Greeting
Good day, dear Professor Doctor …,
I would now like to present the patient Ms. Iris Berner to you.
She is 27 years old, 174 cm tall and weighs about 75 kg. The body mass index (BMI) is 24.7 (normal range).
Current history
The patient presented as an emergency because of progressive, dull and stabbing headache as well as pain in the right arm and right upper abdomen after a bicycle accident that had been present for about two hours.
The patient rates the pain intensity as 6/10 in the abdominal area, 7/10 in the upper arm area and 7/10 in the head area.
There is pain-related limitation of movement in the right arm.
In addition, the patient reports arm pain radiating into the shoulder as well as a Paresthesia/ Hypesthesia radiating into the second and third fingers.
As accompanying symptoms the patient noted dizziness, Nausea as well as two episodes of Emesis with food remnants. In addition there was a loss of consciousness of about five minutes with consecutive anterograde Amnesia. Furthermore there are neck muscle tensions, excoriations of about half a palm size in the temporal region and on the auricle, a Hematoma on the right shoulder the size of a clementine and another on the right hip of about palm size.
The following were denied: signs of airway or breathing disorder (e.g. Dyspnea, stridor), visual disturbances, Epistaxis, signs of a basilar skull fracture such as for example raccoon eyes, dental injuries, Tachycardia, Hematuria, Lacerations, visible Malpositions, dislocations or fractures as well as fever.
Accident mechanism
The patient reports having been cycling about two hours earlier when she suddenly had to brake hard to avoid a dog. As a result she fell with her head striking the curb, and she additionally fell onto her right side. According to her own statement she had consumed a glass of beer after university together with her boyfriend, which may have impaired her reaction ability and subsequently contributed to the loss of control of the bicycle.
She was not wearing a helmet.
The time of the last tetanus vaccination is unknown to the patient.
She reports having fallen on asphalt; the surface was not soiled.
The patient reports having had lunch in the canteen about four hours earlier.
Autonomic history
The autonomic history is unremarkable, apart from insomnia in the form of difficulty maintaining sleep related to exam stress and nocturnal calf cramps, a three-year history of constipation and a gluten-free diet due to a known celiac disease.
Past medical history
According to the history there has been hypothyroidism for two years, probably in the context of Hashimotothyroiditis.
For about four years occasional nocturnal calf cramps have occurred, which improve quickly with movement or massage. Iron supplements and other measures have already been tried for relief, but without lasting success.
A year ago a right-sided osteitis pubisdeveloped, presumably promoted by prolonged sitting during studies.
In addition there are recurrent bilateral otitis externa (“swimmer’s ear”).
Previous operations
——–
Note: If a statement can be objectively confirmed by a medical examination – for example by visible scars – the indicative is appropriate. (No physical examination takes place in the specialist language exam.)
Gynecology
The patient reports premenstrual symptoms (PMS) in the form of mood swings, headaches and occasional lower abdominal pain. She occasionally takes diclofenac (Voltaren) for the headaches; exercise and relaxation alleviate the mood swings. While taking Jaz positive effects were observed.
Medications
Euthyrox, 75 once in the morning
Jaz for 3 years
Valeriantablets for calming
Otalgan
water-soluble Voltaren as needed
Note: If a statement can be objectively confirmed by a medical observation – for example by a prescription – the indicative is appropriate.
Allergies
There are allergies to wasp stings with the occurrence of urticaria and angioedema and to crustaceans with abdominal pain.
Noxae
The patient is a non-smoker.
She occasionally consumes a glass of wine or beer.
In the past she occasionally smoked joints.
Social history
The patient is studying computer science and is in her final semester. She lives in a partnership and lives with her boyfriend. She has no children.
Family history
The patient’s father underwent surgery at the age of 70 for coronary artery disease (bypass surgery using a great saphenous vein from the right leg).
The mother experienced a right-sided visual field defect and ten years ago was diagnosed with and operated on for a breast carcinoma on the right. For about one year she has again been receiving chemotherapy.
Suspected and differential diagnosis
In my assessment, the anamestic information suggests a polytrauma with multiple injuries. With regard to the headaches, differential diagnosis should include a concussion (commotio cerebri) and an intracranial hemorrhage . Because of the abdominal pain, intra-abdominal organ injuries, particularly of the spleen or the liver, must be excluded. For the arm pain, fractures or dislocations should particularly be considered in the differential diagnosis. In addition, other body regions such as the spine, thorax, pelvis and lower extremities should be carefully examined clinically.
Diagnostic workup
Since the patient has suffered a polytrauma, inpatient admission is necessary to perform further diagnostic and therapeutic measures. The following should be two large-bore venous catheters placed, the fluid balance corrected and blood group and rhesus factor determined and blood units made available for possible transfusion .
physical examination
First, as with any trauma, the ABC scheme should be performed to secure the airway, breathing and circulation.
This is followed by a focused examination. On inspection, hematomas, abrasions, lacerations, cyanosis, edema, an asymmetric abdominal wall due to a hemoperitoneum as well as signs of hypovolemia such as pale skin or impaired respiratory movements may be observed.
On palpation, tenderness, crepitus, instability, subcutaneous emphysema as well as abdominal guarding may be detected.
On percussion a hyperresonant note may indicate a pneumothorax or a dull note with hemothorax or pleural effusion. In the abdominal area, percussion tenderness or altered tympany may indicate intra-abdominal injuries.
On auscultation, signs such as tachycardia, diminished or absent breath sounds (e.g., with pneumothorax or hemothorax) as well as additional noises such as crackles or stridor may be noted.
In addition, specific examinations should be carried out. These include testing the cranial nerves, side-to-side comparison of the two body halves and examination of the extremities for sensation and motor function (active, passive, range of motion, reflex status) as well as circulation using pulse status and capillary refill time.
• N. olfactorius (I): olfactory nerve
• N. opticus (II): optic nerve
• N. oculomotorius (III), N. trochlearis (IV), N. abducens (VI): ocular motor nerves
• N. trigeminus (V): facial sensation and masticatory muscles
• N. facialis (VII): facial muscles, taste
• N. vestibulocochlearis (VIII): hearing and balance
• N. glossopharyngeus (IX): taste, swallowing reflex
• N. vagus (X): parasympathetic innervation of the viscera
• N. accessorius (XI): shoulder and neck muscles
• N. hypoglossus (XII): tongue movement
Laboratory tests
As part of the initial diagnostics, the following laboratory parameters should be determined for further clarification: complete blood count, coagulation parameters, blood group determination and rhesus factor, creatinine and electrolytes, amylase, lipase, β-hCG !! as well as liver values (including alanine aminotransferase (ALT, GPT), aspartate aminotransferase (AST, GOT) and gamma-glutamyltransferase (γ-GT)).
Electrocardiogram
Exclude traumatic cardiac injuries or detect cardiac arrhythmias
Anatomical diagnosis
FAST ultrasound (Focused Assessment with Sonography for Trauma)
FAST ultrasound is a rapid ultrasound examination performed in trauma patients to detect free fluid (e.g., blood) in body cavities.
It includes four standardized scanning areas:
right upper abdomen (Morison’s pouch: liver – kidney),
left upper abdomen (spleen – kidney),
pelvis (Douglas pouch),
pericardium (subxiphoid view of the heart for cardiac tamponade).
You must lie calmly on your back for this – we apply some gel to the skin and examine four specific areas of the body with the probe. The examination is painless, requires no special preparation and is completely risk-free – complications are not to be expected.
X-ray examination:
In polytrauma, the following X-ray images should be obtained as part of the trauma series:
• Cervical spine in anterior-posterior (AP) and lateral projection
• Thorax in anterior-posterior (AP) projection, exclusion of pneumothorax/hemothorax or rib fractures
• Pelvis in anterior-posterior (AP) projection,
• Shoulder and arm images in two planes.
(Images of joints or bones that appear deformed or are painful.)
An X-ray examination is an imaging procedure that visualizes internal structures such as bones, the lungs and other tissues using X-rays. The patient removes jewelry and clothing in the area to be examined and stands facing the X-ray plate. The examination only takes a few seconds and is completely painless.
