Greeting
Good day, dear Professor Doctor …,
I would like to present the patient Ivana Slivoviz to you now.
She is 34 years old, one meter sixty-nine tall and weighs about 70 kg. This results in a body mass index (BMI) of approximately 24.5 kg/m², which places her within the normal weight range (upper normal range).
Presenting history
The patient presented because of generalized pain in multiple body regions for about six months, in several body regions notably in the neck-, shoulder-, back– as well as hip and legarea.
According to her report, there has been a marked increase in symptoms over the last four to six weeks.
She stated the pain was bilateral, dull-aching and sometimes painful even with slight pressure. Mild movement and warm showers lead to improvement.
Additionally, the patient reports intermittently occurring, diffuse, cramp-like abdominal pain that usually improves after bowel movements .
There is an alternation between constipation and diarrhea, with up to four to six bowel movements daily reported during diarrheal phases.
Concomitantly, the patient complains of pronounced fatigue, rapid exhaustion and morning stiffness.
She further describes evening and nocturnal sensations in the legs with a strong urge to move, making it considerably difficult to fall asleep.
Concentration problems and reduced performance in everyday life are reported.
From time to time she experiences panic attacks with palpitations, a feeling of tightness in the chest, dyspnea, hyperhidrosis and inner restlessness — usually without a clear trigger or in stressful situations.
Fever, Night sweats, weight changes, neurological deficits, visual disturbances as well as urogenital or gynecological complaints are denied.
Extensive internal medicine and cardiological evaluations including colonoscopy and laboratory tests have, according to her, already been performed and were without pathological findings.
The patient is insured with the Techniker Krankenkasse, abbreviated TK.
Autonomic history
In the autonomic history, an initiating insomnia in the context of a possible restless legs syndrome is notable.
Past medical history
Her known past medical history includes the following:
About ten years ago she had a mild depressive episode that did not require pharmacological therapy.
No known chronic internal medical conditions are present.
Previous surgeries
A tonsillectomy was performed at about age 12 without complications.
Note: When a statement can be objectively confirmed by a medical examination — for example by visible scars — the indicative is appropriate. (No physical examination takes place during the Fachsprachprüfung.)
Gynecology
Her last menstruation was five days ago, the cycle is regular. She is not currently pregnant.
Medications
She takes as needed ibuprofen 400 mg and paracetamol 500 mg.
She has been vaccinated against TBE and against COVID-19.
Note: When a statement can be objectively confirmed by a physician’s observation — for example by a prescription — the indicative is appropriate.
Allergies
She has an allergy to Novalgin with occurrence of urticaria.
. In addition, there is a penicillin allergy with dyspnea and dizziness in the sense of an anaphylactic reaction.
.
Exposures The patient is a former smoker and smoked until about two years ago around half a pack of cigarettes per day for a period of five years, corresponding to 2.5.
pack-years
. There is occasional alcohol consumption, mainly on weekends in the form of beer or wine.
In the past there was occasional hashish use.
Currently no drugs are being used.
Social history
She is single and lives independently.
No pets.
Family history
The mother died at the age of 75 from the consequences of a stroke.
The father is 88 years old and suffers from a Prostate carcinoma; in addition, there is a status post stroke.
Suspected and differential diagnosis
Due to the chronic, generalized musculoskeletal pain, pronounced fatigue, functional gastrointestinal complaints, and accompanying anxiety and sleep disturbances, there is suspicion of a fibromyalgia syndrome in combination with irritable bowel syndrome and an anxiety disorder. In addition, there are indications of a possible Restless Legs Syndrome.
Differentially, inflammatory-rheumatologic diseases such as rheumatoid arthritis or Polymyalgia rheumatica should be considered; however, systemic symptoms such as fever, night sweats, and weight loss are absent. Furthermore, previous laboratory inflammatory parameters, particularly C-reactive protein (CRP), were unremarkable.
Endocrinological causes such as hypothyroidism or an adrenal gland dysfunction should also be considered, but typical clinical signs such as cold intolerance, weight gain, hyperpigmentation, or blood pressure changes are lacking.
Neurological diseases such as Multiple Sclerosis or a polyneuropathy should also be considered differentially, although previous examinations were unremarkable and no focal neurological deficits were detected.
Diagnostic evaluation
Since neither red-flag signs nor a vital emergency are present, the patient can be cared for and treated on an outpatient basis.
It is essential to consistently exclude organic causes.
physical examination
Following the history, a comprehensive physical examination is performed, beginning with the assessment of vital signs, including heart rate, blood pressure, respiratory rate, oxygen saturation and temperature.
