Instructor's Manual Family Medicine Cases

Case Studies in Family Medicine Instructor Manual
Instructor Manual
This program was created by the Deparment of Family Medicine and the Office of Faculty and Instructional Development,
Virginia Commonwealth University School of Medicine. Funding for this program is provided in part by the Bureau of Health
Professions, Health Resources and Services Administration, US Department of Health and Human Services.
Consult CD wallet for complete listing of content authors.

Manual developed by John Priestley.
Copyright © 2005 Virginia Commonwealth University.
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Table of Contents
How to use this manual........................................................................................................... 3
Program introduction .............................................................................................................. 3
Program objectives ................................................................................................................. 3
How CSFM is used in clinical instruction .............................................................................. 4
Getting started ......................................................................................................................... 4
Case menu ............................................................................................................................... 5
Case structure ......................................................................................................................... 5
Check marks and required keywords ....................................................................................................... 8
Case outlines ........................................................................................................................... 9
Miguel: ......................................................................................................................................................... 9
Alexander: ................................................................................................................................................. 12
Willa Mae: .................................................................................................................................................. 15
Charlotte: ................................................................................................................................................... 18
Wanda: ....................................................................................................................................................... 20
Tammy: ...................................................................................................................................................... 24
Sean: .......................................................................................................................................................... 27
Sean ........................................................................................................................................................... 30
Help ......................................................................................................................................... 34
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How to use this manual

This manual is designed to help instructors facilitating discussion of the case studies. It includes an
exhaustive list of search terms used to access case content. This information should not be shared with
students, as doing so would obviate a significant feature of the program – namely that it requires
students to think critically without being given specific prompts for the decisions they make.
Program introduction
Case Studies in Family Medicine (CSFM) is a set of eight interactive case studies developed by VCU
School of Medicine clinical faculty, covering common patient presentations in the family medicine
setting. The goal of the program is to enhance instruction in basic clinical reasoning for third-year
medical students. It is designed for students' self-paced study to standardize learning across
geographically distributed clerkship sites. It is especially useful as content for faculty-moderated online
discussions.
Each case depicts a common medical problem with specific practical skills to be learned in a context
that requires careful attention to cultural competency and other psychosocial factors. (Cases are outlined
below).
Text-based content is enhanced with video vignettes and images. Each case is divided into seven
modules to simulate the steps of a patient encounter (see outline on facing page). The program
presentation is entirely user-driven, requiring students to practice critical thinking and initiative at each
step.
Students access information in the clinical modules (Differential Diagnosis, Patient History, Physical
Examination, Labs & Diagnostic Tests, and Treatment) via a database interface with a search window.
Rather than selecting clinical activities from a provided list of discrete options, students must enter
focused keywords in order to call up relevant points of inquiry. Nothing happens until the student
begins to apply his/her existing knowledge to a novel situation.
Program objectives
 To stimulate students to practice and perfect clinical reasoning skills.

 To expose students to several common outpatient presentations in their psychosocial contexts.
 To enhance students' understanding of cultural competency, substance abuse, motivational
interviewing to promote behavioral change, domestic violence, and barriers to behavior change.
 To provide a basis for discussion on caring for the whole patient in a family context.
 To standardize learning across geographically distributed clerkship sites.
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How CSFM is used in clinical instruction