Computed tomography
The trauma series of X-rays is increasingly being replaced by CT examination of the cervical spine, thorax, abdomen and pelvis. This is a fast and effective method to identify obvious fractures and organ injuries in multiply injured patients who are often unconscious or intubated and therefore difficult to examine clinically.
In head CT for polytrauma, intracranial hemorrhages, skull base fractures and brain contusions are particularly relevant. An epidural hematoma typically appears as a lens-shaped, sharply demarcated hyperdensity, a subdural hematoma as a crescent-shaped, widely spread bleeding along the brain surface.
If the patient is allergic to contrast medium, a CT without contrast can be performed.
Computed tomography (CT) is an imaging procedure that creates detailed cross-sectional images of the internal organs using X-rays. The patient is pushed into a tube-shaped scanner and must lie still during the examination. Sometimes a contrast agent is administered to allow a more detailed presentation. The examination is painless and takes only a few minutes. Before an examination with contrast medium it is important that you drink enough fluids. Certain medications such as metformin should be paused beforehand – we will clarify that with you. In rare cases an allergic reaction to the contrast medium can occur (but do not worry: we are prepared and have all necessary medications and measures on site).
MRI (magnetic resonance imaging)
In an emergency such as suspected polytrauma, MRI is usually not preferred because it takes more time and cannot be performed as quickly as a CT scan. An MRI without contrast may not provide the same level of detail in assessing bleeding or organ injuries as a CT with contrast.
MRI can assess spinal cord injuries as well as soft tissue injuries such as ligament ruptures, muscle injuries or meniscal damage.
An MRI (magnetic resonance imaging) is an imaging procedure that uses magnetic fields and radio waves to create detailed images of organs, tissues and structures in the body. The patient must first remove jewelry and other metallic objects and inform about implants. Then they are slid into a tube-shaped scanner. During the examination, which lasts about 20 to 60 minutes, the patient must lie still. In some cases contrast medium may be administered to better depict certain structures
Consultations
Neurosurgery/ Surgery / Trauma Surgery / Orthopedics, Anesthesiology
Treatment:
• Monitoring (ECG, blood pressure, O₂ saturation, temperature)
• Pain therapy
• Volume and blood replacement
• Ventilation, if required
• if applicable, hemostasis
• if applicable, chest drainage for hemothorax or pneumothorax
• Fracture management according to orthopedic-trauma surgical principles (initially splinting/stabilization, later definitive operative treatment)
• Treatment of concussion is largely symptomatic and supportive.
• For proximal humerus fractures conservative therapy is often possible. Crucial is the angle of the humeral head and its position relative to the shaft, which determine whether further repositioning is required. Operative options include open reduction with internal fixation or prosthetic joint replacement.
• Anterior shoulder dislocation is the most common form and typically occurs after a fall onto an abducted arm. It presents with severe pain, loss of movement and a visible deformity in the shoulder area. If a fracture is also present, reduction should be performed with particular caution to avoid further displacement of the fracture
• Thrombosis prophylaxis is generally required for femoral neck fracture (hip fracture), femoral shaft fracture, tibia and fibula fractures as well as ankle fractures (ankle joint fracture) with immobilization or operative treatment.
Extra
Names:
Vera Fischer, Franziska Feil, Monika Müller, Matheus Kühn, Haiko Maas, Markus Linder, Clemens Fischer
Medical history:
He had a wound on the back of his head.
The patient has been vegan for 1.5 years.
Course of the fall:
She left the party (graduation party) and was drunk. Then she arrived home and her roommates brought her to the hospital.
The patient, a scaffold builder by profession, had fallen from the first floor of a building while at work and presented with a right-sided head injury as well as pain in the right shoulder and right hip joint.
Accident with skateboard on the left side, collided with a box.
He said he had overlooked a construction site.
The patient was on the way to university when a squirrel suddenly ran onto the path in the English Garden. She braked hard and fell onto her right side.
Previous illnesses:
Right-sided pyelonephritis. On inquiry the patient stated she had stayed in hospital for four days for this.
Dog bite wound
abdominal gradivity
phimosis surgery
Achilles tendinitis
tinnitus
Allergies:
Bee stings
Lactose intolerance with meteorism.
Brown adhesive dressing with erythema
Social history:
Teacher (English, History) at a grammar school
studies educational science
Questions
1. What indications and complications are associated with the placement of a chest drain?
A chest drain is used for pneumothorax, hemothorax, pleural effusions or empyema.
In most patients it can be placed without problems under local analgesia and light sedation while awake.
The chest drain is typically placed in the fifth intercostal space in the anterior axillary line.
Because the anterior chest wall is up to 1 cm thicker than the lateral, needle decompression (e.g. in emergency tension pneumothorax) is more effective in a lateral position.
The most common complications include:
• inadequate pain or sedation control
• incomplete penetration of the pleura with formation of a subcutaneous drainage tract
• lacerations of the lung or the diaphragm
• intra-abdominal malposition of the drain when passing through the diaphragm
• bleeding
(We would like to place a so-called chest drain for you. This means that we insert a thin tube through the chest wall into the space between the lung and the ribs. This allows us to drain air, blood or fluid from the chest cavity.
The procedure is usually performed under local anesthesia and sedatives.)
2. What is an adrenaline pen and how is it used?
An adrenaline pen is an emergency auto-injector for treating severe allergic reactions (anaphylaxis). It is injected intramuscularly, usually into the thigh.
3. What initial dose of levothyroxine is recommended for example in younger patients?
Approximately 1.5 µg per kilogram body weight per day.
4. What do you do if symptoms of thyrotoxicosis occur under levothyroxine therapy?
In this case the dose of levothyroxine is reduced or the intake is temporarily paused. Additionally, thyroid values (TSH, fT3, fT4) should be checked.
5. Name two important eating disorders.
Two important eating disorders are anorexia nervosa, characterized by self-induced underweight due to restrictive eating behavior and a disturbed body image, and bulimia nervosa, characterized by recurrent binge eating followed by compensatory behaviors such as vomiting, laxative use or excessive exercise.
6. What is meant by hyposensitization and when is it indicated?
Hyposensitization (specific immunotherapy, SIT) refers to a treatment method in which the patient is repeatedly given small, increasing doses of the triggering allergen over a longer period to achieve tolerance development.
Indications are mainly pollen allergy, house dust mite allergy, bee and wasp stings
7. Why is it important that the patient had the accident on the way back from work?
Because this is a commuting accident (Wegeunfall), which is legally treated like an occupational accident and is therefore covered by statutory accident insurance.
8. Which health insurances do you know in Germany?
In Germany there is statutory health insurance (GKV) and private health insurance (PKV). Statutory health insurance is mandatory for the majority of the population, whereas private health insurance is mainly an option for civil servants, self-employed persons and employees with higher incomes.
9. What is the difference between a sensation of heaviness and a sensation of weakness?
A sensation of heaviness describes a subjective feeling of strain, pressure or “heavy limbs”, as can occur for example with venous insufficiency. A sensation of weakness, by contrast, denotes reduced strength or performance, as seen in neurological or muscular diseases.
10. In which situation can we identify neck stiffness?
Neck stiffness typically occurs in meningitis or in subarachnoid hemorrhage and is tested by passive flexion of the head, during which the patient cannot bend the neck because of severe pain and muscle tension.
11. What other situations can cause induration and neck pain on turning?
Besides meningitis, neck pain and induration on turning can be caused by degenerative changes of the cervical spine (e.g. cervical spondylosis), muscular tension due to poor posture or stress, trauma (e.g. whiplash), as well as cervical disc herniations.
12. What is the most common injury in people who play tennis?
The most common injury in tennis players is epicondylitis humeri radialis, also known as tennis elbow. This is a painful overuse of the tendon insertions of the forearm extensors at the lateral elbow.
13. What is meant by osteosynthesis and what is its goal?
Osteosynthesis refers to the surgical stabilization of a fracture using implants such as screws, plates, wires or nails. The goal is to restore bone stability, correct alignment and enable rapid mobilization of the patient.
14. What do you do if the blood count shows anemia with a hemoglobin value of 7 g/dl?
With anemia and Hb = 7 g/dl inpatient admission is required. The cause of the anemia should be investigated and a transfusion of packed red blood cells should be considered.