On inspection, we specifically look for signs of anemia, such as pallor of the skin or conjunctivae, as well as skin changes like erythema, scaling, or subcutaneous nodules, as may occur in rheumatologic diseases.
On palpation we primarily assess tenderness to pressure at characteristic pain sites and the thyroid for size and consistency.
On auscultation we pay attention to heart and lung sounds, particularly the presence of heart murmurs as an indication of cardiac disease.
On percussion of the abdomen we may detect signs of hepatomegaly and/or splenomegaly.
During the history we ask specifically about mood and anxiety to identify possible comorbidities such as depression or anxiety disorders.
Laboratory testing
The following laboratory tests are performed:
|
Parameter |
Result |
Reference range |
|
Hemoglobin (Hb) |
13.4 g/dl |
12.0–16.0 g/dl |
|
Leukocytes |
6.2 ×10⁹/l |
4.0–10.0 ×10⁹/l |
|
Platelets |
265 ×10⁹/l |
150–400 ×10⁹/l |
|
CRP |
<0.5 mg/dl |
<0.5 mg/dl |
|
ESR (1 h) |
8 mm |
<20 mm |
|
TSH |
1.8 mIU/l |
0.4–4.0 mIU/l |
|
Ferritin |
45 µg/l |
15–150 µg/l |
|
Vitamin B12 |
420 pg/ml |
200–900 pg/ml |
|
Vitamin D (25-OH) |
24 ng/ml |
>30 ng/ml |
|
CK |
98 U/l |
<170 U/l |
|
Creatinine |
0.78 mg/dl |
0.5–1.1 mg/dl |
|
eGFR |
>90 ml/min |
>60 ml/min |
|
AST (GOT) |
22 U/l |
<35 U/l |
|
ALT (GPT) |
19 U/l |
<35 U/l |
|
Calcium |
2.32 mmol/l |
2.15–2.55 mmol/l |
|
Fasting glucose |
92 mg/dl |
70–100 mg/dl |
Electrocardiogram
An electrocardiogram serves for basic assessment and to exclude cardiovascular causes.
Consultations
psychological
Treatment
The treatment mainly includes educational measures and psychotherapeutic interventions. This includes supportive aspects such as empathetic communication, psychoeducational measures, and reassurance in terms of calming and informing the patient.
A central therapeutic approach is cognitive behavioral therapy (CBT).
It is also important to identify and adequately treat accompanying depression or anxiety disorders early, for example with selective serotonin reuptake inhibitors (SSRIs).
For symptom management, targeted pharmacological measures can be used, for example to treat diarrhea with loperamide or diphenoxylate.
After exclusion of anemia as well as iron or vitamin D deficiency, if restless legs syndrome is present, a pharmacological therapy such as pregabalin or pramipexole may be considered, whereby especially with pramipexole a careful benefit–risk assessment is required.
Complications
The complaints particularly impair the patient’s everyday life and occupational performance.
Extra
Names:
Stefan Krüger, Jan Petersen, Katharina Braun, Miriam Köhler
Professions:
Electrician, teacher
Medical history:
About ten years ago there was a major depression (MDD) with suicidal thoughts, in the absence of sufficient psychosocial support.
Medications:
Citalopram 20 mg once daily
Loperamide
Questions
1. What do I actually have? And why have all examinations been unremarkable so far?
That is a very understandable question. From what you have described to me, and since all previous examinations were unremarkable, much speaks for a so-called functional disorder. That means the complaints are real and distressing for you, but no organic cause is found in the usual examinations. This is not dangerous, but it can be very burdensome. It is important that we now look together at how we can gradually relieve your complaints and improve your everyday life.