Case Studies in Family Medicine is designed to augment a distributed, almost entirely clinical clerkship.
Students complete the cases in their free time, then discuss the cases in the context of their own clinical
experiences. At VCU School of Medicine we have chosen to use an asynchronous internet discussion
platform for the discussions. Additionally, students complete an Objective Structured Clinical
Examination (OSCE) at the end of the clerkship. Some of the OSCE cases resemble the patients from
the program.
Getting started
 Review the minimum system requirements:
 Pentium or higher processor
 Windows XP
 64MB of RAM
 Monitor with at least 800 X 600 pixel resolution and at least 16-bit color
 CD-ROM drive
 Updated web browser software (such as Internet Explorer v6, Netscape v7, Mozilla v1.7,
Firefox v1, etc., or better). Enable JavaScript in your web browser preferences. Pop-up
blockers may prevent some windows from opening.
 Some cases include external web links that require an Internet connection and videos that
require Apple QuickTime software. An installer is provided on the CD.
 Insert the CD into your CD-ROM drive. Wait a minute for the program to run automatically. If
it does not, open My Computer and find the file Start_Here.exe on the CD labeled CSFM.
 You will be asked to log in. A file tagged with the name you enter will be saved to the
computer's hard drive. This is so that multiple users can use the program on a given computer,
quitting and resuming at any time. If you run the program on a different computer, you will have
to start at the beginning.
 From the main menu, select a case by clicking on the corresponding button. This will open the
case menu.
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Case menu
The Case menu contains two key program elements:
 The Action items list serves as the primary means of navigating to the different program
modules. Click on each item in sequence from top to bottom.
 The simulated patient record is automatically updated with patient data as the student progresses
through the program. Click on each of the tabs for more information. Note that some screens have
two columns of tabs, as shown.
Case structure
The following program modules correspond to the Action items list referenced above.
 The Introduction module contains case learning objectives and at least a brief description of
the patient. Some cases contain a more extensive and interactive introduction, providing an
opportunity to observe a doctor's initial encounter with the patient and review a critique of the
doctor's performance. In those cases you will access program information in the manner
described below (see the Differential Diagnosis section).
 A didactic module follows the Introduction. Its title varies across cases to reflect its special
content. (In Miguel's case, shown in the preceding illustration, the didactic module is titled
"Cultural Competency.")
The didactic module contains psychosocial or biomedical background information
essential to a thorough understanding of the case. In all cases, the didactic module opens an
external web browser, which you may need to close in order to view the main program window.
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 The Differential Diagnosis module provides a structure for developing an extensive list
of tenable diagnoses, and then reviewing the list as new information is added. The differential is
drawn from a database of relevant diagnoses for each case – most of which are incorrect, but still
worth exploring. To construct it you will perform key word searches, review the general
descriptions of any diagnoses you find, and then choose whether to add each diagnosis to your
list. Refer to the illustration below as you read the following instructions.
To begin your differential, type a keyword related to a possible diagnosis into the text
entry field (the top field on the screen). Then click on the search button (marked with a
magnifying glass icon) or strike the Enter key on your keyboard.
You can target your search by selecting search options displayed immediately under the
text entry field. For example, you can search by:
 Headings (the terms under which a diagnosis is listed) if you believe you know the name of the
diagnosis
 Content (the text describing a diagnosis) if, for example, you want to display all the diagnoses
associated with a given symptom.
 You can also choose to search for:
 Exact phrase if you want to narrow your search to find only a specific phrase exactly as typed
 All words if you want to find only diagnoses that contain all the words you type (in any order)
 Any word if you want to type several keywords and produce a list of all diagnoses related to
any of them.
 If your search is successful, you will see a list of diagnoses in the headings field. If not, you will
receive feedback for each type of search you selected (exact phrase, all words, and any word). If
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you're getting no hits, try a less restrictive search (select Content and Any word); if you're
getting too many hits to review in a reasonable time, try a more restrictive search (select
Headings and Exact phrase).
Click on an item in the headings field (the second field from the top) to review its
content. Text content will be displayed in the content field. If additional media elements
(images, sounds, movies) are available for this diagnosis, one of the three media buttons to the
right of the content field will be illuminated. Click to display the media item, and then click
anywhere to dismiss it.
When you review a content item, it is automatically added to your list of reviewed
items. You can then add it to your add it to your current differential by clicking on it
in the reviewed items list and then clicking on the add button, marked with a right-pointing blue
arrow and a plus sign (+). You can remove an item from the differential by clicking on it and
then clicking on the remove button, marked with a left-pointing blue arrow and a minus sign (–).
When you have edited your differential to your satisfaction, exit the module by clicking
on the Continue button. While it is also possible to exit by clicking on the navigation bar at
the top of the screen, this will not save the changes you made.
The Differential Diagnosis module is placed toward the beginning of the sequence to
prompt you to begin constructing your differential as soon as you encounter the patient. Make it
as extensive as you can, based on your initial impression, and then reduce it as you gather data
from the subsequent modules. You will be prompted to revise your differential after each
clinical module.
 The Patient History module provides an opportunity to ask focused questions of the patient
or caregiver and receive responses in the patient's own words. The mode of interaction is the
same as in the Differential Diagnosis module (see above), except that no review list is
constructed. When you exit the module, the patient's responses are translated into "doctorese"
and noted in the patient record. Check under the History and HPI sub-tabs of the Encounter
Notes tab.
Some cases automatically display a movie following the Patient History module, showing
additional scenes from a patient encounter.
 The Physical Examination module lets you request examinations, listed in the database by
body parts (or groups of body parts commonly examined together). The mode of interaction is
the same as in the Differential Diagnosis module (see above), except that no review list is
constructed. When you exit the module, findings are noted in the patient record. Check under
the Physical sub-tab of the Encounter Notes tab.
 The Lab & Diagnostic Testing module lets you order labs and tests relevant to the case.
Feedback consists of lab reports, diagnostic imaging, etc. The mode of interaction is the same as
in the Differential Diagnosis module (see above), except that no review list is constructed. Be
sure to check any of the media buttons that may be illuminated, indicating that images, sounds,
and/or movies are available. When you exit the module, the reports and media are filed in the
patient record. Check under the Lab tab and/or the Diagnostic tab.
 The Treatment module lets you select a treatment plan for the patient. First you are prompted
to finalize your diagnosis by returning to the Differential Diagnosis module and reducing the list
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to only the items you consider to be supported by the information you have gathered. To register
your final diagnosis, click on the Finalize diagnosis button under the Differential
Diagnosis sub-tab of the Encounter Notes tab.
You may be prompted to complete a thorough history and physical exam before making
your final diagnosis. If so, that means you have not seen all the required elements in one or more
of those modules.
Check marks and required keywords