15. What is the costodiaphragmatic recess?
The costodiaphragmatic recess is the spatial reserve between the costal pleura and the diaphragmatic pleura that fills with lung on deep inspiration. It represents the lowest point of the pleural cavity and is clinically important because fluid (pleural effusion) often accumulates there.
16. What is the difference between vegetarian and vegan?
The difference between vegetarian and vegan is that vegetarians abstain from meat and fish but still consume animal products such as milk, eggs and honey. Vegans, on the other hand, avoid all animal products, including milk, eggs, honey and anything derived from animals.
17. How much blood alcohol is permitted in Germany when cycling and why was the driver’s license revoked by the police?
In Germany there is a blood alcohol limit of 1.6 ‰ when cycling. From this value one speaks of absolute unfitness to drive, which constitutes a criminal offense. A heavy fine (about one month’s salary), three points in Flensburg and a medical-psychological assessment (MPU) may be imposed. If this is not passed, the driving license can be permanently revoked.
Already from about 0.3 ‰ relative impairment of driving can be present — for example swerving, balance disturbances or an accident — which can also lead to fines and points
18. Why was the driving license confiscated?
If the patient had more than 1.6 ‰ alcohol in the blood while cycling, the police and the licensing authority classified this as a serious traffic offense. This requires an MPU and usually involves revocation of the driving license, even if they were traveling by bicycle.
19. What complication does an auricular hematoma have and how is it treated?
An auricular hematoma can lead to cauliflower ear (Othematoma). Fibrosis and cartilage changes result in permanent deformity of the auricle.
Treatment consists of early decompression of the hematoma (incision or aspiration), subsequent application of a pressure dressing to prevent reaccumulation of blood and, if necessary, administration of antibiotics to prevent perichondritis.
20. Consent for playing volleyball
Notes
BMI
Body Mass Index (BMI)
Definition and calculation:
BMI is an empirical measure for classifying body weight in relation to height. It is calculated by dividing body weight in kilograms by the square of height in meters (kg/m²).
Paresthesia/
Paresthesia
Description:
Paresthesias are disturbing, non-painful abnormal sensations such as tingling, ‘pins and needles’, prickling or slight burning on the skin.
Hypesthesia
Hypesthesia
Description:
Hypesthesia denotes a reduced sensation to touch, temperature or pain. Affected areas respond weakly to tactile stimuli.
Nausea
Nausea
Description:
Nausea is the subjective sensation of feeling sick or the oppressive feeling that one needs to vomit.
Emesis
Emesis (Vomiting)
Description:
Emesis denotes the forceful expulsion of gastric contents through the mouth and throat as the result of coordinated motor processes.
Amnesia
Amnesia
General definition:
Amnesia denotes a partial or complete loss of memories or an impairment in the ability to form memories.
Types and brief distinction:
Retrograde amnesia: Loss of memories that existed before a precipitating event.
Anterograde amnesia: Impaired ability to form new long-term memories after a precipitating event.
Hematoma
Hematoma
A hematoma is a localized collection of blood in the tissue due to vascular injury. Externally it usually appears as a bruise or ‘black-and-blue’ mark; color and consistency change over time.
Dyspnea
Dyspnea
Definition:
Dyspnea denotes the subjective sensation of shortness of breath or difficulty breathing. It is a symptom, not a diagnosis.
Epistaxis
Epistaxis
What it means:
Epistaxis is the medical term for nosebleed, i.e., bleeding from the nasal cavities.
Typical causes and hints:
Causes range from local injuries and dry mucosa to inflammatory processes and coagulation disorders. Course, amount and accompanying circumstances provide clues to the underlying cause.
raccoon eyes
raccoon eyes
Term explanation:
“raccoon eyes” refers to periorbital hematomas, i.e., bruising around the eye sockets. In German medical terminology this is called periorbital hematomas.
Clinical relevance:
Such findings can occur after trauma, in fractures of the skull base or in certain systemic diseases and serve as an important diagnostic clue in further evaluation.
Tachycardia
Tachycardia
Definition:
Tachycardia denotes an increased heart rate compared to the resting pulse; it is a clinical sign, not an independent disease.
Hematuria
Hematuria
What is understood:
Hematuria denotes the presence of blood in the urine; it can be macroscopic (visible) or microscopic (detectable only in the laboratory).
Lacerations
Laceration
A laceration is a skin injury caused by external force with marginal tissue loss; colloquially it is also called a gaping wound. Depth and extent of the wound as well as the amount of bleeding are decisive. In deep lacerations, subcutaneous tissue, tendons, nerves or vessels can be affected, increasing the risk of functional impairment and infection.
Malpositions
Malposition
A malposition denotes a visible or palpable misalignment of a body part from the anatomically expected position. It can be congenital or caused by injuries and diseases and is often associated with impaired function or deformity. Visible misalignments are clinically important because they provide clues to bony or soft-tissue damage.
Kerb
Kerb
A kerb is the raised edge strip between roadway and sidewalk, usually made of concrete, natural stone or asphalt. It separates traffic areas and serves for demarcation and drainage and presents a hard impact surface in collisions or falls.
Insomnia
Insomnia
Insomnia denotes a sleep disorder with difficulty falling or staying asleep or non-restorative sleep. It can be temporary due to stressful life phases or chronic and often presents with daytime sleepiness, concentration problems and reduced performance. Causes are diverse and range from psychological stress to somatic diseases or medication effects.
Constipation
Constipation
Constipation denotes altered bowel evacuation with less frequent stools, difficult bowel movements or hard stools. Affected individuals often report a feeling of blockage, straining or incomplete evacuation. Causes can include dietary habits, lack of exercise, medications or organic diseases; long-standing constipation can impair quality of life.
Celiac disease
Celiac disease
Celiac disease is a chronic autoimmune disorder in which an intolerance to the glue protein gluten leads to inflammatory damage of the small intestinal mucosa. This damage impairs nutrient absorption and can present as gastrointestinal complaints, weight loss, deficiencies or, in children, growth retardation. Long-term treatment consists of a lifelong avoidance of gluten, which usually leads to resolution of symptoms and mucosal healing. If untreated, deficiencies, bone metabolism disorders, fertility problems and rare malignant complications can occur.
Hashimoto
Hashimoto’s thyroiditis
Hashimoto’s thyroiditis is a chronic autoimmune disease of the thyroid in which the body’s immune cells damage thyroid tissue. This destruction often leads to hypothyroidism.
Clinical features
Typical complaints are pronounced fatigue, weight gain, cold intolerance, brittle hair up to hair loss, depressive symptoms and constipation.
Diagnostics
Investigation includes laboratory determinations of thyroid hormones and TSH as well as detection of autoimmune antibodies against thyroid tissue; ultrasound of the thyroid can be used as an adjunct imaging method.
Therapy
Treatment aims to replace the hormone deficiency; this usually involves lifelong levothyroxine substitution. Further measures depend on clinical course and comorbidities.
nocturnal calf cramps
Nocturnal calf cramps
Definition
Nocturnal calf cramps are sudden, usually painful, involuntary contractions of the calf muscles that typically occur during sleep or periods of rest.
Characteristics
The cramps last seconds to a few minutes and can often be relieved by stretching or massage.
Possible triggers and associations
Triggers can include dehydration, electrolyte disturbances (e.g., imbalances of magnesium or potassium), circulatory disorders, nerve compressions or side effects of certain medications. In recurring or very painful episodes, medical evaluation is advisable.
Osteitis pubis
Osteitis pubis
Definition
Osteitis pubis is a non-infectious inflammatory reaction of the pubic symphysis and adjacent soft tissues, favored by repetitive loading or microtrauma.
Clinical presentation
Typical complaints are dull to sharp pain in the pubic area or groin, which increase with exertion and certain movements; tenderness over the pubic symphysis may be present.
Causes and diagnostics
Common triggers are overuse, sports stress, malalignment, or pelvic procedures; imaging techniques can be used to confirm the diagnosis and exclude other causes.
Therapy
Treatment primarily includes activity reduction, targeted physiotherapy, and pain management measures. For persistent symptoms, local injections or, in selected cases, surgical interventions may be considered.
Otitis externa
Otitis externa
Definition
Otitis externa is an inflammation of the skin of the external auditory canal, which can occur acutely or chronically.