|
Diagnostic criteria Fibromyalgia syndrome (ACR) |
||
|
Criterion |
Description |
Requirement |
|
Generalized pain |
Pain in multiple body regions (above and below the waist, left and right, axial skeleton) |
≥ 3 months |
|
Widespread Pain Index |
Number of painful body regions (0–19) |
WPI ≥ 7 and SS ≥ 5 or WPI 4–6 and SS ≥ 9 |
|
Symptom Severity Scale (SS) |
Assessment of fatigue, non-restorative sleep, cognitive symptoms and somatic complaints (0–12) |
Part of the diagnosis |
|
Fatigue |
Marked physical and mental exhaustion |
frequently present |
|
Sleep disturbances |
Non-restorative sleep, difficulty falling or staying asleep |
frequently present |
|
Cognitive symptoms |
Concentration and memory impairments (“fibro fog”) |
frequently present |
|
Exclusion of other causes |
No other disease that better explains the symptoms |
mandatory |
|
Laboratory findings |
No inflammatory or structural abnormalities |
typically unremarkable |
|
Diagnostic criteria Irritable bowel syndrome (Rome IV) |
||
|
Criterion |
Description |
Requirement |
|
Leading symptom abdominal pain |
Recurrent abdominal pain |
≥ 1 day/week |
|
Time criterion |
Complaints have been present for at least 6 months |
mandatory |
|
Relation to defecation |
Pain improves or worsens with bowel movements |
≥ 1 criterion |
|
Stool frequency |
Relation to altered stool frequency |
≥ 1 criterion |
|
Stool form |
Relation to altered stool form (hard / soft / watery) |
≥ 1 criterion |
|
Exclusion of organic causes |
No structural or inflammatory explanation |
mandatory |
|
Laboratory / imaging |
No pathological findings |
typically unremarkable |
Notes
BMI
Term: BMI (Body Mass Index).
Definition and calculation: Ratio of body weight to height; calculated as body weight in kilograms divided by the square of height in meters.
multiple body regions
Term: multiple body regions.
Meaning: Refers to the occurrence of complaints or pain in several anatomical areas simultaneously.
Constipation
Term: constipation.
Explanation: Decreased stool frequency and/or difficult stool passage often with hard stool or a feeling of incomplete bowel emptying.
Diarrhea
Term: diarrhea.
Explanation: Increased stool frequency and decreased stool consistency; often characterized as three or more loose to watery stools per day.
Urge to move
Term: urge to move.
Explanation: A strong inner need to move, often associated with unpleasant sensations such as pulling, tingling or tension that increase at rest and especially in the evening or at night and temporarily improve with movement.
Palpitation
Term: Palpitation.
Explanation: Subjective perception of the heartbeat, for example as pounding, racing heart, or irregular heart sensations.
Dyspnoea
Term: Dyspnoea
Definition and characteristics: Dyspnoea denotes the subjective sensation of breathlessness or labored breathing. It can present as breathlessness on exertion, at rest, or as a sudden feeling of tightness.
Clinical classification: Dyspnoea can have organic causes (e.g., cardiac or pulmonary diseases, anemia, metabolic disorders) as well as psychogenic causes (e.g., panic attacks). Objective accompanying signs may include rapid breathing, visible use of accessory respiratory muscles, or cyanosis.
Extensive internal medicine and cardiology evaluations
Term: Extensive internal medicine and cardiology evaluations
Meaning: This phrase describes a comprehensive diagnostic approach by specialists in internal medicine and cardiology to clarify internal or cardiac complaints.
Typical components: Such evaluations include history-taking and physical examination as well as basic cardiological diagnostics (e.g., resting ECG, Holter ECG, echocardiography) and orienting laboratory tests. Depending on the suspected diagnosis, supplementary procedures such as stress testing, imaging techniques, or specialty-specific examinations may be added.
Techniker Krankenkasse
Term: Techniker Krankenkasse
General description: The Techniker Krankenkasse is a statutory health insurance provider operating in Germany. It provides its insured persons access to medically necessary services within the framework of statutory regulations.
Scope of services (general): These include care by physicians, reimbursement of legally prescribed medications and remedies, as well as preventive offers and other legally defined benefits for insured persons.
depressive
Term: depressive
Definition: The adjective ‘depressive’ refers to states or conditions with pronounced low mood. In clinical practice it often describes a depressive episode or depressive disorder.
Core features: Typical features are persistent low mood, loss of interest or pleasure, reduced drive, sleep and appetite disturbances, concentration difficulties, and in severe cases suicidal thoughts. Severity and duration vary and determine classification (e.g., mild, moderate, severe).
Tonsillectomy
Term: Tonsillectomy
Definition: A tonsillectomy is the surgical removal of the palatine tonsils (tonsillae palatinae).
Indications: Frequent or complicated tonsillar disease, obstructive airway impairment due to enlarged tonsils, or therapy-refractory peritonsillar disease can be indications for the procedure.
Procedure: The operation is generally performed under general anesthesia; surgical techniques and aftercare may vary.
Major risks: Relevant complications include postoperative bleeding (primary or secondary), severe pain on swallowing, as well as wound-healing disorders or infections; postoperative hemorrhage is considered a particularly significant complication.
Ibuprofen
Drug class and mechanism
Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID). It works by inhibiting cyclooxygenase enzymes (COX) and thereby reducing the formation of prostaglandin-like mediators involved in pain and inflammatory processes.