You'll notice that as you visit each module, a check mark appears beside its link in the Action
items list. If it's a grey check mark, that means you have visited the module; if it's green, you have
completed the module.
How is completeness determined? The case authors have designated certain items in the Patient
History and Physical Examination modules of each case as required viewing. These are thought to
be critical to a thorough understanding of the given patient's presentation (at least for our target
audience of 3rd-year medical students; more experienced users may be better equipped to make more
efficient inferences). These required elements are checked off when you enter the corresponding
keywords. If you don't get all the required elements, it is still possible to complete the program
without the affirmation of the green check mark; however, a pop-up window will prompt you to
complete a thorough history and physical before entering the Treatment module. Simply click on the
button labeled "Live dangerously" to dismiss the warning and proceed.
Since there is no way (and no need) to track how much you read in the didactic module (e.g.
Cultural Competency in Miguel's case), the check mark for that module remains grey no matter what
you do. Similarly Differential Diagnosis module doesn't track how many diagnoses you review, so
the check mark remains grey until you register your final diagnosis. Most cases don't require any
labs or diagnostics to support the final diagnosis, so that module is not tracked either.
Some students get hung up on this visual cue, and will futilely persist until all the check marks
are green. It may help to advise them that this is not at all necessary, and that they are not evaluated
on the completeness of each module, but should rather aim for a holistic understanding of the case
and how correct diagnosis and treatment are supported by clinical interaction with the patient.
The required elements for each module are listed below within the case outlines. These should
not be shared with students; doing so would obviate the exercise of their reasoning through the
process. However, you may find it helpful to be prepared to offer them specific guidance on these
elements.
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Case outlines
Miguel:
An 11-month-old male with GI complications caused by intussusception. This case presents a
complex problem due to communication barriers and varying cultural health beliefs: the infant can't
communicate specific symptoms, and his mother speaks only Spanish. The situation is aided by a
translator (and considerable attention is given to the appropriate selection and use of interpreter
services), but the mother's traditional health beliefs remain a barrier to communication with
biomedical healthcare providers.
 Objectives
After successfully completing this case study you will be better able to:
 appropriately select and use interpreter services for patients who do not speak
English
 practice culturally appropriate interpersonal dynamics in a clinical setting
 correctly diagnose an infant patient presenting with a gastrointestinal complaint
 recommend treatments appropriate for your diagnosis and for your patient's cultural
background.
 Introduction
 Summary: Miguel and his mother and aunt are introduced in a brief video vignette. The
encounter goes badly, and you are given an opportunity to critically review the doctor's
performance.
 Responses for the critical review section. (Use keywords from these phrases to call up
program content.)
1. Use a professional interpreter, not a family member.
2. Address the patient, not the interpreter.
3. Take the time to ask about relevant cultural aspects during the patient history.
4. Learn about folk illnesses common to the patient population.
5. Maintain an attitude of openness and cultural relativism.
6. Offer a culturally appropriate greeting.
7. Sit down.
8. Use nonverbal communication to show empathy.
 Cultural Competency
 Summary: A redaction of some recommendations for doctors caring for patients from other
cultures. Students should be cautioned against applying general ethnic and cultural
formulations too rigidly to specific patients. The information provided in the didactic
modules on cultural competency should serve as a general set of issues that may arise when
working with some broadly defined groups.
 Differential Diagnosis
 The following diagnoses are available. The correct diagnosis appears in bold. (Use keywords
from these phrases to call up program content.)
1. infectious gastroenteritis
2. peptic ulcer
3. intussusception
4. clostridium difficile colitis
5. intestinal malrotation
6. appendicitis
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7. celiac disease
8. protein allergy
9. milk intolerance
10. lactose intolerance
11. Meckel's diverticulum
12. Hirchsprung disease with toxic megacolon
13. inflammatory bowel disease
14. duplications of the GI tract
15. peritonitis
16. non-GI infection
 Patient History
 The following questions are available. Required elements appear in bold. (Use keywords
1. What do you think is wrong with your son?
2. Has he had a fever?
3. Has he been vomiting? When? How often?
4. How often does he have bowel movements? Has he had diarrhea? What is his
stool like?
5. How have his symptoms changed over time? What concerns you most?
6. How much has he been sleeping?
7. Has he been urinating or wetting his diapers?
8. Does he cry? Does he drool?
9. Has he been drinking liquids?
10. Has he been playful? Does he interact with you or with others?
11. Has he been coughing?
12. How is his breathing? Has he been short of breath?
13. Has he had a runny nose?
14. Does he have pain in his ears? Does he pull on them?
15. Has he had a rash or any other changes in his skin?
16. How is his energy level? Is he active?
17. What does he usually eat?
18. What are his usual bowel habits?
19. Do you think there's any chance of food poisoning?
20. Has he swallowed anything he shouldn't, such as toxic chemicals or small
objects?
21. Has he had a problem with colic?
22. Has he taken any medicine or antibiotics recently?
23. Has he been exposed to any ill people, at home or in day care?
24. Tell me about his birth.
25. Has he been seriously ill before this? Has he been hospitalized or had any
surgery?
26. Tell me about his development -- milestones like sitting up, crawling, motor skills,
and communication.
27. Tell me about his home life and family.
28. Does anyone smoke or use alcohol or other drugs in the house?
29. Is he allergic to any foods or medicines?
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30. Where does Miguel seem to hurt?

