point in the interview because it immediately acknowledges her illness concern. This legitimation/ validation of her emotions tells her you have heard not only her history, but its emotional significance and context. This keeps you and the patient on the same page. Failing to respond right away may be interpreted as a lack of interest, and distract her. A and D seek appropriate information, but should be delayed until you respond to her feelings. C is premature reassurance. E is helpful, but a less direct response to her emotions than B. NOTE: Her urine showed 50-100 white cells and grew out > 100,000 E. coli, with positive blood cultures. Malaria smears were negative. Treatment for pyelonephritis led to recovery without problems or recurrence.
In the Emergency Department, you are directed to see a 30 year old man who will be admitted to assess the presence or absence of a heart attack, then write the admitting orders and page your supervising resident. Bob L. is a 30 year old software engineer who appears concerned but not in distress. Bob reports left sided chest pain intermittently since yesterday, and the nursing notes state that he has an elevated cholesterol and family history of coronary artery disease. What is your preferred next statement? A. Was the pain sharp or dull? B. Can you describe your chest pain? C. Have you ever had this type of pain before? D. On a scale of 0 to 10 with 10 being the worst, how bad was this pain? E. Would you tell me a bit more about your family and your current life situation?
B is recommended, as an open question with a focus on the primary symptom, and a question that will help you determine the urgency of the situation. A, C, and D are important, but they are closed questions that do not invite the patient to tell the full story and may limit your ability to perform a full assessment if asked too early. E is equally important, but also a closed question and should be asked later if the patient does not spontaneously include sufficient detail after your open invitation.
What exactly do you mean by shortness of breath? Which of the following correctly names the question/ statement above? a) Open question b) Clarification c) Closed question d) Verbalize transitions e) Summarization
B. Clarification.
Ms. Dole tells you that she really doesn't know why she's been falling. You then tell her you're happy she's come in to see you, but you're wondering why now, ten days after the injury rather than earlier. She replies, "I couldn't come in until today because it's just been hard to get away from work and home. My husband's out of town today so it was more convenient." At this point, choose the recommended response statement. A. It sounds like your schedules are pretty busy. B. It's best to come in soon after this kind of injury so you can avoid further damage. C. Sometimes when I've heard symptoms or seen problems like yours, I've learned that the patient is being hurt or hit at home. Could that possibly be happening to you? D. I'd like to refer you to a primary care physician for follow-up if you don't already have one. E. Is someone hurting you?
C is preferred because you are following up on the "red flag" about her husband being out of town before she comes in. A ignores the red flag (an empathic response might be good here, but to be effective should address the red flag- example: "You had to wait until your husband was away.") B and D are important, but both ignore the red flag. E is likely to provoke shame or guilt, and would be vastly improved by adding a preface and including your thinking, as in C. NOTE: Mrs. D. did disclose her husband's abuse. Alcohol and drug screening questions showed no risky behaviors. Physical exam showed additional bruises on her torso and back. You express concern for her safety and assure her that she doesn't deserve to be hurt or abused. She agrees to speak with the social worker on call for further assessment and counseling. (M 28 has more on Domestic Violence.)
Bob (from previous question) tells you the pain is moderately severe and feels like a stabbing sensation in his left chest, and he reveals that he's worried about a possible diagnosis of heart attack. At this point, which statement below is recommended? A. Can you show me where it's hurting you? B. Go back to the beginning. What were you doing when this began? C. What worries you the most? D. Have you had any shortness of breath with this? E. So, who in your family has had a heart attack?