Indications
It is used to relieve mild to moderate pain as well as inflammatory conditions and fever.
Dosage forms and precautions
Ibuprofen is available in various formulations, for example as tablets, capsules, suspensions, and suppositories. Important risks include gastrointestinal irritation up to bleeding tendency, deterioration of renal function, hypersensitivity reactions, and an increased cardiovascular risk with long-term use. Preexisting stomach, kidney, or heart diseases and concomitant use of other NSAIDs require special caution.
TBE (FSME)
Pathogen and transmission
TBE (Frühsommer-Meningoenzephalitis) is caused by a tick-borne flavivirus.
Clinical course and progression
The disease typically can proceed in two phases: an initial flu-like phase and, in a subset of affected individuals, later involvement of the central nervous system with meningitis, encephalitis, or myelitis.
Treatment and prevention
There is no specific antiviral therapy; treatment focuses on symptom relief and support of vital functions. Vaccination approved for risk areas provides protection against infection.
COVID-19
Manual review required: The note contains an unclearly established or inconsistent time definition for ‘Long COVID’ (different guidelines use different time thresholds). Due to this uncertainty, no substantive addition was made.
Urticaria
Definition and presentation
Urticaria, also called hives, is a skin reaction characterized by transient, predominantly itchy wheals (raised, reddened areas of skin).
Classification and causes
Acute urticaria is distinguished from chronic urticaria; the latter persists for longer periods and often requires further evaluation. Triggers can include allergens, infections, medications, or physical stimuli; it is often based on the release of mediators such as histamine from mast cells.
Relevant relations
Urticaria can occur in isolation or as part of a systemic allergic reaction; in recurrent or long-lasting cases, specialist evaluation is advisable.
anaphylactic reaction
Definition and severity
An anaphylactic reaction is a rapidly occurring, potentially life-threatening systemic hypersensitivity reaction that can affect multiple organ systems.
Clinical features
Typical manifestations are airway constriction with breathing difficulties, circulatory collapse with blood pressure drop, skin signs such as redness or wheals, and gastrointestinal symptoms. Symptoms usually occur shortly after contact with a triggering agent (e.g., medications, foods, insect venom).
General management (contextual)
Anaphylaxis is a medical emergency requiring immediate emergency medical care; typical acute medical measures aim to stabilize breathing and circulation.
Pack years
Definition
Pack years are a measure of cumulative tobacco exposure over time and are used to estimate the risk associated with smoking.
Calculation
To calculate pack years, divide the number of cigarettes smoked daily by 20 (one pack) and multiply the result by the years of smoking: (cigarettes per day ÷ 20) × years smoked.
Significance
Higher pack years correlate with an increased risk for tobacco-associated diseases such as chronic lung disease, cardiovascular diseases, and malignancies.
Prostate carcinoma
Definition
Prostate carcinoma is a malignant neoplasm of the prostate and is among the most common cancers in males.
Risk factors
Important factors include advancing age and family history; hormonal aspects play a role in pathogenesis and progression.
Clinical presentation
Early stages often proceed without symptoms. In advanced disease, urinary problems, pain from bone metastases, or general signs of illness can occur.
Diagnostics and monitoring
Evaluation includes clinical examination including digital rectal examination, laboratory diagnostics (e.g., PSA measurement) and histological confirmation via prostate biopsy; additional imaging procedures are used for staging.
Restless legs syndrome
Definition
Restless legs syndrome is a neurological disorder that causes an irresistible urge to move the legs, usually accompanied by unpleasant sensations.
Clinical features
Symptoms occur mainly at rest and in the evening or nighttime, are relieved by movement, and often lead to sleep disturbances and daytime sleepiness.
Associations
Affected individuals frequently have iron deficiency states; neurological or systemic underlying diseases may also be present. Diagnosis is based on the typical history and clinical criteria.
rheumatoid arthritis
Definition
Rheumatoid arthritis is a chronic inflammatory systemic disease that predominantly affects the joints and is autoimmune mediated.
Clinical features
Characteristic are symmetrical involvement of small joints with pain, swelling, and pronounced morning stiffness that typically lasts a long time.
Diagnostics
Diagnosis relies on clinical examination, laboratory inflammatory markers, and detection of specific autoantibodies (e.g., rheumatoid factor, anti-CCP). Imaging techniques complement the assessment of joint findings.