31. How long has Miguel been sick?
32. Does anything make his distress better or worse?
33. What do you think caused the problem?
34. Why do you think it started when it did?
35. What do you think the sickness does? How does it work?
36. How severe is the sickness? Will it have a long or a short course?
37. What kind of treatment do you think Miguel should receive?
38. What are the most important results you hope Miguel receives from this treatment?
39. What are the chief problems the sickness has caused?
40. What do you fear most about the sickness?
41. Has he had all his immunizations?
 Tech notes: In this case, a video vignette depicting an improved patient encounter pops up
immediately after you complete the Patient History module. The same actress who in the
first vignette plays the patient's aunt appears here as a professional interpreter. This may
confuse some students.
 Physical Exam
 The following examinations are available. Required elements appear in bold. (Use keywords
1. temperature
2. pulse
3. respiratory rate
4. weight
5. height
6. head circumference
7. appearance
8. head
9. eyes
10. ears
11. nose
12. mouth
13. neck
14. lungs
15. heart
16. abdomen
17. rectum
18. genitalia
19. skin
20. musculoskeletal
21. neurological
22. blood pressure
 Labs & Diagnostic Tests
 The following labs & diagnostic tests are available. None of these items are required, as it is
possible in this case to diagnose the patient based on the history and physical alone.
However, this case is special in that one of the diagnostic tests (the barium enema) often
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turns out to be therapeutic, in that it insufflates the colon, which can cause the
intussusception to unfold. (Use keywords from these phrases to call up program content.)
1. CBC (complete blood count)
2. basic metabolic profile
3. comprehensive metabolic profile
4. amylase
5. AST (aspartate aminotransferase)
6. ALT (alanine aminotransferase)
7. stool WBC
8. stool cultures
9. urine culture
10. c. diff toxin in stool
11. stool fat
12. stool reducing sugars
13. urinalysis
14. abdominal x-ray
15. barium enema
16. ultrasound
17. barium swallow and endoscopy
 Treatment
 The following treatment options are available. Two options that are considered appropriate
appear in bold. The barium enema may have been performed as a diagnostic test, in which
case further imaging studies would be appropriate, and no further treatment may be needed.
1. surgery
2. barium enema
3. pneumatic reduction
4. antibiotics
5. Direct Mrs. Lopez to continue monitoring the situation from home.
6. Admit Miguel to the hospital for observation.
7. colonoscopic reduction
8. wormwood tea
9. abdominal massage
Alexander:
A 38-year-old male with a persistent cough caused by asthma. Though physically active, Alexander
is a smoker and will have to modify his behavior. Didactic materials in this case introduce
motivational interviewing to help the patient move through the stages of change. Pharmacological
and behavioral therapies are also discussed and applied.
 Objectives
 correctly diagnose a patient presenting with a respiratory complaint
 take an appropriate smoking history
 explain barriers to smoking cessation
 appropriately select and prescribe smoking cessation treatments for a patient's
specific needs
 apply guidelines for the treatment of pulmonary disease based on disease severity.
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 Introduction
 Summary: Alexander's case is briefly outlined along with the objectives listed above.
 Smoking Cessation
Outlines a strategy to help patients quit smoking, based on the stages of change model.
Describes pharmacological and behavioral therapies.
1. asthma
2. chronic obstructive pulmonary disease
3. congestive heart failure
4. upper respiratory tract infection
5. gastroesophageal reflux disease
6. lung cancer
7. pneumonia
8. foreign object obstruction
9. tuberculosis
10. sarcoidosis
 Patient History
1. Tell me why you are here today.
2. Tell me more about your cough.
3. How long have you had this cough?
4. What makes your cough better or worse?
5. What medications have you taken so far to help your cough?
6. Do you cough up anything?
7. Do you have any other symptoms?
8. Do you feel any tightness or discomfort in your chest?
9. Do you get short of breath when lying down or when sleeping at night?
10. Do you have any sharp pains in your chest?
11. Do you have any irregular heart beats?
12. Have you had a fever or chills?
13. Do you get short of breath when you exert yourself?
14. Do you ever wheeze?
15. Do you have any cold symptoms, such as a runny nose, nasal congestion, sinus
pain, or sore throat?
16. Have you had previous episodes of coughing or shortness of breath similar to
this?
17. How did the previous coughing episodes resolve?
18. Do you have night sweats?
19. Do you feel tired?
20. Do you have heartburn?
21. Are you allergic to any medications?
22. Do you have any environmental allergies?
23. Have you ever been diagnosed with asthma?
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24. How has this cough, chest tightness, and shortness of breath affected your life?
25. What medical conditions do you have?
26. What medical conditions did you have as a child?
27. Have you ever had a blood transfusion?
28. Do you smoke?
29. How much do you smoke?
30. Tell me more about your smoking.
31. How long have you been smoking?
32. Have you ever tried to quit smoking?
33. What medical conditions run in your family? And who has them?
34. Does anyone in your family have asthma or allergies?
35. Do you have any headaches?
36. Have you had any recent weight changes?
37. Any change in your appetite?
38. Any change in bowel movements?
39. Are your legs swollen?
40. Do you have leg pain or cramps?
41. Has your cough gotten better or worse in the last week?
42. Do you have any nausea or vomiting?
43. Do you feel any pain in your jaw or your left arm?
44. Have you traveled to any unusual places recently?
45. Have you suffered any kind of trauma or accidents recently?
46. Have you ever been hospitalized for any medical problems or psychiatric problems?
47. Tell me about your eating habits.
48. Do you drink alcohol or use any other recreational drugs?
49. Do you exercise regularly?
50. Where do you work?
51. Tell me about your home life.
52. Have you been having any headaches, backaches, swelling, cramps, muscle aches
or weakness?
53. Have you felt any changes in your appetite or bowel movements, or noticed any
discolored stools?
 Physical Exam
1. appearance
2. respiratory
3. pulse
4. respiratory rate
5. ENMT
6. eyes
7. head
8. neck
9. cardiovascular
10. abdominal
11. genitalia
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12. musculoskeletal
13. neuro
14. skin
15. lymph
possible in this case to diagnose the patient based on the history and physical alone. (Use
keywords from these phrases to call up program content.)
2. chemistry panel
3. chest x-ray
4. peak flow
5. pulmonary function test
6. echocardiogram
7. allergy test
8. electrocardiogram
9. pulse oximetry
10. sputum culture
11. sputum cytology
12. sputum gram stain
 Treatment
 The following treatment options are available. Correct options appear in bold. (Use
1. inhaled beta2-agonist
2. ipratropium bromide
3. short-course oral steroids
4. systemic beta2-agonist
5. inhaled steroids
6. vaccines
7. smoking cessation
8. animal allergen control
9. dust-mite control
10. cockroach control
11. indoor mold control
12. outdoor allergen control
13. long term beta2-agonist
14. Cromolyn sodium
15. leukotriene receptor agonist
16. Combivent inhaler
Willa Mae:
A 75-year-old female with elevated blood pressure caused by essential hypertension. She has no
particular health complaints, but her blood pressure reading raised a flag at a health screening event
sponsored by her church. As with Alexander, lifestyle modification is emphasized along with
pharmacological treatment. Cultural competency and patient compliance are addressed specifically
in terms relevant to geriatric care.
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 Objectives
 correctly identify and measure hypertension in the elderly
 formulate an evaluation including physical findings lab/ancillary testing
 appropriately select and prescribe hypertension treatments, including antihypertensive
medications, for an elderly patient's specific needs
 formulate a treatment plan compliant with established guidelines, considering
comorbid diagnosis and risk factors.
 Introduction
 Summary: Willa Mae's case is outlined briefly along with the objectives listed above.
 Geriatric Hypertension
 A brief module on diagnosing and treating geriatric hypertension, with a focus on cultural
issues pertaining to elderly patients.
1. essential hypertension
2. renal disease
3. renovascular hypertension
4. primary hyperaldosteronism
5. Cushing's syndrome
6. pheochromocytoma
7. thyroid disease
8. coarctation of the aorta
9. sleep apnea
 Patient History
1. How can I help you today?
2. How long has your blood pressure been high?
3. Prior to this health fair at church, had you ever been told your blood pressure
was high before?
4. How high was your blood pressure at the last reading?
5. Have you tried anything on your own to lower your blood pressure?
6. How have you been feeling?
7. Are you having any chest pain?
8. Have you had any shortness of breath?
9. Do you have any pain in your calves when you walk, that gets better with rest?
10. Do you ever have any swelling in your hands or feet?
11. Do you have any numbness or tingling anywhere?
12. Do you have any weakness in your hands or legs?
13. Have you had any vision changes?
14. Have you experienced any palpitations, or irregular heartbeats?
15. Have you had any pain in your shoulder or neck or left arm that you can't
explain?
16. Have you had any nausea or unexplained sweating?
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17. Have you had any severe headaches?