Causes
Common triggers are moisture and local skin damage; pathogenic microorganisms such as certain bacteria or fungi can be involved.
Symptoms
Typical complaints are ear pain, itching, redness and swelling of the ear canal, and possibly purulent discharge and temporary hearing loss.
Treatment
Essential measures are drying and protecting the ear as well as local therapy directed at the causative pathogen group (topical antibacterial or antifungal agents). In pronounced cases, specialist cleaning and further treatment are necessary.
Premenstrual complaints
Premenstrual complaints (PMS)
Definition
Premenstrual complaints encompass physical and psychological symptoms that occur in the luteal phase of the cycle and usually resolve with the onset of menstruation.
Clinical presentation
Typical complaints range from headaches, breast tenderness and bloating to fatigue and mood swings such as irritability or depressed mood.
Management
To alleviate symptoms, lifestyle measures such as regular exercise, a balanced diet and stress reduction are recommended; for burdensome symptoms, symptomatic analgesics, hormonal contraceptives or, for pronounced psychological complaints, specific pharmacological therapies may be considered and should be assessed individually.
Euthyrox
Group: Synthetic thyroid hormone (levothyroxine).
Effect: Replaces or supplements endogenous thyroxine (T4), thereby normalizing metabolism and thyroid hormone levels and indirectly lowering TSH.
Indications: Used for hypothyroidism and for reduction of goiter size; levothyroxine is also used in certain treatment concepts for thyroid carcinoma to suppress TSH.
Important risks: Excessive dosing can cause hyperthyroid symptoms (e.g., cardiac arrhythmias, weight loss, nervousness) and may increase long-term osteoporosis risk; caution is required in patients with existing heart disease. Exact dosing and adjustments are decided by the treating physician.
Valerian
Definition: Valerian is a medicinal plant whose preparations have traditionally been used to relieve difficulties falling asleep and to reduce mild restlessness.
Effects: Valerian preparations are attributed a calming effect, which can particularly promote sleep onset.
Notes: Interactions may occur with other centrally acting depressant substances when taken concurrently. Persistent or severe sleep disorders should be evaluated by a physician.
Voltaren
Group: Nonsteroidal anti-inflammatory drug (NSAID), active ingredient diclofenac.
Effect: Diclofenac inhibits cyclooxygenase enzymes (COX‑1 and COX‑2) and thereby reduces prostaglandin formation, producing analgesic, anti-inflammatory and antipyretic effects.
Indications: For symptomatic treatment of pain and inflammatory complaints.
Important risks: Common side effects affect the gastrointestinal tract (e.g., discomfort, ulcers) and it can impair renal function and blood pressure. There is an increased risk of cardiovascular events (e.g., myocardial infarction, stroke), especially with long-term use. Allergic reactions are also possible. In patients with existing gastric, renal or cardiac disease or when taking other high-risk medications, consultation with a physician is required.
Otalgan
Group: Ear drops for local pain relief in otic complaints.
Effect and use: When applied locally, such preparations relieve ear pain, for example in problems of the external auditory canal; use only if the tympanic membrane is intact.
Important risks: Use is contraindicated in a perforated tympanic membrane or unclear middle ear problems. Local irritation or allergic reactions may occur. Persistent or severe symptoms should prompt medical advice.
Wasp stings
Wasp stings occur from the sting of wasps, which are stinging insects. Clinically, they usually cause immediate local symptoms such as pain, redness and swelling at the sting site. In sensitized individuals, however, hypersensitivity reactions can occur, presenting as generalized urticaria, tissue swelling (angioedema) or, in severe cases, systemic allergic reactions with respiratory or circulatory involvement. Such severe reactions require medical evaluation and treatment.
Crustaceans
Crustaceans are a group of invertebrate marine animals that include, for example, shrimps, crabs, lobsters and crayfish. They are common food allergens and can trigger allergic reactions in sensitive individuals, which may vary in severity and occasionally include gastrointestinal symptoms.
Computer Science
Computer science is the science and engineering of information processing using formal methods and electronic systems. Its central areas include algorithms and data structures, programming, computer architectures, databases, networks and applications such as artificial intelligence and software development. The goal is to understand, design and apply systems for efficient storage, processing and transmission of information.
Partnership
A partnership denotes a close relationship between two people that can be based on mutual commitment, trust and reciprocal support. It can take private forms, such as a romantic or domestic partnership, or legally structured forms like marriage. Key aspects are emotional closeness, shared responsibility and often legal or financial arrangements between the partners.
Visual field loss
A visual field loss describes the partial or complete loss of perception in a portion of the normal visual field. Such losses can be focal (scotoma) or extensive and have various causes, such as retinal diseases, optic nerve damage, elevated intraocular pressure or lesions along the visual pathways up to brain injuries (e.g., due to vascular events). The exact pattern and location of the loss provide clues to the underlying cause.
Visual field defect
A visual field defect describes the partial or complete loss of perception in a section of the normal visual field. Such defects can be focal (scotoma) or widespread and have various causes, for example diseases of the retina, damage to the optic nerve, increased intraocular pressure, or lesions in the optic pathway up to damage in the brain (e.g., due to vascular events). The exact pattern and location of the defect provide clues to the underlying cause.
Breast carcinoma
Term: Breast carcinoma
Definition: Malignant tumor of breast tissue, predominantly arising from glandular or ductal epithelial cells of the breast.
Risk factors: Increased risk is associated with family history, hormonal influences and certain lifestyle factors; other factors can modulate the disease risk.
Clinical signs: Possible signs include a palpable mass in the breast, changes of the skin surface (e.g., retraction or altered texture), displacement or inversion of the nipple and, rarely, nipple discharge; pain is not typical as an isolated symptom.
Diagnostics: The basis is clinical examination complemented by imaging such as mammography and ultrasound; histological confirmation is obtained by biopsy; MRI can be used additionally if indicated.
Therapeutic principles: Treatment options include surgical procedures (breast-conserving surgery or mastectomy), systemic medical therapies (e.g., chemotherapy, endocrine and targeted therapies) and radiotherapy; the choice depends on tumor biology, stage and patient factors.
Chemotherapy
Term: Chemotherapy
Definition and group: Chemotherapy refers to the use of cytotoxic or cell division–inhibiting drugs to treat cancers.
Mode of action: The agents target rapidly dividing cells and inhibit cell division processes or induce cell death.
Indications: Chemotherapy can be used curatively, adjuvantly, neoadjuvantly or palliatively, depending on the tumor type and disease stage.
Important risks: Side effects result from damage to healthy rapidly dividing cells (e.g., bone marrow, mucous membranes, hair follicles) and can include infection risk, nausea, fatigue and organ toxicities; monitoring and supportive measures are important.
Concussion (Commotio cerebri)
Term: Concussion (Commotio cerebri)
Definition: Temporary functional disturbance of the brain following a head injury, without necessarily detectable structural damage on imaging.
Typical symptoms: Headache, dizziness, nausea, concentration and memory disturbances, and varying degrees of consciousness impairment frequently occur.
Course and diagnostics: Symptoms develop immediately or shortly after the trauma and usually resolve within days to weeks; clinical assessment and, if indicated, imaging are used to differentiate from more severe head injuries.
intracranial hemorrhage
Term: intracranial hemorrhage
Definition and classification: Intracranial hemorrhages are bleeding events within the skull; important types include intracerebral, subarachnoid, subdural, and epidural hemorrhages.
Causes: Common triggers are arterial hypertension (in intracerebral hemorrhage), ruptured cerebral aneurysms (in subarachnoid hemorrhage), and trauma (in subdural or epidural hemorrhages).
Clinical and imaging features: Symptoms vary depending on location and extent and range from headache and altered consciousness to focal neurological deficits. On CT, acute bleeds are typically hyperdense; subdural hematomas often appear crescent-shaped, while epidural hematomas are more lentiform.
Relevance: Intracranial hemorrhages often require rapid diagnostics and specific therapeutic decisions depending on location, size, and clinical condition.
Spleen
Term: Spleen
Function and injury types: The spleen is a parenchymal organ with immunological and hematologic significance; blunt abdominal trauma can cause an acute rupture or a delayed (two‑phase) rupture.