Therapeutic principles
The aim is early modification of disease course with disease-modifying antirheumatic drugs (DMARDs) and adjunct anti-inflammatory measures as well as rehabilitative interventions to preserve function.
Polymyalgia rheumatica
Definition:
Polymyalgia rheumatica (PMR) is an inflammatory rheumatic disease of older age, typically occurring in people over 50 years.
Clinical presentation:
Characteristic are bilateral pain and pronounced morning stiffness, especially in the shoulder region and pelvic girdle; the complaints are often symmetrical.
Laboratory and imaging:
Typically there are elevated inflammatory markers (e.g. ESR, CRP), while conventional joint imaging often remains unremarkable. It is, however, possible that inflammatory parameters are normal in individual cases; this does not completely exclude the disease.
Therapy and diagnostic hints:
The symptoms usually respond rapidly to administration of systemic glucocorticoids, which can be diagnostically supportive; however, a sole response to steroids does not constitute definitive proof of the disease. Further clarification and exclusion of other differential diagnoses are required.
Multiple Sclerosis
Definition:
Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system with autoimmune pathogenesis, in which myelin-containing structures in the brain and spinal cord are destroyed.
Clinical presentation:
The disease often presents in relapses with various neurological deficits, such as sensory disturbances, visual disturbances (e.g. optic neuritis), motor weakness, coordination disorders and disturbances of bladder or bowel function.
Diagnostics:
The diagnosis is based on evidence of spatial and temporal dissemination of neurological lesions; clinical findings are combined with imaging techniques (MRI) and supplementary investigations such as cerebrospinal fluid analysis.
Therapy:
Acute relapses are often treated with high‑dose glucocorticoids; various disease‑modifying therapies are available to alter the course of the disease and are chosen individually.
Blood pressure
Term and significance:
Blood pressure denotes the force that circulating blood exerts on the vessel walls; it is described by systolic and diastolic components.
Measurement method and device:
Blood pressure measurement is usually performed with an inflatable cuff and either a stethoscopic auscultation method or an automatic oscillometric device. An appropriately sized cuff is important for valid results.
Practical notes:
Measurement under standardized conditions (sitting, arm supported, rest period) improves comparability. If arterial hypertension is suspected, repeated measurements or ambulatory/home blood pressure monitoring are advisable to secure the diagnosis.
Respiratory rate
Term and normal range:
Respiratory rate is the number of breaths per minute and is one of the basic vital parameters. In adults, the normal respiratory rate is usually in the range of about 12 to 20 breaths per minute.
Deviations:
An increased respiratory rate (tachypnea) occurs in various cardiorespiratory or metabolic disorders; a decreased rate (bradypnea) can also be clinically relevant.
Measurement method:
The respiratory rate should preferably be unobtrusively observed for at least 30 seconds and then extrapolated to one minute to avoid measurement errors due to obvious observation or patient alteration of breathing.
Oxygen saturation
Term and measurement principle:
Oxygen saturation (SpO2) is a percentage approximation of haemoglobin saturation and is determined noninvasively by pulse oximetry. An oximetric device measures light absorption at a body site (e.g. finger, earlobe) and thus provides an estimate of arterial oxygen binding.
Limitations and practical aspects:
Pulse oximeters provide an approximation and can be affected by factors such as poor perfusion, motion, nail polish, skin pigmentation or certain dysglobulinemias. In unclear cases, arterial blood gas analysis and clinical assessment should be considered.
Temperature
Term and measurement sites:
Body temperature describes the warmth of the body; measurement sites include rectal, oral and axillary, with rectal measurements being closest to core temperature.
Comparison of measurement sites:
Oral measurements typically lie slightly below rectal values, axillary measurements generally show even lower values than oral. Due to these systematic differences, results from different sites should not be equated 1:1.
Practical notes:
If an accurate determination of core body temperature is required, choosing the appropriate measurement site and knowing the usual differences between methods is important.
Tenderness to pressure
Tenderness to pressure
Tenderness to pressure denotes the onset or intensification of pain when pressure is applied to a body region. It is a clinical sign that may indicate local irritation or inflammatory processes in the skin, soft tissues, muscles, joints or organs. In assessment, location, intensity, reproducibility and accompanying symptoms are important, as they can provide clues to possible causes such as inflammation, hematoma, infection or mechanical irritation. Differentially, one should distinguish between hypersensitive sensitivity (hyperalgesia/allodynia) and a clearly localizable pressure pain; findings must be interpreted in the context of history and further examinations.
Percussion
Percussion
Percussion is a clinical examination method in which the sound produced by tapping the body surface is assessed to draw conclusions about the underlying structures. Different sounds (e.g. resonant, tympanitic, dull) indicate air, tissue or fluid conditions.