18. Have you had any weight changes?
19. Have you had any nosebleeds?
20. Do you ever have episodes of anxiety that you cannot explain?
21. What medicines are you taking?
22. What kinds of diseases run in your family?
23. Do you smoke?
24. How much alcohol do you drink?
25. Do you use any street drugs?
26. Do you exercise regularly?
27. Tell me about your daily life -- do you take care of your own chores, bills, shopping,
driving...?
 Physical Exam
1. temperature
2. respiratory rate
3. height
4. weight
5. pulse
6. blood pressure
7. general appearance
8. head
9. eyes
10. ENMT
11. neck
12. lungs
13. cardiovascular
14. abdomen
15. rectum
16. genitalia
17. skin
18. breasts
19. musculoskeletal
20. extremities
21. psychological
22. neurological
23. lymph
4. urinalysis
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5. chest x-ray
6. echocardiogram
7. ECG
8. TSH (thyroid stimulating hormone)
9. lipid profile
10. cardiac stress test
11. serum creatine and creatinine clearance
 Treatment
1. lifestyle changes
2. diuretics
3. calcium channel blockers
4. B-blockers
5. ACE inhibitors
6. vasodilators
7. antiadrenergics
Charlotte:
A 32-year-old female with a knee injury caused by an incident of domestic violence. Screening
questions and analysis of her patient record reveal that this is not her first such incident, but she is
now contemplating changing her domestic situation. Didactic content in this case provides brief,
practical instruction on recognizing and responding to domestic violence as well as resources for
change.
 Objectives
 correctly diagnose a knee injury
 take an appropriate history to assess immediate causes of a traumatic injury and its
social context
 appropriately select treatments and/or referrals for a patient's specific needs
 appropriately discuss community resources with a patient potentially at risk for
domestic violence.
 Introduction
 Summary: Charlotte's case is outlined briefly along with the objectives listed above.
 Domestic Violence
 Outlines the bio-psycho-social context for domestic violence and gives strategies
1. knee contusion
2. prepatellar bursitis
3. anterior cruciate ligament (ACL) tear
4. posterior cruciate ligament (PCL) tear
5. medial meniscus tear
6. lateral meniscus tear
7. medial collateral ligament (MCL) tear
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8. lateral collateral ligament (LCL) tear

9. patellofemoral syndrome
10. degenerative joint disease
11. rheumatoid arthritis
12. gouty arthritis
13. septic arthritis
14. systemic lupus erythematosis
 Patient History
1. I see you're having some problems with your right knee. What happened?
2. What part of your knee is hurting?
3. When did this accident happen?
4. How did you fall?
5. Did you have any other pain?
6. Did you seek medical attention at the time?
7. Tell me about this fight you had with your husband - do the two of you often
fight like that?
8. What kinds of things have your tried or thought about trying to keep yourself
safe?
9. How old are your children?
10. How would you describe the pain? How intense is it, on a scale from 1-10?
11. Have you had knee pain like this before?
12. Have you found that anything helps the pain or makes it worse?
13. Have you had a fever or chills? Any noticeable changes in your weight?
14. Have you had any changes in your vision?
15. Have you had any ear pain or hearing loss?
16. Have you had any heart problems or breathing problems?
17. Have you had any intestinal problems - diarrhea, constipation, bloating? Or any
stomach problems, like nausea and vomiting.
18. Tell me about your menstrual periods: When was your last period? Are they regular?
Are they painful? Have you had any vaginal discharge?
19. Did you lose consciousness at any time after the fall? Have you felt any
numbness, tingling, or weakness? Have you had any unusual headaches?
20. Tell me about your mental health status. Have you been feeling fear or anxiety
since the incident?
21. Have you been expecially thirsty, or urinating more than usual? Have you
noticed any change in your tolerance to heat or cold?
22. Have you noticed any swelling in your lymph nodes? Any bruises or bleeding
not related to injuries? Have you ever been evaluated for anemia?
23. Do you have any allergies or immune diseases?
24. Have you tried to treat yourself with any over the counter medications?
25. When was your last menstrual period?
26. Do you have any other joint pain?
27. What kinds of past medical problems have you had?
 Physical Exam
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1. general appearance
2. head
3. eyes
4. ENMT
5. neck
6. respiratory
7. cardiovascular
8. breasts
9. abdomen
10. skin
11. genitourinary
12. psychological
13. neurological
14. musculoskeletal
15. lymph
16. temperature
17. pulse
18. respiratory rate
19. weight
20. height
1. MRI
3. chem 12
4. rheumatoid factor
5. antinuclear antibody
6. erythrocyte sedimentation rate (ESR)
7. joint aspirate
 Treatment
1. orthopedic surgery
2. counseling for domestic violence
3. knee brace
4. analgesics
5. physical therapy
6. rest, ice, compression, elevation (RICE)
Wanda:
A 39-year-old female with fatigue caused by metabolic syndrome and deconditioning. The
diagnosis requires attention to subtle distinctions from diabetic symptoms. Stressful life conditions
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seem a likely contributor to her health problems. Motivational interviewing is discussed as a key
support for lifestyle change for her biopsychosocial needs.
Error alert: Due to a coding error in this case (detected after the production and release of CDs),
you will be told your diagnosis is incorrect even if you get the right diagnosis (metabolic syndrome
with cardiac deconditioning). Instructors should advise students of this issue so they will not get
hung up on it. The error does not completely derail the case; students can proceed to the treatment
plan despite the erroneous feedback. A downloadable content update fixes this bug:
http://www.medschool.vcu.edu/ofid/id/csfm/update.html
 Objectives
 correctly differentiate the possible causes of fatigue
 formulate an evaluation including physical findings and lab/ancillary testing
 select and prescribe appropriate treatments to promote recovery and long-term health
in a middle-aged patient
 formulate a treatment plan compliant with established guidelines, considering
comorbid diagnosis and risk factors.
 Introduction
 Summary: Wanda's case is outlined briefly along with the objectives listed above.
 Motivational Interviewing
 Outlines a model for applying motivational interviewing in a family medicine environment to
help patients make positive lifestyle changes
1. anemia
2. depression
3. cardiomyopathy
4. congestive heart failure
5. diabetes
6. acute infections
7. lung disease
8. medications
9. fibromyalgia
10. sleeplessness
11. hypothyroidism
12. hyperthyroidism
13. sleep apnea
14. hepatitis C
15. renal failure
16. cardiovascular deconditioning
17. metabolic syndrome
 Patient History
1. What brings you to see us today?
2. What do you think could be causing this problem?
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3. Have you had this problem before?

