If the doctor asks you about anything other than these , just say “ no ,” or provide an answer that a normal patient might give.
You are a 23-year-old man who comes to the emergency department with rectal bleeding
History of present illness
. Symptoms started with small blood speaks in stools for the last month ; have been passing frank blood for the past 3 days . Chronic constipation for past 5 years . Often have to strain while defecating and sometimes has severe pain with bowel movements . Diet low in fruits and vegetables . Bowel movements have increased in frequency recently to 3 times a day . Associated symptoms: - Crampy , mild pain (2-3/10) in lower abdomen - No nausea or vomiting ; no black , tarry stools - Mild fever (37.8’C[100F]) without chills for the past 4-5 days - No recent change in weight or appetite
Past medical / family / social history
. No similar episodes in the past . No otters medical issues , surgeries , or hospitalization . No medications . No drug allergies . Father died of colon cancer at age 65; other family history its unknown . Single , with multiple , recent female sexual partners ( Do not always use condoms) , no history of sex with men . Occupation: Restaurant manager and bartender . Smoking : No . Alcohol : 1-2 drinks a week . Recreational drugs : No
Physical examination
HEENT : . No scleral icterus or pallor
Heart : . Regular rate and rhythm . No murmurs
Lungs : . Clear to auscultation
Abdomen : . Soft , Non-tender , no -distended . Normal bowel sounds
—————
Case 43 sim. pt. checklist
Following the encounter , check which of the following items were performed by the examinee
History of present illness/ review of systems
. Asked about the description of the bleeding (eg, color [red/purple/black], quantity , blood on feces or mixed in) . Asked about the onset and course over time . Asked about pain during defecation and tenuous . Asked about abdomen pain . Asked about any prior gastrointestinal bleeding . Asked about nausea and vomiting . Asked about usual and recent bowel and dietary habits . Asked about appetite and changes in weight . Asked about fever and chills
Past medical /family/social history
. Asked bout otters medical issues . Asked bout past hospitalizations and surgeries . Asked about current medications (especially aspirin) . Asked about medication allergies . Asked about family health (especially gastrointestinal malignancy) . Asked out tobacco , alcohol , and recreational drug use . Asked occupation . Asked about sexual history
Examination
. Washed heads before examination . Examined without gown , not through gown . Examined abdomen (inspection, auscultation , superficial and deep palpation)
Counseling
. Explained the physical finding and possible diagnosis . Explained further workup . Discussed the need for rectal examination
Communication skills and professional conduct
. Knocked before entering the room . Introduced self and greeted you warmly . Used your name to address you . Paid attention to what you said and maintained good eye contact . Asked opened questions . Asked non-leading questions . Asked one question at a time . Listened to what you said without interrupting me . Used plain English rather than technical jargon . Used appropriate transition sentences . Used appropriate draping techniques . Summarized the history and explained physical findings . Expressed empathy and gave appropriate reassurances . Asked whether you have any concerns/questions
The following represents a typical note for this patient encounter . the detail may vary depending on the information given by the simulated patient.
History : Describe the history you just obtained form this patient . Include only information (Pertinent positives and negatives) relevant to this patient’s problem(s).
. 23-yo man with rectal bleeding . Mild symptoms for 1 month , passing frank blood last 3 days. . Associated with crampy pain and low-grade fever . History of chronic constpation
ROS : No change in weight or appetite , no nausea or vomiting PMHx : Unremarkable PSHx : None Meds : None Allergies : None FHx : Father died of colon cancer at age 65 SHx : Single , works as restaurant manager and bartender , sexually active with multiple female partners, light alcohol intake , no tobacco or drug use
Physical examinations : Describe any positive and negative findings relevant to this patient’s problem(s) . be careful to include only those parts of the examination performed in this encounter.
. Vital signs : Temperature , 38.3’C(100.9F) ; blood pressure , 110/60mmHg ; pulse , 90/min; and respirations , 18/min . HEENT : No scleral icterus or pallor . Heart : RRR with no murmur . Lungs ; Clear to auscultation . Abdomen : Soft , non-tender, normal bowel sounds
Data interpretation : Based on what you have learned from the history and physical examination, list up to 3 diagnosis that might explain this patient’s complaint(s) . List your diagnoses from most to least likely . For some cases , fewer than 3 diagnosis will be appropriate . the , enter the positive and negative findings form the history and the physical examination (if present) that support each diagnosis . Finally , list initial diagnostic (if any) you would order for each listed diagnosis (eg,restricted physical examination maneuvers, laboratory tests , imaging ECG , etc).