Clinical presentation: A splenic injury typically presents with pain in the left upper abdomen, signs of internal bleeding such as tachycardia or hypotension, and occasionally referred shoulder pain (Kehr sign).
Diagnostics and management: Evaluation includes clinical assessment and imaging modalities such as FAST ultrasound and CT; treatment ranges from conservative observation in hemodynamically stable patients to surgical management or splenectomy for ongoing bleeding or circulatory instability.
Two large-bore venous catheters
Two large-bore venous catheters
Purpose: Large-bore venous accesses allow rapid administration of fluids, blood products, and medications as well as repeated blood sampling in severely injured patients.
Possible access sites: Commonly used accessible, relatively large peripheral veins include the brachial vein in the upper arm or the femoral vein in the groin; selection depends on accessibility and urgency.
Key risks: Infection at the puncture site, hematoma, vascular or nerve injury, and thrombosis; placement and care of the catheters follow clinical judgment and hygiene standards.
Fluid balance
Fluid balance
Term: Fluid balance describes the equilibrium of water and dissolved electrolytes in the body and their distribution among body compartments.
Clinical significance: Deviations affect blood pressure, organ perfusion, and metabolism; clinically they are assessed by vital signs, urine output, skin findings, and laboratory parameters.
Therapeutic principles: Disorders are corrected specifically, e.g., by adjusted fluid administration, diuretic measures, or electrolyte replacement; choice of infusion solutions depends on the cause and individual situation.
Blood group and Rhesus factor
Blood group and Rhesus factor
Definition: Blood group is classified in the ABO system as A, B, AB, or 0; the Rhesus factor mainly refers to the D antigen and is given as Rh-positive or Rh-negative.
Clinical relevance: Correct determination is essential for safe blood transfusions and for assessing sensitization risks during pregnancy.
Blood units
Blood units
Term: Blood units are processed and stored blood products from donations used for therapeutic purposes.
Components and use: Common components are packed red blood cells, platelet concentrates, and plasma; selection depends on the patient’s specific needs (e.g., treatment of anemia, coagulation disorders, or thrombocytopenia).
Organization: Blood products are managed under defined storage conditions and tested for compatibility before use.
Transfusion
Transfusion
Term and indication: A transfusion is the administration of blood products to treat blood loss, anemia, or coagulation disorders.
Safety measures: Before every transfusion, blood group testing and crossmatching are required; vital signs are monitored during and after administration and the transfusion product and its labeling are checked.
Risks: Transfusions can cause immunological reactions, febrile or allergic events, and other complications; appropriate precautions and monitoring are standard practice.
Guarding (abdominal)
Guarding (abdominal)
Definition: Guarding is the involuntary contraction of the abdominal muscles during palpation and is a clinical sign of peritoneal irritation.
Clinical significance: The presence of guarding suggests possible peritonitis or other serious intra-abdominal conditions and typically requires further diagnostic evaluation.
Percussion
Percussion
Technique: Using the distal phalanx of a finger placed on the body, a short blow is struck with the index finger of the other hand to produce closed sound phenomena from underlying structures.
Meaning: The resulting sounds differ depending on the proportion of air, fluid, or tissue beneath the surface. A more resonant, air-filled percussion note (hyperresonant) can indicate pneumothorax or large air collections, while a dull sound suggests fluid collections or dense tissue such as pleural effusion, hemothorax, or consolidation.
Abdomen: In the abdominal cavity, percussion provides clues to increased tympany with gas accumulation or dullness with fluid or extensive organ enlargement; percussion tenderness may indicate peritoneal irritation.
Reflex status
Reflex status
Purpose: Testing deep tendon reflexes assesses the integrity of reflex arcs, spinal segments, and helps distinguish central from peripheral lesions.
Important reflexes and their segments:
– Biceps tendon reflex: largely C5–C6, mediated via the musculocutaneous nerve.
– Radial periosteal/brachioradialis reflex: predominantly C5–C6, via the radial nerve.
– Triceps tendon reflex: mainly C6–C7, via the radial nerve.
– Patellar tendon reflex (knee jerk): L2–L4.
– Achilles tendon reflex (ankle jerk): S1–S2.
Assessment: Side-to-side comparison, reinforcement or attenuation, and presence of spasticity or changes in muscle tone are clinically relevant.
Pulse status
Pulse status
Definition and aim: Pulse status involves palpation of peripheral arteries to assess pulse rate, rhythm, stroke volume/amplitude differences, and side-to-side comparison.
Common palpation sites: These include, among others, the radial artery at the wrist and the dorsalis pedis artery on the dorsum of the foot; additional sites are examined as needed.
Clinical relevance: Abnormalities such as absent or markedly diminished pulse, asymmetry, or irregular rhythm provide clues to circulatory disturbances, vascular occlusion, or circulatory problems.
Capillary refill time
Manual testing required: The common statement that capillary refill time must be “less than 2 seconds” is context-dependent and methodologically variable (age, temperature, measurement method). Therefore the medical assertion about strict cutoff values here is uncertain and can be misleading without further specification.
Complete blood count
Complete blood count
General: The complete blood count provides information about the cellular composition of the blood and offers clues to various pathological processes.
Key parameters and their significance:
– Hemoglobin: Reflects the blood’s oxygen-carrying capacity and may be decreased in acute or chronic blood loss or in anemias.
– White blood cell count: Elevated values often indicate infection or inflammatory processes; deviations can also be caused by stress, medications, or hematologic diseases.
Limitation: Changes in the complete blood count must always be interpreted in the clinical context and, if necessary, with additional laboratory tests.
Creatinine
Creatinine
Significance: Creatinine is a biomarker for estimating kidney function because it is primarily filtered by the glomerulus and its concentration rises with declining renal function.
Interpretation: An elevated creatinine value indicates reduced glomerular filtration, but can result from various causes including prerenal factors (e.g., decreased perfusion), renal injury, or postrenal obstruction. Therefore the cause of a creatinine increase must be investigated separately.
β-hCG
β-hCG
β-hCG is a hormone produced by the placenta whose detection in the blood serves as a marker for an existing pregnancy. In the initial evaluation of female patients it is routinely measured when a pregnancy should be excluded or confirmed, since it rises early in the course and is readily measurable in serum.
Rib fractures
Rib fractures
Rib fractures usually result from direct blunt force to the thorax and can cause local pain and guarded respiration. Affected persons often breathe shallowly to avoid pain; when fracture edges are in contact, crepitus or rubbing sounds can be palpated or heard on examination. Diagnostics and course depend on the extent, displacement and accompanying injuries.
PatientSalutation: Mr/Ms Senior Physician ……….., I would like to present to you the patient Mrs Iris Berner introduced. |
Date05/08/2025 |
| Age27 years | Weight75 kg | Height174 cm |
Allergies (keywords)
Wasp sting → urticaria and angioedema
Crustaceans → abdominal pain
Substances / drugs (keywords)
Non-smoker
Occasional alcohol (wine/beer)
Occasional joints in the past
Social history (keywords)
Studying computer science (final semester)
In a relationship, lives with partner
No children
Family history (keywords)
Father: CAD, bypass surgery with V. saphena magna, at age 70
Mother: right-sided visual field loss (at 63), right-sided breast cancer (surgery 10 years ago, chemotherapy restarted 1 year ago)
Medications (keywords)
Euthyrox® 75 µg once in the morning
Jaz® for 3 years
Valerian pills for calming
Otalgan® as needed
Voltaren® (diclofenac, water-soluble) as needed
History (full sentences)
The patient presented as an emergency after a polytrauma sustained about two hours earlier as a result of a bicycle fall.
Pain intensity was reported as 6/10 in the abdominal area, 7/10 in the upper arm area and 7/10 in the head area.
There is pain-related restriction of movement of the right arm.
The arm pain radiates into the shoulder, and there are additionally paresthesias/hypoesthesias in the second and third fingers.
Accompanying symptoms: dizziness, nausea, two episodes of emesis with food remnants, approximately 5-minute loss of consciousness with anterograde amnesia, neck tension.
There were excoriations about half the size of the palm in the temporal region and the auricle as well as hematomas on the right shoulder, about the size of a clementine, and on the right hip, about the size of the palm.