4. How long have you had problems with fatigue?
5. How did your fatigue start? Was it sudden or gradual?
6. How would you describe the severity of your fatigue?
7. Have you noticed any other symptoms that accompany the fatigue?
8. Does anything make the problem better or worse?
9. Have you had any shortness of breath?
10. Have you had any heart problems or chest pain?
11. Have you been feeling sad lately, been crying more, or had difficulty enjoying
activities you used to enjoy?
12. Have you had any weight gain or weight loss?
13. Have you had any changes in appetite?
14. Have you noticed being especially bothered by heat or cold?
15. Have you noticed any changes in your skin?
16. What are some sources of stress in your life?
17. How do you typically deal with stress?
18. What friends or family can you rely on for help and support?
19. Have you been constipated?
20. Have you had night sweats?
21. Have you had a fever?
22. Do you know if you snore or choke or gasp when you're sleeping?
23. Do you fall asleep during the day or while driving?
24. Have you had blurred vision?
25. Have you been more thirsty or urinating more frequently?
26. Have you noticed any burning, tingling or numbness in your hands or feet?
27. Are you taking any medications?
28. Have you had any surgeries or hospitalizations in the last year?
29. When did you first start menstruating?
30. Tell me about the births of your children
31. Have you noticed any sexual problems?
32. Do you have any allergies to medications?
33. Tell me about your family's medical history.
34. Tell me about your home life and work.
35. How have you been eating?
36. Have you ever smoked? If so, how many packs per day?
37. Do you drink alcohol or use any recreational drugs?
38. How often do you exercise?
 Physical Exam
1. appearance
2. head
3. eyes
4. ENMT
5. neck
6. lung
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7. cardiovascular
8. abdominal
9. genital urinary
10. rectal
11. skin
12. breast
13. lymph nodes
14. musculoskeletal
15. neurological
16. temperature
17. pulse
18. blood pressure
20. weight
21. height
1. lipid profile
3. erythrocyte sedimentation rate (ESR)
4. fasting blood glucose, serum
5. thyroid stimulating hormone (TSH)
6. total T4
7. free T4 (FT4)
8. purified protein derivative (PPD) of tuberculin
9. Lyme titer
10. pulse oximetry
11. glycosylated hemoglobin assay (HbA1c)
12. glucose tolerance
13. urine albumen
15. liver profile
16. hepatitis screen
17. electrolytes
18. urinalysis
19. monospot/heterophile antibody (mononucleosis)
20. sleep study
21. chest x-ray (CXR)
22. echocardiogram (ECG)
23. electrocardiogram (EKG)
24. pulmonary function test (PFT)
 Treatment
 The following treatment options are available. The correct option appears in bold. (Use
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1. stress management
2. antidepressants
3. anti-anxiety agents
4. metformin
5. Xenical (orlistat)
6. diet
7. exercise
8. lifestyle changes
9. ACE inhibitors
10. hydrochlorothiazides
11. beta blockers
Tammy:
A 16-year-old female with mucopurulent cervicitis and herpes simplex virus. Screening
questions reveal the infection to have been transmitted by her current (and only) sex partner, who
has resisted using protection and seeking medical attention. Special attention is devoted to
cultural competency issues particularly as applied to a minor with sex-related problems.
 Objectives
 practice age-appropriate and culturally appropriate interpersonal dynamics in a
clinical setting
 ask appropriate questions for a sexual history
 adapt interviewing and exam skills to common African-American health beliefs
 correctly diagnose a patient presenting with a vaginal complaint
 Introduction
 Summary: Tammy is introduced in a brief video vignette. The encounter goes badly, and
you are given an opportunity to critically review the doctor's performance.
 Responses for the critical review section. (Use keywords from these phrases to call up
program content.)
1. slow down
2. one question at a time
3. be discreet
4. show sensitivity in sex-related questions
5. lead with an open-ended question
6. avoid jargon
7. use effective nonverbal interpersonal skills
8. show empathy
9. encourage questions
 Cultural Competency
 Contains reviews of several articles on cultural with African-American patients. For
additional general information on cultural competency, see the Cultural Competency module
from Miguel's case.
1. genital herpes simplex
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2. condyloma acuminatum
3. syphilis
4. chancroid
5. bacterial vaginosis
6. trichomoniasis
7. vulvovaginal candidiasis
8. mucopurulent cervicitis (MPC)
9. chlamydia
10. gonorrhea
11. pelvic inflammatory disease (PID)
12. urinary tract infection
 Patient History
9. How long have you had these symptoms?
10. How would you describe your symptoms?
11. Have you had a fever?
12. Have you seen any vaginal discharge?
13. Have you had any vaginal bleeding?
14. Do you have any abdominal pain?
15. Do you have any itching?
16. Do you have any sores or lesions?
17. Do you have a rash now or in the past month?
18. Have you tried to treat yourself with any over the counter medications?
19. Do you have any burning when you urinate?
20. Do you have any back pain?
21. Have you lost any weight?
22. When was your last menstrual period?
23. Have you ever been pregnant?
24. Are you in a relationship now?
25. How long have you been in this relationship?
26. What have you and your partner done together? Kissed? Oral sex, anal sex, or
vaginal sex?
27. When did you first start having sex?
28. How many partners have you had since you have started to have sex?
29. Does your partner have any problems?
30. Are your sex partners male or female, or both?
31. Have you ever had any sexually transmitted diseases?
32. Have you had any vomiting?
33. Have you ever had a Pap smear?
34. Have you ever been on birth control?
35. Do you use condoms?
36. Have you ever been tested for HIV?
37. Have you ever been abused, sexually or verbally?
38. Do you smoke cigarettes?
39. Do you drink alcohol?
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40. Do you smoke weed?