Diagnosis #1 : Hemorrhoid
History finding(s) . Visible lower gastrointestinal bleeding . Chronic constipation and low-fiber intake
. Seizes (secondary to head trauma , infections , drugs , metabolic disorders) . Hypoglycemia . Syncope . Migraine . Stroke . Psychogenic seizure . Space-occupying lesion . Alcohol or drug withdrawal
—————
Case 42 sim.pt. instruction
If the doctor asks you about anything other than these , just say “ no ,” or provide an answer that a normal patient might give.
You are a 30-year-old man who is brought to the emergency department with a new seizure
History of present illness
. Seizure occurred a few hours ago . Witnesses (coworkers) noted shaking lasting about 3 minutes , followed by 20 minutes of loss of consciousness . Symptoms preceded by nausea . Bit tongue but did not pass urine or feces during the episode . Have noticed some weakness in the right hand for the past 3 months . Chronic, occasional mild headaches , but recently the headaches are constant and more severe . No history of head trauma
Review of systems
. Mild fever ; cold and flu-like symptoms for the past couple of days . No ear discharge or sinus pain . No neck pain
Past medical / family / social history
. Type 1 diabetes diagnosis 15 years ago and treated with insulin pump (If the examinee asks you if you think this could be due to hypoglycemia , say: “ I don’t think so because I know what that looks like.’ ) . No other medical issues , hospitalizations , or surgeries . No otters medications . No drug allergies . Father , mother , and sister are healthy ( No family history of seizures) . Single , not sexually active . Occupation : Postal clerk . Smoking : No . Alcohol : Social occasions only ; last drink was 2 days ago . Recreational drugs : No
Physical examination
HEENT : . Normal , no injuries
Neck : . Supple with no goiter or lymphadenopathy
Heart : . regular rate and rhythm . No murmurs
Chest / lungs : . Clear to auscultation and percussion
Neurologic : . Awake and alert . Cranial nerve examination normal . Motor strength and reflexes normal
—————
Case 42 sim. pt. checklist
Following the encounter , check which of the following items were performed by the examinee
History of present illness/ review of systems
. Asked bout a description of the seizure - Duration - Shaking - Automatisms (eg, lip smaking) - Fecal/urinary incontinence - Biting of tongue or other injuries - Post-seizure confusion /loss of consciousness . Asked about aura (prodromal symptoms) and activities at the onset of seizures . Asked about any recent head trauma . Asked about associated symptoms: - Palpitations , chest pain - Headaches - Nausea / vomiting - Fever - Muscle weakness . Asked about any past seizures of loss of consciousness
Past medical /family/social history
. Asked about other medical issues(especially diabetes , meningitis /encephalitis, neurologic disorders) . Asked about prior hospitalizations and surgeries . Asked about current medications . Asked bout medication allergies . Asked about family health . Asked about tobacco , alcohol , and recreational drug use ( including most recent alcohol use and any history of alcohol withdrawal) . Asked about occupation
Examination
. Washed heads before examination . Examined without gown , not through gown . Examined for head injury and neck stiffness . Checked motor power , reflexes, and sensation in all limbs . Examined the cranial nerves . Examined eyes with ophthalmoscope . Examined ears with otoscope . Examined heart and lungs . Examined abdomen
Counseling
. Explained physical findings and possible diagnosis . Explained further workup . Discussed family support
Communication skills and professional conduct
. Knocked before entering the room . Introduced self and greeted you warmly . Used your name to address you . Paid attention to what you said and maintained good eye contact . Asked opened questions . Asked non-leading questions . Asked one question at a time . Listened to what you said without interrupting me . Used plain English rather than technical jargon . Used appropriate transition sentences . Used appropriate draping techniques . Summarized the history and explained physical findings . Expressed empathy and gave appropriate reassurances . Asked whether you have any concerns/questions
. CBC with differential . Serum electrolytes (Na,K, Cl, CO2, BUN, Cr, Ca, Mg) and glucose . LFTs . Urinalysis and urine toxicology screen . Head CT scan . Lumber puncture . EEG
—————
Case 42 clinical summary
Clinical Skills Evaluation Case 42 Patient Note
The following represents a typical note for this patient encounter . the detail may vary depending on the information given by the simulated patient.