The following were denied: dyspnea, stridor, visual disturbances, epistaxis, signs of basilar skull fracture, dental injuries, tachycardia, hematuria, lacerations, visible malpositions, dislocations, fractures, fever.
Regarding the course of the accident the patient stated that she fell from her bicycle while avoiding a dog, hit her head on the curb and fell to the right side. She was not wearing a helmet and had consumed a glass of beer before the accident. Tetanus immunization status is unclear. The fall occurred on clean asphalt. Her last meal was about four hours earlier at a cafeteria lunch.
Autonomic History: unremarkable except for insomnia (exam stress, difficulties staying asleep), nocturnal calf cramps for years, constipation (for 3 years), gluten-free diet (celiac disease).
Past illnesses: hypothyroidism (likely Hashimoto), recurrent nocturnal calf cramps, osteitis pubis on the right (1 year ago), recurrent otitis externa (“swimmer’s ear”).
Gynecology: PMS (mood swings, headaches, lower abdominal pain). Improvement with exercise, relaxation and OCP (Jaz).
Suspected diagnosis – differential diagnosis (full sentences)
Polytrauma after bicycle fall
Headaches: concussion, intracranial hemorrhage
Abdominal pain: intraabdominal organ injury (spleen, liver)
Arm pain: fractures or dislocations
Further examination: spine, thorax, pelvis, lower extremities
Further management – therapy (full sentences)
Clinical and imaging evaluation (cCT, abdominal ultrasound, X-ray arm/shoulder, if necessary CT thorax/pelvis)
Monitoring of vital signs
Analgesia as needed
Check tetanus immunization status, booster if necessary
Inpatient admission for further diagnostics and monitoring
Signature
First name Last name
With kind regards
1. Course of accident
Traffic accident:
• Bicycle / e-scooter / skateboard
Sudden hard braking (avoiding a dog)
Fall with head impact against curb/box
Impact additionally on right/left side of body
• Motorcyclist
Unprotected, especially at higher speeds
• Pedestrian
Impact on the hood, then fall onto the roadway
1. Course of accident
Fall from a great height:
• Fall at work (1st floor, scaffolding)
Right-sided/left-sided head injury
• Construction worker from roof / window / ladder
• Rider falling from a horse
2. Symptoms
• Head/neck: headache, dizziness, nausea, episodes of emesis, loss of consciousness (for X minutes), amnesia (usually anterograde), neck tension
• Neurological: paresthesias / hypoesthesias,
• Thorax/abdomen/extremities: arm pain (with radiation), upper abdominal pain (common), pain-related restriction of movement
• Skin/soft tissue: excoriations, hematomas
3. Important negatives
No evidence of airway or breathing disturbance (no stridor, no dyspnea), no visual disturbances, no epistaxis, no signs of basilar skull fracture (e.g. raccoon eyes, hemotympanum, CSF leak), no dental injuries, no tachycardia, no hematuria, no lacerations, no visible malpositions, dislocations or fractures, no fever
4. Initial measures
A – Airway: Secure airway (keep clear, suction if necessary, intubation)
B – Breathing: Check and ensure breathing (O₂ administration, ventilation if insufficent)
C – Circulation: Stabilize circulation (establish access, give fluids, control bleeding)
D – Disability: Neurological status (consciousness, pupils, GCS)
E – Exposure/Environment: Completely undress patient, examine for additional injuries, maintain warmth
5. Physical examination
Inspection: Hematomas, abrasions, lacerations, cyanosis, edema, asymmetric abdominal contour, pale skin, abnormal respiratory movements
Palpation: Tenderness to pressure, crepitus, instabilities, subcutaneous emphysema, guarding
Percussion: hyperresonant percussion note (pneumothorax), dull percussion note (hemothorax/pleural effusion)
Auscultation: tachycardia, diminished/absent breath sounds, crackles, stridor
5. Physical examination
• Cranial nerve examination
• Extremities: compare body halves
Sensation
Motor function (active/passive, range of motion)
Reflex status
Perfusion: pulse status, capillary refill time
6. Laboratory
6.
Blood count, coagulation parameters, blood group determination, rhesus factor, creatinine, electrolytes, amylase, lipase, β-hCG, liver enzymes (ALT/GPT, AST/GOT, γ-GT), urinalysis
7. Further management
• ECG
• FAST ultrasound: Morison’s pouch, left upper quadrant, Douglas space, pericardium
• X-ray: cervical spine, chest, pelvis, affected extremity (two views)
• CT: head CT (if suspected TBI), possibly whole-body CT (trauma CT)
8. Therapy
• Monitoring (ECG, blood pressure, O₂ saturation, temperature)
• Analgesia
• Volume and blood replacement
• Ventilation, if required
• if needed, hemostasis
• if needed, chest drain for hemothorax or pneumothorax
8. Therapy
• Fracture management: splinting/stabilization → definitive operative treatment
• Concussion: symptomatic, supportive
• Intraabdominal organ injuries, particularly of the spleen, liver or uterus
• Proximal humerus fracture: often conservative; depending on angle/position; possibly ORIF or prosthesis
8. Therapy
• Anterior shoulder dislocation: most common form; after a fall onto an abducted arm; symptoms: severe pain, inability to move, visible deformity; reduction with caution if accompanied by fracture
• Thrombosis prophylaxis: required for femoral neck fracture, femoral shaft fracture, tibia/fibula fracture, ankle fracture (with immobilization/operation)
9. Imagine: How would you typically describe a patient with polytrauma?
The patient presented emergently due to approximately 2 hours of progressive, dull and stabbing headache as well as pain in the right arm and right upper abdomen after a bicycle fall.
Pain intensity was reported as 6/10 in the abdominal area, 7/10 in the upper arm area and 7/10 in the head area. There is pain-related restriction of movement of the right arm.
9. Imagine: How would you typically describe a patient with polytrauma?
Also arm pain radiating into the shoulder as well as paresthesias/hypoesthesias radiating into the second and third fingers.
Associated symptoms: dizziness, nausea, two episodes of emesis with food remnants, approximately 5-minute loss of consciousness with anterograde amnesia, neck stiffness.
Lesions: abrasions at the temporal region and auricle, hematomas on the right shoulder and right hip.
Common term:
1. the headache
2. the nausea
3. the vomiting
4. the memory loss / the gap in memory
5. the tingling / the numbness
6. the abrasion
7. the laceration
8. the bruise
Technical term:
1. the cephalgia
2. the nausea
3. the emesis
4. the amnesia
5. the paresthesia
6. the hypoesthesia
7. the excoriation
8. the laceration
Common term:
9. the shortness of breath / the breathlessness
10. the wheezing breath sound
11. the nosebleed
12. the dislocation / the luxation
13. the bone fracture
14. the palpitations / the rapid heartbeat
15. the blood in the urine
16. the malalignment
Technical term:
9. the hematoma
10. the dyspnea
11. the stridor
12. the epistaxis
13. the luxation
14. the fracture
15. the tachycardia
16. the hematuria
Common term:
17. the shortness of breath / the breathlessness
18. the wheezing breath sound
19. the nosebleed
20. the dislocation / the luxation
21. the bone fracture
22. the palpitations / the rapid heartbeat
23. the blood in the urine
24. the malalignment
Technical term:
17. the dyspnea
18. the stridor
19. the epistaxis
20. the luxation
21. the fracture
22. the tachycardia
23. the hematuria
24. the malposition
Common term:
25. the blue discoloration (of the skin/lips)
26. the swelling / the water retention
27. the hard abdomen / the abdominal cramping
28. the air in the chest cavity
29. the blood in the chest cavity
30. the water in the chest cavity
Medical term:
25. cyanosis
26. edema
27. muscular guarding
28. pneumothorax
29. hemothorax
30. pleural effusion
10. Shoulder joint (Articulatio humeri)
Bones: humeral head, glenoid cavity (scapula)
Glenoid: glenoid with labrum glenoidale
Joint capsule & ligaments: capsule, ligamentum glenohumerale, ligamentum coracohumerale
Other structures: bursa subacromialis, bursa subdeltoidea, rotator cuff
11. Elbow joint (olecranon)
Bones: humerus (trochlea, capitulum), ulna (incisura trochlearis, olecranon), radius (radial head)
12. Hip joint (Articulatio coxae)
Bones: femoral head, acetabulum (ilium, ischium, pubis)
Acetabular socket: acetabulum with labrum acetabulare
Joint capsule & ligaments: iliofemoral ligament, pubofemoral ligament, ischiofemoral ligament, ligamentum capitis femoris
Other structures: joint capsule, articular cartilage
13. Additional questions
• Tetanus status
• Contamination of the accident site
• Last meal
fachleiterinfo@gmail.com
instagram.com/fachleiterinfo
fachleiterinfo@gmail.com
instagram.com/fachleiterinfo
To run an AI simulation, download the PDF with the prompt, then upload it to an AI application such as ChatGPT.