Clinically, percussion is used to delimit organ boundaries and to detect changes such as enlarged or altered organs as well as fluid collections. In the abdomen, percussive findings can help estimate organ enlargement such as hepatomegaly or splenomegaly and detect abnormal distributions of air or fluid; findings should always be combined with other examination results.
PatientSalutation: Mr/Ms Senior physician ……….., I would like to present the patient Ivana Slivoviz to you. |
Date01/02/2025 |
| Age 34 years | Weight 70 kg | Height 169 cm |
Allergies (keywords)
Novalgin (urticaria)
Penicillin (dyspnea and dizziness in the sense of anaphylaxis)
Substances / drugs (keywords)
Former smoker, until 2 years ago, approx. ½ pack/day for 5 years equals 2.5 pack-years.
Occasional alcohol consumption (weekends, beer or wine)
Former occasional cannabis use
No current drugs
Social history (keywords)
Occupation: geriatric nurse
Single
Lives independently
No pets
Family history (keywords)
Mother: deceased at 75 years from stroke
Father: 88 years, prostate carcinoma, status post stroke
Medications (keywords)
Paracetamol/ibuprofen as needed
No long-term medication
History (full sentences)
The patient presented due to generalized pain in multiple body regions for about six months, particularly in the neck, shoulder, back, as well as hip and leg areas. According to her, the symptoms have markedly increased over the last four to six weeks.
She stated the pain was bilateral, dull and pulling, and partly painful even with light pressure.
In addition, the patient reports intermittently occurring, diffuse, cramp-like abdominal pain, which usually improves after bowel movements.
There is an alternation between constipation and diarrhea, with up to four to six bowel movements daily during diarrhea phases.
Accompanying complaints include pronounced fatigue, rapid exhaustion, and morning stiffness. She also describes evening and nighttime paresthesias in the legs with a strong urge to move, which significantly impairs falling asleep.
Concentration difficulties and reduced performance in daily life are reported.
Occasionally panic attacks occur with palpitations, a feeling of tightness in the chest, dyspnea, hyperhidrosis, and inner restlessness, mostly without a clear trigger.
Fever, night sweats, weight changes, neurological deficits, visual disturbances, and urogenital or gynecological complaints are denied.
Extensive internal medicine and cardiological evaluations including colonoscopy and laboratory tests have reportedly already been performed and were without pathological findings.
Past illnesses / surgeries:
Tonsillectomy at about age 12
Mild depressive episode about 10 years ago, currently not in treatment
No known chronic internal medical conditions
Suspected diagnosis – differential diagnosis (full sentences)
Due to the chronic, generalized musculoskeletal pain, pronounced fatigue, functional gastrointestinal complaints, and accompanying anxiety and sleep disturbances, a fibromyalgia syndrome in combination with irritable bowel syndrome and an anxiety disorder is suspected. The patient also shows signs of a possible restless legs syndrome.
Differentially, inflammatory-rheumatologic diseases, endocrine causes, and neurological disorders should be considered, although previous investigations were unremarkable.
Further approach – therapy (full sentences)
A structured interdisciplinary follow-up treatment is recommended. Planned are a repeat clinical examination, basic laboratory control, and if necessary a rheumatological consultation to exclude organic causes.
In addition, psychosomatic or psychotherapeutic linkage for co-treatment of the anxiety and sleep disorder is recommended. The patient was informed about the functional character of the complaints and the further procedure.
Signature
First name Last name
Kind regards
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Page 1 · 1–20 / 57
DOCTOR: Hello,
My name is Dr. Ziegler.
I am working today as the junior doctor on the ward.
I would like to conduct a medical history interview with you.
If you did not understand something correctly or have questions, please let me know.
First I need some personal information, then we can continue.
What is your name?
PATIENT: My name is Ivana Slivoviz.
DOCTOR: Did I spell your name correctly: Ivana Slivoviz?
PATIENT: Yes, that is correct.
DOCTOR: Ah, thank you for the correction.
First of all, I would like to find out whether you consider the pain or complaints tolerable.
PATIENT: The pain has been present for several months.
I can manage it until the end of the conversation.
DOCTOR: Alright. How old are you, Ms. Slivoviz?
PATIENT: I am thirty-four years old.
DOCTOR: When exactly were you born?
PATIENT: My birthday is on December ninth, 1989.
DOCTOR: How tall are you?
PATIENT: I am one point sixty-nine meters tall.
