How to Answer Patient Chief Complaints Questions (Complete Guide)

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Break the problem into smaller parts and analyze each logically.

Key Explanation

This topic involves patient chief complaints. A strong answer should include explanation, application, and examples.

Original Question

Patient’s Chief Complaints and History of Present Illness Mrs. H.J. is a 40-year-old woman with an 18-year history of multiple sclerosis. Her chief complaints today are numbness on the left side of her face and tongue, progressive weakness in her right leg, and constipation. “My balance is getting lousy when I walk,” she states. “Sometimes I veer like an old drunken sailor.” She has not had a bowel movement in three days. She denies pain during straining episodes. Over-the-counter laxatives have been ineffective. She developed a “bad cold” two weeks ago and these symptoms began occurring at the same time as she was recovering from the illness. Past Medical History • First attack of apparent MS at age 22: Patient had been in excellent health and suddenly lost sensation in tip of index finger of right hand, spread to all fingers of right hand, up into right arm and neck, right arm and neck muscles became weak; symptoms resolved. • Second attack of apparent MS at age 25: Vision in left eye became distorted, colors faded (especially red), vision became blurry with vigorous exercise, eyesight recovered after several Weeks. • Third attack of MS at age 28: Weakness in left leg and foot, patient had to be extremely cautious with each step, bringing the entire leg up with the knee bent and extending the leg outward with an exaggerated movement, diagnosis of MS confirmed. • Fourth attack of MS at age 32: Severe constipation with stomach cramps, resolved. • Fifth attack of MS at age 36: Sensations of “electrical buzzing” in her body whenever she lowered her head; right hand became severely numb during the course of 24 hours, soon followed by sensation of numbness in the right hip; the next day, patient developed a sensation of “spinning,” became extremely nauseous with severe vomiting, lost sense of balance and had to hold onto objects to remain vertical; left foot became numb and muscles in both legs and left arm became weak; developed mild incontinence; began losing sight in right eye. • Sixth attack of MS at age 38: Complete loss of balance, could not stand, vertigo and muscle weakness, period of vomiting; developed limp after walking a short distance; chronic fatigue; muscle cramps frequent; none of the symptoms seemed to remit. • Negative for chlamydial infections or syphilis • Negative for seizures. Family History The patient is of Belgian descent. She was born and raised in northeastern Wisconsin. She has no siblings. Both parents are alive and well. There is no family history of neurologic disease. Social History The patient is married and employed as a special procedures nurse at the hospital. She and her husband have one son (age 20, in college). She denies smoking and intravenous drug use. Patient drinks 1 cup of coffee every morning and has 3-4 glasses of wine each week with dinner. She is involved in a strictly monogamous relationship with her husband of 22 years. Patient enjoys music and reading. She plays cello. She gave up tennis years ago due to weakness and loss of coordination in her arms and legs. Medications Ibuprofen 400 mg po PRN for occasional headache Allergies No known drug allergies Review of Systems • Progressive weakness in arms and legs • Reports feeling “run down” • Recent past difficulty with incontinence • Subjective feeling of extreme weakness in hot weather • Reports lower abdominal fullness • Denies any current swallowing or speech problems Physical Examination and Laboratory Tests General The patient is a middle-aged white woman who appears to be her stated age. She does not appear to be in acute distress. The patient’s gait is slow and deliberate, but she is able to walk without assistance. Her affect is sad and she is tearful throughout the examination. She states that she is very concerned about the progression of her disease. Vital Signs Table #1atient Case Table 44.1 Vital Signs BP 115/70 RR 13 and unlabored WT 121 lbs P 74 and regular T 97.2°F HT 5 ft 5 in Skin • Warm and dry with normal turgor and color • No rashes or lesions noted Head, Eyes, Ears, Nose, and Throat (HEENT) • Pupils equal at 3 mm, round, reactive to light and accommodation • Funduscopic exam normal • Nystagmus is present • Slight dysfunction of extra-ocular muscles bilaterally • External auricular canals clear • Tympanic membranes intact • Oropharynx well hydrated without erythema Neck/Lymph Nodes Supple without adenopathy or thyromegaly Heart • Regular rate and rhythm • S1 and S2 normal with no additional cardiac sounds • No gallops, murmurs, or friction rubs Lungs Clear to auscultation throughout Abdomen • No tenderness or guarding • No masses or bruits • Hypoactive bowel sounds • (-) organomegaly • (+) slight distension Rectal • Diminished anal reflex • Heme-negative stool • Large amount of stool in rectal vault • No fissures, hemorrhoids, or strictures Musculoskeletal/Extremities • Normal range of motion • Peripheral pulses 2 + throughout Neurologic • Alert, oriented, and cooperative • Mild subjective sense of auditory distortion despite intact auditory acuity • Cranial nerves II-XII intact • Motor strength 4/5 upper extremities and left leg, 3/5 in right leg • Motor tone is spastic throughout • Deep tendon reflexes 3_ throughout • Sensory exam reveals significant reductions in light touch and pinprick bilaterally • Coordination testing reveals moderate-to-severe unsteadiness with walking • Positive Romberg sign Laboratory Blood Test Results Table #2Patient Case Table 44.2 Laboratory Blood Test Results Na 143 meq/L Hb 14.2 g/dL AST 12 IU/L K 4.0 meq/L WBC 6,900/mm3 ALT 39 IU/L Cl 109 meq/L Plt 292,000/mm3 Alk phos 67 IU/L HCO3 23 meq/L BUN 11 mg/dL Total bilirubin 0.6 mg/dL Ca 9.2 mg/dL Cr 0.8 mg/dL Alb 3.9 g/dL Hct 38% Glu, fasting 109 mg/dL Total protein 6.8 g/dL Spinal Tap • CSF clear and colorless • (+) mild lymphocytosis • (+) elevated IgG concentration • (+) elevated myelin basic protein level • Glucose: 60 mg/dL • Protein: 60 mg/dL MRI Scanning of Brain and Spinal Cord Multiple plaques in the perivascular white matter, cerebellum, and spinal cord. Plaque sizes have uniformly increased in size since MRI 3 years ago. New plaques observed since last MRI. 1. Why is lymphocytosis in the CSF consistent with an attack of multiple sclerosis? 2. Before a definitive diagnosis of multiple sclerosis is made, healthcare providers will often conduct various tests on patients. Briefly explain the rationale for each of the following tests. a. serum vitamin B12 concentration b. serum folate concentration c. erythrocyte sedimentation rate d. antinuclear antibody (ANA) test e. serology for Lyme disease e. VDRL test.

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