Page 1 · 1–20 / 95
DOCTOR: Hello,
My name is Doctor Feil.
I am working today as a junior doctor on the ward.
I would like to conduct an anamnesis interview with you.
First of all I would like to find out whether you find the pain tolerable.
PATIENT: Hello Doctor, The pain is quite severe, so I would like a painkiller.
DOCTOR: We will look at it together in a moment, and I will ask you a few questions.
After that you will get something for relief.
If you do 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 Iris Berner.
DOCTOR: Could you please spell your first and last name slowly?
PATIENT: Of course,
My first name: I, R, I, S
and my last name: B, E, R, N, E, R
DOCTOR: How old are you, Ms. Berner?
PATIENT: I am twenty-seven years old.
DOCTOR: When exactly were you born?
PATIENT: My birthday is on the third of October 1998.
DOCTOR: How tall are you?
PATIENT: I am one hundred seventy-four centimetres tall.
DOCTOR: How much do you weigh?
PATIENT: I weigh about seventy-five kilograms.
DOCTOR: What is the name of your general practitioner?
PATIENT: My GP is Doctor Karla Scholz.
DOCTOR: What brings you to us today?
PATIENT: I fell off my bicycle and now have pain in my arm, my head and also in my abdomen.
DOCTOR: Do you have breathing problems or are you short of breath?
PATIENT: No, I can breathe normally.
DOCTOR: Have you noticed anything about your voice?
Or have you heard a wheeze when breathing?
PATIENT: No, my voice is as usual, and I do not hear any wheezing when breathing.
DOCTOR: Have you had chest pain, tightness, palpitations or dizziness since the accident?
PATIENT: I feel somewhat dizzy.
DOCTOR: Have you noticed anything that looks broken or dislocated?
So something out of place, like a misalignment?
PATIENT: No, I don’t think so.
I haven’t noticed anything unusual.
DOCTOR: Have you ever had stomach or intestinal ulcers?
Or problems with your kidneys?
PATIENT: No, I’ve never had anything like that before.
DOCTOR: Could it be that you are pregnant?
PATIENT: No, I am using contraception.
DOCTOR: Are you feeling nauseous?
I’m asking whether you can take a painkiller or whether we should give you something else.
PATIENT: Yes, I feel nauseous now, and I have already vomited twice.
DOCTOR: What exactly did you vomit?
PATIENT: It was food remains and stomach acid.
DOCTOR: Then I will inform the nurse now – you will receive a painkiller shortly and also something for nausea and vomiting.
Could you please tell me when, where and how the accident happened?
PATIENT: I was riding my bike about two hours ago when I suddenly had to brake hard to avoid a dog.
I fell and hit my head on the curb.
To be honest, after university I had a beer with my boyfriend.
That’s probably why I lost control of the bike when braking.
DOCTOR: What happened after that?
PATIENT: I toppled over.
When I came to, I heard the ambulance siren and saw that the emergency team was coming to me.
A passerby had apparently called the rescue service.
DOCTOR: Do you know how long you were unconscious?
PATIENT: Not exactly, but probably about five minutes.
Page 2 · 21–40 / 95
DOCTOR: Do you remember everything?
PATIENT: Not exactly.
After the accident I was a bit confused, and the images and sounds were not completely clear to me.
DOCTOR: Where were you headed?
PATIENT: I was on my way home.
DOCTOR: Were you wearing a helmet and protective gear?
PATIENT: No, I wasn’t wearing anything.
DOCTOR: Which direction did you fall?
Forward, backward, to the right or to the left?
PATIENT: I fell onto my right side.
DOCTOR: Which body region hit the ground?
PATIENT: I fell onto my right side.
DOCTOR: Did you brace yourself with your hand when you fell?
PATIENT: No, I couldn’t brace myself.
DOCTOR: Where exactly does it hurt?
PATIENT: I have pain all over my head.
Also my right arm and my abdomen hurt.
DOCTOR: Have the pains improved, worsened, or remained the same over time?
PATIENT: The pains have become somewhat stronger.
DOCTOR: How would you describe the pain?
PATIENT: The pains are dull and stabbing.
DOCTOR: Do the pains radiate anywhere?
PATIENT: The arm pain radiates up to the shoulder.
DOCTOR: How would you rate the intensity of your pain on a scale from 1 to 10, where 1 is mild and 10 is unbearable pain?
PATIENT: I would rate the abdominal pain as 6 out of 10, the arm as 5 to 7 out of 10, and the head also as 7 out of 10.
DOCTOR: Do you have wounds or hair loss on your head?
PATIENT: Yes, I have an abrasion on my head.
DOCTOR: Where exactly is it and how large is it?
PATIENT: In the temple area and on the auricle, about the size of half a palm.
DOCTOR: Do you have vision problems like double vision or blurred vision?
PATIENT: No, I see normally.
DOCTOR: Do you have a nosebleed?
PATIENT: No, I don’t have a nosebleed.
DOCTOR: Have you noticed any abnormalities like bruising behind the ears or around the eyes?
PATIENT: No, I haven’t seen anything unusual behind my ears.
DOCTOR: Are your teeth intact?
PATIENT: Yes, I have no dental injuries.
DOCTOR: Have you noticed hearing problems or any discharge from the ear?
PATIENT: No, nothing at all.
DOCTOR: Do you have neck pain or neck stiffness?
Can you move your head freely in different directions?
PATIENT: Yes, when I turn my neck I feel pain.
DOCTOR: Do you have a cough or are you breathing faster or slower than usual?
PATIENT: No, I have no breathing problems.
Page 3 · 41–60 / 95
DOCTOR: When did you last eat something?
PATIENT: About four hours ago I had lunch in the cafeteria.
DOCTOR: Do you have problems with bowel movements or urination, for example pain or blood?
PATIENT: No, I have no complaints.
But I have had constipation for about 3 years.
It often takes a long time before I can go to the toilet, and I feel like my bowel is not completely emptied.
PATIENT: My family doctor said it could also be due to my underactive thyroid.
DOCTOR: So you suffer from an underactive thyroid.
Are you taking medication for that, for example Euthyrox?
PATIENT: Yes, Euthyrox, 75 once in the morning – for two years already.
DOCTOR: Do you remember the exact diagnosis of the underactive thyroid?
PATIENT: Yes, my doctor said it was a kind of chronic inflammation of the thyroid.
DOCTOR: Do you perhaps also suffer from other autoimmune diseases like diabetes or vitiligo?
PATIENT: No
DOCTOR: One small tip: The best relief for constipation is a diet with enough fluids and fiber.
That means at least 1.5 to 2 liters of water per day, which is roughly 6 to 8 glasses of water, and high-fiber foods like whole grains, fruit and vegetables.
Also exercise – ideally about 2 to 3 times a week for at least 30 minutes.
Have you noticed pain or blood with bowel movements?
PATIENT: No, nothing.
DOCTOR: Do you have abrasions or lacerations on other body areas?
PATIENT: No, I haven’t noticed any other injuries.
DOCTOR: Have you noticed any bruises or contusions?
PATIENT: Yes, I have bruises on my right shoulder and on my right hip.
DOCTOR: How large are they?
PATIENT: On the shoulder about the size of a small clementine and on the right hip about the size of a palm.
DOCTOR: Do you have swelling?
PATIENT: No, nothing noticeable.
DOCTOR: Have you noticed an increase in your abdominal girth?
PATIENT: No, I haven’t noticed that.
DOCTOR: Are there limitations in movement?