C is recommended, because it addresses his concerns, is an open invitation that allows him to disclose as much or as little as he chooses, in whatever direction he chooses. This moment is often called a "window of opportunity" and keeping it open usually makes interviews more efficient, addresses patients' concerns in the moment, and improves clinical outcomes. His responses to the other questions are very important, and if he does not give data that answers them in response to C, you will need to ask each of them—but do so after respond to his concern. Bob says that what worries him most is that a heart attack that might preclude his continuing as a committed amateur weight-lifter! Then he reveals that he suddenly had a sharp pain in his lateral chest while bench pressing, and since then has had pain off and on when he twists a certain way or externally rotates his left shoulder. Except for point tenderness in a small area in the lateral pectoralis, exam is normal, his EKG is normal and there is no pneumothorax on chest s-ray. You summarize for the resident and decide to not admit him- Bob is relieved.
Mrs. P.(from previous question) shares additional information, revealing that her husband's job requires travel, so she is left alone frequently with the new baby and little support. She's uncomfortable with how much he drinks when he's at home, although he's not been abusive. She feels "down in the dumps," and cries frequently, has been sleeping poorly, awakening at 4-5AM even when the baby is quiet, and feels fatigued most of the time. She's lost 10 pounds more than the weight she gained while pregnant, and says that taking care of the baby is always effortful rather than pleasurable.. Which diagnosis seems the least likely based upon Mrs. P's history? A. Complex migraine B. Post-partum thyroiditis C. Major depressive episode D. Transient ischemic attack
D is correct. Given the patient's age, the absence of predisposing risk factors such the use of tobacco and contraceptives, valvular disease, or arrhythmia. A is highly likely based on this clinical presentation. B is plausible, and a TSH would be helpful. C is also plausible, and she does meet DSM criteria for major depressive disorder, single episode, moderate, with melancholic features, and with post-partum onset. In both B and C, you might not have discovered an important additional diagnosis that needs careful management without your follow up of the cues she gave about her situation.
Bill, a 22 year old college student comes to emergency at 2AM on a busy Saturday with pain in the left side of his chest. You are the supervising physician tonight, and the resident tells you the history- including that he had an injury to his left calf and left chest during a rugby game 2 weeks ago. Tonight he was awakened with the pain, which increased with inspiration. The resident's exam was normal, except for mild left rib tenderness, and his chest x-ray was normal, and the resident suggests that he sign the patient out with a diagnosis of left sided rib injury, possible occult rib fracture, after you see him. At this point, choose the recommended statement. A. After you examine Bill's heart, lungs and chest wall counter-sign the resident's note and discharge Bill with the diagnosis of rib contusion. B. Review the chest x-ray and then ask the resident to order spot rib films. C. Ask the resident to check on the possibility of transferring Bill to the college infirmary for overnight observation. D. Ask Bill to tell you more about his symptoms and their evolution over time. E. As supervisor, ask the resident to share his thinking about the case with you before you decide on the next step.
D is recommended. Bill might indeed have a rib contusion, but the onset of pleuritic pain many days after the injury is unexplained by what the resident told you. When there are unexplained elements in the patient's history, you must take the time to get the story directly from the patient. The question "Why is the patient coming in at this moment?" is always relevant. Neither A nor C fulfills your professional responsibility in this case. B and E may be appropriate, but getting the story straight first is the most important next step. When you got more detail, Bill revealed that after the rugby game his rib was sore, and he had a "bad bruise" and swelling of his left calf, and that both had improved. Tonight's awakening was entirely unexpected and different. Bill was evaluated with D-dimer and CT angiography and had a left lower lobe pulmonary embolus.
"I'd like to ask a few more questions about your past medical history." Which of the following correctly names the question/ statement above? A. Open question B. Clarification C. Closed question D. Verbalize transitions E. Summarization
D. Verbalize transitions.
"What inhaler did you use?" Which of the following correctly names the question/ statement above? a) Open question b) Clarification c) Closed question d) Verbalize transitions e) Summarization
c) Closed question
"So my understanding so far is that you developed shortness of breath and wheezing yesterday that didn't respond to your usual inhalers." Which of the following correctly names the question/ statement above? a) Open question b) Clarification c) Closed question d) Verbalize transitions e) Summarization
e) Summarization