History : Describe the history you just obtained form this patient . Include only information (Pertinent positives and negatives) relevant to this patient’s problem(s).
. 30-yo man with new-onset seizure . Onset a few hours ago . Single episode of shaking (3 min) followed by loss of consciousness (20min) . Proceeded by nausea and associated with biting of tongue . Recent history of right hand weakness and increasing headaches
ROS : Mild fever and flu-like illness last few days PMHx : Type 1 diabetes for 15 years PSHx : None Meds : Insulin via pump Allergies : None FHx : Father , mother , and sister are healthy SHx : Single , works as postal clerk ; social alcohol , no tobacco or drug use
Physical examinations : Describe any positive and negative findings relevant to this patient’s problem(s) . be careful to include only those parts of the examination performed in this encounter.
. Vital signs ; Temperature , 37.2’C (99F); blood pressure , 120/80mmHg; pulse , 82/min; and respirations , 18/min . HEENT : PERRLA , EOMI, no papilledema . Neck ; Supple without thyromegaly or lymphadenopathy . Heart : RRR with no murmurs . Lungs : Clear to auscultation and percussion . Neurologic ; Awake and cranial nerves II-XII intact , motor strength and reflexes normal
Data interpretation : Based on what you have learned from the history and physical examination, list up to 3 diagnosis that might explain this patient’s complaint(s) . List your diagnoses from most to least likely . For some cases , fewer than 3 diagnosis will be appropriate . the , enter the positive and negative findings form the history and the physical examination (if present) that support each diagnosis . Finally , list initial diagnostic (if any) you would order for each listed diagnosis (eg,restricted physical examination maneuvers, laboratory tests , imaging ECG , etc).
Diagnosis #1 : Intracranial mass
History finding(s) . New seizure . Increasing headaches . Recent subjective weakness
Physical examination finding(s) . None
Diagnosis #2 : Hypoglycemia
History finding(s) . Type 1 diabetes . Use of insulin pump
Physical examination finding(s) . None
Diagnosis #3 : Alcohol withdraw
History finding(s) . New Seizure . Last alcohol intake 2 days ago
Physical examination finding(s) . None
Diagnostic studies
. CT scan of the head . CBC with differential . Serum electrolytes and glucose . Urine toxicology screen . Lumbar puncture . EEG
JuanFe
發表於： 2018/09/13 08:04am
41 Case 41 scenario ( dizziness )
Doorway information about patient
The patient is a 60-year-old man who comes to the office due to dizziness
If the doctor asks you about anything other than these , just say “ no ,” or provide an answer that a normal patient might give.
You are a 60-year-old man who has dizziness
History of present illness
. Onset 4 days ago . Intermittent espies latina 2-5 minutes . Worse when standing up form a seated position ; better when lying down . Sometimes associated with palpitations and sweating . No associated loss of consciousness . During an espies earlier today , you noticed weakness in the right lower leg that lasted 10 minutes and resolved spontaneously
. Asked this questions: “ Doc , did I have a stroke? “ . If the examinee asked you to clarify the quality of dizziness , say: “ If feels alike I might fall over or pass out.”
Review of systems
. No headaches . No changes in hearing or ringing in the ear . No nausea , vomiting , or diarrhea . No chest pain . No incontinence of bowel or bladder . Decreased force of urine stream with nocturia 1 or 2 times a night
Past medical / family / social history
. Type 2 diabetes : Diagnosed 15 years ago and treated with glyburide twice daily and atovastatin ; finger -stick blood glucose has recently been 120-160 mg/dl’ . Hypertension : Diagnosed 10 years ago ; changed 1week ago form atenolol (which you had taken for many years ) to terazosin due to increasing symptoms of benign prostatic hyperplasia . No history of heart dies or stroke . No other medications . No drug allergies . No surgeries or hospitalizations . Father and motor died in their 80s due to chronic obstructive pulmonary disease . Married , live with wife . Occupation : Supermarket cashier . Tobacco : 2 packs a day for last 30 years . Alcohol : No . Recreational drugs : No
Physical examination
HEENT : . Cerumen accumulation in both ears . Normal nares , mouth ,and pharynx
Neck : . No goiter or palpable lymph modes
Cardiovascular : . Regular rate and rhythm . No murmur . No carotid bruits . Pedal pulses faint but palpable
Neurologic : . Gait slow and hesitant . Cranial nerves normal . Normal balance and coordination . Normal strength and reflexes
If the examinee performs the Dix-Hallpike maneuver (lie back quickly with head turned 45 degrees ), there are no eye movements elicited but say :” I feel kind of dizzy.”