In which directions do these occur?
PATIENT: I cannot move my right arm – the pain prevents me from doing so.
DOCTOR: Have you noticed numbness, tingling or muscle weakness?
PATIENT: I have a feeling of heaviness and a kind of numb/tingly sensation in the arm that radiates into the index and middle finger.
DOCTOR: Have you noticed any misalignment, dislocation or a fracture?
PATIENT: No, I haven’t noticed anything like that.
DOCTOR: Is there anything noticeable about your legs?
For example bruises, wounds or discoloration?
PATIENT: No, there is nothing noticeable there.
DOCTOR: Are you able to stand and walk?
PATIENT: Yes, that is possible without problems.
DOCTOR: Have you felt any clicking or grinding, for example when moving?
PATIENT: No, I haven’t noticed that.
DOCTOR: Are there injuries to the nails?
PATIENT: No
DOCTOR: When were you last vaccinated against tetanus?
PATIENT: I can’t remember, but you can call my family doctor and ask – I’ll give you the contact details.
DOCTOR: Sure, was the place where you fell clean – for example asphalt – or rather dirty, for example with soil or trash?
PATIENT: I fell on asphalt.
The ground was not dirty.
Page 4 · 61–80 / 95
DOCTOR: Do you have fever, night sweats, chills or episodes of sweating?
PATIENT: None
DOCTOR: How is your appetite?
PATIENT: I like to eat almost everything.
DOCTOR: How do you eat?
Vegan, vegetarian, or omnivore?
PATIENT: You know, Doctor, I can’t tolerate gluten – so things with wheat, rye or barley.
If I eat that, I get stomach aches, bloating and sometimes diarrhea.
I really have to be careful, otherwise I feel really bad.
That’s why I have to eat gluten-free.
DOCTOR: Have you recently lost or gained weight unintentionally?
PATIENT: No, my weight has stayed the same.
DOCTOR: Do you have difficulty falling asleep or staying asleep?
PATIENT: I usually sleep poorly through the night, especially when exams are coming up.
I think it’s due to stress.
Also, for 4 years now I’ve sometimes had very severe cramps in my calf at night – it really tenses up.
Yes, I know that – it was like that for me too.
DOCTOR: Have you already done anything about it?
PATIENT: Yes, I take valerian dragees to calm down – I find that helpful.
For the cramps I have already tried iron and other remedies, but unfortunately nothing really helped.
DOCTOR: How long do the cramps usually last?
PATIENT: Only a few seconds, sometimes a minute or so.
DOCTOR: Is there anything that makes the cramps better?
PATIENT: Yes, if I move the leg or someone massages the calf, it gets better quickly.
DOCTOR: Do you have difficulty urinating?
PATIENT: No, I have no problems with urination.
DOCTOR: Do you remember the exact diagnosis of the hypothyroidism?
PATIENT: Yes, my doctor said it was a chronic inflammation of the thyroid.
DOCTOR: Do you perhaps also suffer from other autoimmune diseases such as diabetes or vitiligo?
PATIENT: No
DOCTOR: Do you have any other chronic illnesses, for example high blood pressure or elevated blood lipids – apart from the hypothyroidism?
PATIENT: Yes, for one year I have had an inflammation of the pubic bone on the right side.
It shows itself mainly by pain when sitting for a long time and when getting up.
My doctor said this could also have been caused by long periods of sitting during my studies.
I also swim often.
Afterwards sometimes both ear canals itch, and furthermore I often go swimming, and afterwards I sometimes have itching and redness in both ears.
My doctor said that was swimmer’s ear.
Then I always use ear drops for it.
DOCTOR: You should best wear earplugs when swimming.
What’s the name of the drop?
PATIENT: I think it’s called Otalgan.
DOCTOR: Do you take any other medications?
PATIENT: I take the contraceptive pill and occasionally a water-soluble Voltaren for pain.
DOCTOR: What’s the name of your contraceptive pill and how do you take it?
PATIENT: The pill is called Jaz. I have been taking it daily at the same time for 3 years, one tablet each time.
I have another question: What should I do if I forget to take the contraceptive pill?
DOCTOR: If you only forget one pill, take it immediately as soon as you remember – even if that means taking two pills that day.
Then continue as normal.
PATIENT: And if I forget two pills in a row?
DOCTOR: It depends on which week you are in.
If it happens in the first or second week, take two pills on the day you notice, and two again the next day.
After that you continue as normal.
Why do you take exactly the water-soluble form of Voltaren?
PATIENT: Because it simply helps faster.
DOCTOR: Please note that Voltaren should not be taken on an empty stomach, because it can otherwise cause stomach problems such as an ulcer.
Do you have a prescription for your medications?
PATIENT: Yes, I do.
DOCTOR: Are you fully vaccinated, meaning have you had all the vaccinations since your childhood?
PATIENT: Yes, I am fully vaccinated.
DOCTOR: When was your last period?
Is it regular?
PATIENT: About two weeks ago, comes every 30 days.
DOCTOR: Do you have known problems in the area of women’s health?
For example very severe pain or unusually heavy bleeding?
PATIENT: So, I often have complaints before my period.
I get mood swings, headaches and sometimes lower abdominal pain.
The bleeding itself is usually normal, not particularly heavy or unusual.
Page 5 · 81–95 / 95
DOCTOR: How long do the complaints last?
And what treatments have you tried so far?
PATIENT: The complaints usually start a few days before the period, about three to five days, and then slowly stop with the start of the bleeding.
For the headaches I sometimes take Voltaren.
For the mood swings a bit of exercise or relaxation helps me, for example walking or yoga.
My doctor also advised me to make sure I get enough sleep and a balanced diet.
In addition, Jaz has shown positive effects for me.
DOCTOR: Have you ever been pregnant before?
PATIENT: No.
DOCTOR: Do you have any known allergies or intolerances, for example to foods, medications, animals or other substances?
PATIENT: I have problems with wasp stings, and I also cannot tolerate crustaceans.
DOCTOR: How do your allergies manifest?
PATIENT: Once I was on a trip and I was stung by a wasp.
Afterwards I got a rash all over my body and my lips swelled.
I then went to the emergency room and got an injection there.
Since then I always carry an EpiPen with me.
I also get stomach pain when I eat crustaceans.
DOCTOR: Do you smoke?
PATIENT: I am not a smoker.
DOCTOR: Do you drink alcohol?
What kind?
How much?
PATIENT: Yes, for example at celebrations and parties I occasionally drink alcohol – usually a glass of wine or beer.
DOCTOR: May I ask whether you have ever used drugs?
PATIENT: Occasionally at parties I have smoked joints.
DOCTOR: What is your occupation?
PATIENT: I study computer science and am now in my final semester at Ludwig Maximilian University in Munich.
If all goes well, I will graduate in a few months.
DOCTOR: Computer science – that is surely a very sought-after subject.
You will certainly have good prospects after your studies.
What is your marital status?
PATIENT: I am in a relationship.
DOCTOR: Who do you live with?
PATIENT: I live with my boyfriend.
DOCTOR: Are there important illnesses in your family, for example in your parents, siblings or other close relatives?
PATIENT: My father had heart surgery at the age of 70 in the hospital.
They basically grafted a new vessel from his right leg because circulation was no longer working properly.
My mother suddenly lost the right visual field at the age of 63.
The doctors could not find a precise cause for that.
In addition, she was diagnosed with right-sided breast cancer ten years ago, which was operated on at the time.
For about a year now she has been receiving chemotherapy again.
DOCTOR: Have you traveled recently?
PATIENT: No, I have not traveled recently.
DOCTOR: Do you have pets?
PATIENT: I do not have pets.
DOCTOR: We are finished with the medical history.
Please say: How much have your symptoms improved?
PATIENT: I no longer feel nauseous, and the pain has gotten much better.
DOCTOR: Good to hear. Do you have any further questions?
PATIENT: Do I need surgery?
DOCTOR: We cannot say that for sure at the moment.
You have sustained multiple injuries, and we now need to clarify with X-rays, CT and ultrasound whether there are bone fractures or internal injuries.
Only after that can we decide whether an operation is necessary or whether we can treat the injuries without surgery.
Now I will perform a physical examination to assess your current health status more precisely.