DOCTOR: How much do you weigh?
PATIENT: I weigh about seventy kilograms.
PATIENT: DOCTOR: What is the name of your general practitioner?
PATIENT: My GP is Doctor Karla Scholz.
DOCTOR: Could you tell me more precisely where it hurts?
PATIENT: I have pain in several parts of the body, for example in the neck, shoulders, back and also in the legs.
But I came today because it has become noticeably worse in the last four to six weeks.
DOCTOR: When did the pain start exactly?
PATIENT: About six months ago.
DOCTOR: Is the pain more on one side or both sides?
And does it affect the upper body, the lower body, or both?
PATIENT: Actually on both sides.
It hurts in my neck and shoulders, but also in my back, hips and legs.
It feels like my whole body is affected.
DOCTOR: Does the pain radiate anywhere, for example into the arms?
PATIENT: No, not really.
DOCTOR: How do you perceive the pain?
Is it more dull, stabbing or pulling?
PATIENT: Mostly it’s dull, pulling pain.
But in addition I also have abdominal pain, which comes in waves.
DOCTOR: I see.
Is there anything that improves or worsens the pain, for example movement, showering, exertion or medication?
PATIENT: Yes, light movement and warm showers help me a bit.
I also tried ibuprofen 400 a few times, but that didn’t do much.
DOCTOR: Are the painful areas also sensitive when touched lightly or pressed?
PATIENT: Yes, sometimes even light pressure hurts.
DOCTOR: Can you tell me more about the abdominal pain?
Are there accompanying symptoms such as diarrhea or constipation?
PATIENT: I get rather diffuse, cramp-like abdominal pains.
Usually it gets better after bowel movements.
Also I frequently alternate between constipation and diarrhea.
DOCTOR: How long does such a phase usually last?
And how often do you need to go to the toilet when you have diarrhea?
PATIENT: Such a phase usually lasts a few days, sometimes one to two weeks.
When I have diarrhea I often have to go to the toilet four to six times a day.
DOCTOR: Have you noticed blood in the stool or black, tarry stool?
PATIENT: No, not at all.
DOCTOR: How do you usually feel?
PATIENT: I am often tired and get exhausted quickly.
DOCTOR: How do the pains affect your sleep and your everyday life?
PATIENT: It’s a bit different in the evenings and at night.
I have a strong urge in my legs; I have to keep moving them, otherwise this unpleasant sensation gets worse.
That’s why I find it very difficult to fall asleep.
During the day I can’t be as productive as I used to be.
DOCTOR: Are you stiff in the morning or do you need a while to get going?
PATIENT: Yes, in the mornings I often feel like I’m rusty; it takes a while before it gets better.
DOCTOR: Do you have problems like concentration difficulties, visual disturbances or unusual sensations?
PATIENT: Yes, I can’t concentrate properly at work, and it has happened that I made some mistakes.
Sometimes I have the feeling, especially in my legs, as if thousands of ants were crawling over my skin.
But I don’t have visual disturbances.
Page 2 · 21–40 / 57
DOCTOR: Do activities still give you pleasure?
Are you interested in your hobbies or things that usually make you happy?
PATIENT: If by that you mean something like depression – no, that’s not the case.
I am generally still interested, but the complaints often make me lack energy.
DOCTOR: Do you have any symptoms like loss of strength or muscle weakness?
PATIENT: No, I don’t have anything like that.
DOCTOR: Do you have the impression that your resilience has declined?
PATIENT: Yes, I get tired more quickly than before, but not to the point of lacking strength – it’s more this constant tiredness.
DOCTOR: Do you have symptoms like pale skin, shortness of breath, a racing heart, or cough?
PATIENT: At the moment I don’t have anything like that.
But sometimes I have an anxiety attack, and during that I have palpitations, a tightness in my chest and the feeling of not getting enough air
DOCTOR: How long does such an attack last?
Do you also sweat heavily during it?
PATIENT: Usually it lasts about ten to twenty minutes.
I do sweat heavily and feel very restless.
DOCTOR: Do you know a specific trigger for it?
PATIENT: I can’t name a very specific trigger.
Sometimes it happens in stressful situations, but sometimes quite suddenly without a clear reason.
DOCTOR: What do you mean exactly by stressful situations?
PATIENT: For example, when there’s a lot of pressure at work, when I feel overwhelmed, or when I notice the pain getting worse again.
Then I become very restless inside, and sometimes an attack develops from that.
DOCTOR: Do you have fever, night sweats or chills?
PATIENT: No, I haven’t noticed any of those symptoms.