41. Have you used drugs like Ectasy, cocaine, heroin?
42. Does your partner use any drugs?
43. Do you have a sore throat?
44. Are you ever short of breath?
45. Do you have any joint pain?
 Physical Exam
1. appearance
2. head
3. eyes
4. ENMT
5. neck
6. lung
7. cardiovascular
8. abdominal
9. genital urinary
10. skin
11. lymph nodes
12. musculoskeletal
13. neurological
14. temperature
15. pulse
17. weight
18. height
1. urinalysis
2. wet mount
3. urine pregnancy test
4. chlamydia by DNA amplification
5. gonorrhea by DNA amplification
6. herpes culture
7. syphilis, RPR
8. HIV ELISA
9. KOH examination
 Treatment
1. antiviral drugs
2. macrolides or tetracyclines
3. metronidazole
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4. antifungal drugs
5. bactrim
6. cephalosporin
7. partner testing and treatment
8. Pap smear testing and family planning counseling
Sean:
A 28-year-old male with chest pain caused by alcohol-induced gastroesophageal reflux disease.
Sean has a stressful work life and is socially isolated. These psychosocial issues seem to drive his
excessive alcohol use, so again motivational interviewing for lifestyle change is an important
component of intervention.
 Objectives
 demonstrate a thorough historical assessment of chest pain in the outpatient setting,
including a comprehensive assessment of risk factors for coronary artery disease and
other common causes of chest pain.
 perform physical exam items relevant to the evaluation of the presenting complain,
given the differential diagnosis suggested by the history
 perform appropriate office-based investigations at the time of initial presentation
 demonstrate an appropriate balance between cost- and safety-consciousness in
ordering additional investigations
 derive the correct diagnosis and treatment plan for this specific case
 Introduction
 Summary: Sean's case is outlined briefly along with the objectives listed above.
 Evaluation of Chest Pain
 Contains links to two articles on the diagnosis of chest pain, hosted by the National Guideline
Clearinghouse (NGC) of the DHHS Agency for Healthcare Research and Quality.
Note: guidelines in this clearinghouse are updated frequently; you may need to search the
NGC online database to find the current versions of the articles cited.
1. at-risk alcohol use
2. gastroesophageal reflux disease (GERD)
3. peptic ulcer disease
4. pancreatitis
5. asthma
6. angina
7. acute myocardial infarction
8. valvular disorder
9. cardiac dysrhythmia
10. intrathoracic neoplasm
11. hyperthyroidism
12. pulmonary emoboli
13. costochondritis
14. panic attacks
27 of 34
 Patient History
1. What brings you here today?
2. How long have you been having these pains?
3. How long do your pains typically last?
4. How often do you have an episode?
5. What makes the pain better or worse?
6. Have you tried anything to alleviate the pain, like over--the--counter pain relievers or
antacids?
7. How would you describe the pain?
8. How severe is the pain? Can you rate it on a scale from 1 to 10?
9. Does the pain have a burning sensation?
10. Where in your chest is the pain located?
11. Does the pain spread to other parts of your body?*
12. Do you have any other pains, such as stomach pain?
13. Have you been experiencing shortness of breath or sweating along with the pain?
14. Do you experience the pain when you exercise?
15. Are you more short of breath than usual when you exercise?
16. When does the pain happen? At work? In the evenings or on weekends? Is it
associated with meals or sleeping?
17. Is the pain more likely to occur if you are in a stressful situation?
18. Have you noticed any bowel problems or discolored stools?
19. Do you exercise?
20. Tell me about your family's medical history.
21. Tell me about your work.
22. How's your social life?
23. Do you use tobacco?
24. Do you use caffeine?
25. Do you use alcohol?
26. How much alcohol do you drink?
27. How many days per week do you drink alcohol?
28. On the days when you drink alcohol, how many drinks do you consume?
29. What's the most alcohol you've had at one sitting in the past 2 months?
30. Do you use any recreational drugs?
31. Are you taking any medications, herbal products or dietary supplements?
32. Are you sexually active?
33. Have your past sex partners been men, women...?
34. Do you use protection during sex?
35. How have these chest pains impacted your life?
36. What do you think causes your chest pains?
37. Do you have a sore throat?
38. Do you ever feel a sense of doom during these episodes of pain?
39. Do you have any chronic medical problems?
40. Do you have any allergies to medications or medical dyes?
41. What childhood illnesses have you had?
28 of 34
42. Do you have any history of mental illness?

43. Have you had any surgeries?
44. Have you suffered any serious injuries?
45. What is your support system?
46. Tell me about your diet.
47. Tell me about your sleeping patterns
48. [CAGE questionnaire] Have you tried to cut back on alcohol? Do you get annoyed
when someone suggests you are drinking too much? Do you ever feel guilty when
you are drinking alcohol? Do you ever have and eye--opener in the morning?
49. How have you been feeling in general?
50. Are you having any problems with your eyes?
51. Are you having any problems with your ears?
52. Are you having any problems with your mouth or throat?
53. Are you having any problems breathing?
54. Are you having any heart problems?
55. Are you having any problems with your bowels?
56. Are you having any problems urinating or with sexual function?
57. Are you having any problems with feeling hotter or colder than other people,
urinating a lot, or drinking a lot of water?
58. Have you had any problems with anemia, bleeding or bruising?
59. Do you suffer with environmental allergies or immune system problems?
60. Do you have problems with any of your joints?
 Physical Exam
1. appearance
2. head
3. eyes
4. ENMT
5. neck
6. lung
7. cardiovascular
8. abdominal
9. genital urinary
10. skin
11. lymph nodes
12. musculoskeletal
13. neurological
14. psychological
15. temperature
16. heart rate
17. blood pressure
19. weight
20. height
29 of 34
1. EKG
2. Pulse oximetry
3. Complete blood count (CBC)
4. Urinalysis
6. Comprehensive metabolic panel
7. amylase
8. lipase
9. Helicobacter pylori antibody
10. chest x-ray
11. lipid profile
12. creatinine phosphokinase - MB
13. cardiac troponins
14. exercise stress test
15. 24-hour Holter monitor
16. cardiac event monitor
17. upper GI series
18. upper GI endoscopy
19. peak flow
20. pulmonary function studies
21. function and myocardial perfusion
22. lung ventilation-perfusion scan
23. sprial chest CT scan
24. echocardiogram
25. fecal occult blood test
 Treatment
1. proton pump inhibitor
2. histamine 2 blocker
3. antacid
4. dietary and substance precautions
5. weight loss
6. small meals
7. avoid nighttime eating
8. elevate head of bed
9. eliminate non-steroidal anti-inflammatory drugs (NSAIDs)
10. metoclopramide (Reglan)
11. surgery
Sean:
Sean returns in a follow-up case several months later. His chest pain has cleared up with
pharmacological treatment and reduced alcohol use, but now he is feeling fatigued and is having
30 of 34
difficulty concentrating. Screening questions reveal that Sean meets criteria for generalized anxiety
disorder. Didactic content provides a detailed guide on psychiatric screening for non-psychiatrist
physicians.
 Objectives
 perform focused yet thorough history related to a symptom complex of fatigue,
worry, and insomnia
 perform a directed physical exam guyded by the differential diagnosis for this
symptom set
 demonstrate parsimony in the selection of labs and other investigations to assist in
formulating your diagnosis
 derive the correct diagnosis and formulate a basic treatment plan for this diagnosis.
 Introduction
 Summary: Sean's case is outlined briefly along with the objectives listed above.
 Psychiatric Screening
 Contains three book chapters on psychiatric screening by Robert K. Schneider, MD. The
MAPSO screening model is described in detail. Major depression, minor depression, and
dysthymia are distinguished, as are subsyndromal anxiety, general anxiety disorder, and
panic disorder.
1. at-risk alcohol use
2. generalized anxiety disorder
3. subsyndromal anxiety disorder
4. adverse effects of caffeine use
5. drug use
6. side effects of herbal medications
7. hyperthyroidism
8. panic attacks
9. depression
10. dysthymia
11. bipolar disorder
12. adjustment disorder
 Patient History
1. What brings you here today?
2. How long have you been experiencing this fatigue and difficulty concentrating?
3. Have you ever had these problems before?
4. What do you think causes your fatigue and difficulty concentrating?
5. How are things going at work?
6. How's your social life?
7. Are you having feelings of anxiety or worry?
8. What has your general mood been like?
9. Do you ever think about suicide?
31 of 34
10. Have you been feeling sad or depressed?

11. How have you been sleeping?
12. Are you feeling physical tension or aches?
13. Are you having any heart problems?
14. Have you felt any tremors?
15. Have you felt intolerant of heat?
16. Have you had loose stools or other bowel problems?
17. Have you had any changes in hair texture?
18. Have you lost weight?
19. Do you ever have dizzy spells?
20. Have you been experiencing shortness of breath?
21. Tell me more about your family's medical history -- is there any history of
anxiety or worrying?
22. Does anything make the fatigue better or worse?
23. Do you have any pain?
24. Do you use tobacco?
25. Do you use caffeine?
26. How much alcohol do you drink these days?
27. On the days when you drink alcohol, how many drinks do you consume?
28. Do you use any recreational drugs?
29. Are you taking any medications, herbal products or dietary supplements?
30. Are you sexually active?
31. How have these symptoms impacted your life?
32. Do you ever feel a sense of doom?
33. Have you made any changes to your diet since we last met?
34. Are you having any problems with your eyes?
35. Are you having any problems with your ears?
36. Are you having any problems with your mouth or throat?
37. Are you having any problems breathing?
38. Are you having any problems with your bowels?
39. Are you having any problems urinating or with sexual function?
40. Are you having any problems with feeling hotter or colder than other people,
urinating a lot, or drinking a lot of water?
41. Have you had any problems with anemia, bleeding or bruising?
42. Do you suffer with environmental allergies or immune system problems?
43. Do you have problems with any of your joints?
44. I'd like to follow up on the problems you were having at your last visit. How is your
chest pain?
 Physical Exam
1. appearance
2. head
3. eyes
4. ENMT
5. neck
32 of 34
6. lung
7. cardiovascular
8. abdominal
9. genital urinary
10. skin
11. lymph nodes
12. musculoskeletal
13. neurological
14. psychological
15. temperature
16. pulse
17. blood pressure
19. weight
20. height
1. thyroid stimulating hormone (TSH)
2. urine toxicology
3. Complete blood count (CBC)
5. Comprehensive metabolic panel
6. urinalysis
 Treatment
1. reduction of caffeine intake
2. selective serotonin reuptake inhibitor (SSRI)
3. benzodiazepines
4. cognitive-behavioral therapy (CBT)
5. buspirone
33 of 34
Help
Q: Why don't my search terms produce any hits?

A: The search algorithms in this program do not involve natural language processing or artificial
intelligence, so you'll find you have to match the terms you seek pretty closely. The case authors have
tried to make it easier by adding lists of related keywords, alternate terms, and alternate spellings (and/or
misspellings) for each database item.
You can also broaden your search using the search options, which appear below the search entry field:
Search by:  Headings  Content Search for:  Exact match  All words  Any word.
If you're not getting enough hits, try less restrictive settings (search by content; search for any word). If
you're getting too many hits and want to narrow it down, try more restrictive (search by headings; search
for an exact match).
Also, note the different structures of content items across modules:
module search for results

Differential Diagnosis diagnoses possibly related to the descriptions of the conditions
patient's condition associated with the given
diagnosis
Patient History questions to be asked of the patient or caregiver's responses
patient or caregiver
Physical Exam body parts and organ systems examination findings
Labs & Diagnostic Tests lab tests and/or diagnostic lab reports, diagnostic media (x-
studies related to the patient's rays, etc.)
condition
Treatment medicines, descriptions of the treatment
behavior modifications, options
therapeutic interventions
Q: Why isn't my patient record being updated as I go through the case modules?
A: Be sure to click on the Continue button to exit a module as you complete it. If you exit by any
other means, your data will not be recorded. Also be sure that you're checking in the right place on the
patient record. Note the tabs along the left side; each displays a separate page. Some of these pages
include a second row of tabs closer to the center of the page.
Q: Why don't I get green check marks on all the modules?

A: The green check marks are most useful as an indication that you have completed a thorough history
and physical, as defined by the case author. But they are not strictly required; you can always proceed
to the next module, or revisit any module you like. On some modules, the notion of completeness may
not be appropriate or necessary, so the check marks may never change to green. See the section on
Check marks and required keywords, above, for a more detailed explanation.
34 of 34

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Case Studies in Family Medicine Instructor Manual

Consult CD wallet for complete listing of content authors.

Copyright © 2005 Virginia Commonwealth University.

How to use this manual........................................................................................................... 3

Program introduction .............................................................................................................. 3

Program objectives ................................................................................................................. 3

How CSFM is used in clinical instruction .............................................................................. 4

Getting started ......................................................................................................................... 4

Case menu ............................................................................................................................... 5

Case structure ......................................................................................................................... 5

Check marks and required keywords ....................................................................................................... 8

Case outlines ........................................................................................................................... 9

Willa Mae: .................................................................................................................................................. 15

How to use this manual

 To stimulate students to practice and perfect clinical reasoning skills.

How CSFM is used in clinical instruction

Check marks and required keywords

30. Where does Miguel seem to hurt?

17. Have you had any severe headaches?

8. lateral collateral ligament (LCL) tear

3. Have you had this problem before?

40. Do you smoke weed?

42. Do you have any history of mental illness?

10. Have you been feeling sad or depressed?

Q: Why don't my search terms produce any hits?

Also, note the different structures of content items across modules:

module search for results

Q: Why don't I get green check marks on all the modules?

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Instructor's Manual Family Medicine Cases

Instructor's Manual Family Medicine Cases