DOCTOR: Do you have problems in other areas, for example with urination or regarding your gynecological health?
PATIENT: No, I don’t have any problems there.
DOCTOR: Have you taken any specific medications recently?
PATIENT: No, nothing special. On my neighbor’s recommendation I bought valerian from the drugstore, but that didn’t help.
DOCTOR: Have you therefore consulted other doctors so far?
PATIENT: Yes. Recently I had a colonoscopy.
I also had several laboratory tests and an evaluation by a heart specialist.
Everything was unremarkable.
DOCTOR: How did you get to the hospital?
PATIENT: My brother drove me here by car.
DOCTOR: How is your appetite?
PATIENT: My appetite is actually normal, but sometimes I eat a little less when the abdominal pain is stronger.
DOCTOR: Have you recently lost or gained weight unintentionally?
How much and over what period?
PATIENT: No, I haven’t noticed anything unusual about my weight recently.
DOCTOR: Do you suffer from any chronic illnesses, that is, do you have a specific diagnosis or are you in treatment for that?
PATIENT: No, I don’t have anything like that.
When I was about 12 years old, my tonsils were very enlarged, and I therefore had frequent throat infections and breathing problems, especially at night.
That’s why a tonsillectomy was performed back then.
DOCTOR: How long were you in the hospital at that time?
PATIENT: About three days.
DOCTOR: Is there anything else you would like to mention?
PATIENT: Yes. I also had a mild depressive phase about ten years ago.
At that time I was not doing well mentally, I was very down and had sleeping problems.
I didn’t need medication then, it stabilized again over time.
DOCTOR: Have you ever had an accident?
PATIENT: No, no accident.
I would also like to ask you a few questions about gynecological health.
DOCTOR: When was your last period?
PATIENT: Five days ago.
DOCTOR: Are you currently using contraception?
PATIENT: Not at the moment.
About six years ago I took the pill Yaz for about a year.
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DOCTOR: Have you ever been pregnant?
PATIENT: No, not so far.
DOCTOR: Are you taking any other medications?
I only take paracetamol as needed.
DOCTOR: Are you fully vaccinated, meaning have you received all vaccinations since childhood?
PATIENT: I don’t know exactly, but I am vaccinated against COVID and TBE.
DOCTOR: Do you have any known allergies or intolerances, for example to foods, medications, animals or other substances?
PATIENT: Yes, to Novalgin and penicillin.
That was identified back when I had my tonsil operation.
DOCTOR: How do they present?
PATIENT: With Novalgin I developed an itchy rash.
After penicillin I experienced shortness of breath and dizziness.
DOCTOR: Can you remember which antibiotic you were given afterwards?
PATIENT: Unfortunately I can’t remember exactly at the moment, I can’t concentrate very well right now.
DOCTOR: Do you smoke?
PATIENT: No, not for two years.
DOCTOR: How many cigarettes did you smoke daily before, and since when?
PATIENT: Before that I smoked about half a pack a day for roughly five years.
DOCTOR: Interesting. Can you tell me what motivated you to quit?
PATIENT: To be honest, mainly for financial reasons — cigarettes are just expensive.
DOCTOR: Do you drink alcohol?
If so, how often and how much?
PATIENT: Occasionally, mostly on weekends.
I then have a glass of beer or wine.
DOCTOR: May I ask if you have ever used drugs?
PATIENT: When I was younger I smoked hash a few times.
DOCTOR: Do you exercise regularly?
What type and how often?
PATIENT: I don’t do much sports.
DOCTOR: What is your occupation?
PATIENT: I am a geriatric nurse.
DOCTOR: What is your marital status?
PATIENT: I am single.
DOCTOR: Are there significant illnesses in your family, for example in your parents or close relatives?
PATIENT: Yes. My mother had a stroke at 75 and died from it about ten years ago.
My father has prostate cancer and also had a stroke; he is now 88 years old.
DOCTOR: I’m sorry to hear about your mother.
Do you have pets?
PATIENT: No, none.
DOCTOR: We are finished with the medical history.
Do you have any questions?
PATIENT: Yes, I’m wondering what I actually have.
And why have all the examinations been normal so far?
DOCTOR: That’s a very understandable question.
From what you’ve described and since all previous examinations were unremarkable, much points to a so-called functional disorder.
That means the symptoms are real and distressing for you, but no organic cause is found in the usual examinations.
This is not dangerous, but it can be very burdensome.
What’s important is that we now look together at how we can gradually relieve your symptoms and improve your everyday life.