—————
Case 41 sim. pt. checklist
Following the encounter , check which of the following items were performed by the examinee
History of present illness/ review of systems
. Asked to clarify the quality of dizziness ( eg, spinning/vertigo , lightheaded) . Asked about the onset and duration of symptoms . Asked about the relation to posture and otters triggering factors ; asked about any relieving factors . Asked whether dizziness is continuous or intermittent . Asked about associated symptoms (eg, visual changes, headaches , tingling /numbness, weakness , loss of consciousness) . Asked about ear problems (eg , loss of hearing , ringing in ears) . Asked about nausea and vomiting
Past medical /family/social history
. Asked about similar episodes in the past . Asked about past medical issues , hospitalizations ,and surgeries . Asked about current medications . Asked about medication allergies . Asked about family health . Asked bout tobacco , alcohol , and recreational drug use . Asked about current living situation and family support . Asked about occupation
Examination
. Washed heads before examination . Examined without gown , not through gown . Checked BP on both arms in sitting , standing , and lying positions . Examined ears , nose , and throat . Checked motor power and sensation in all limbs . Checked reflexes . Examined cranial nerves . Performed Romberg test and coordination / cerebellar function tests (eg, finger-to-nose) . Checked gate . Performed Dix-Hallpike maneuver (patient lies down quickly with head turned 45 degrees to each side) . Examined heart , carotid arteries , and distal circulation
Counseling
. Explained physical findings and possible diagnosis . Explained further workup . Discussed smoking cessation and readiness to quit
Communication skills and professional conduct
. Knocked before entering the room . Introduced self and greeted you warmly . Used your name to address you . Paid attention to what you said and maintained good eye contact . Asked opened questions . Asked non-leading questions . Asked one question at a time . Listened to what you said without interrupting me . Used plain English rather than technical jargon . Used appropriate transition sentences . Used appropriate draping techniques . Summarized the history and explained physical findings . Expressed empathy and gave appropriate reassurances . Asked whether you have any concerns/questions
. CBC . Doppler carotid study . Blood glucose and hemoglobin A1c . Serum electrolytes (Na, K, Cl, BUN, creatinine) . ECG . Head CT
—————
Case 41 clinical summary
Clinical Skills Evaluation Case Patient Note
The following represents a typical note for this patient encounter . the detail may vary depending on the information given by the simulated patient.
History : Describe the history you just obtained form this patient . Include only information (Pertinent positives and negatives) relevant to this patient’s problem(s).
. 60-yo man with 4 days of intermittent dizziness . Brief episodes of nonspecific dizziness triggered by positional changes . Associated with palpitations and 1 episode of leg weakness (resolved spontaneously) but no loss of consciousness
ROS : No headache , hearing symptoms , nausea , chest pain , or incontinence ; positive for lower urinary tract symptoms PMHx : HTN, diabetes , BPH PSHx : None Meds ; Glyburide , atovastatin , terazosin (chenaged from atenolol a week ago) Allergies : None FHx : Father and mother died of COPD SHx : Married , works as casher , 2 PPD smoker for 30 years , no alcohol or drug use
Physical examinations : Describe any positive and negative findings relevant to this patient’s problem(s) . be careful to include only those parts of the examination performed in this encounter.
. vital signs : Temperature , 36.1’C(97F) ; blood pressure , 140/90 mmHg ; pulse , 80/min; and respirations , 16/min . HEENT : Cerumen accumulation bilaterally ; ears , nose , and throat otherwise normal . Neck : No lymphadenopathy or thyromegaly . Heart : RRR with no murmurs , no carotid bouts , pedal pulses palpable but diminished . Neurologic : Slow gait , CN II-XII normal , normal motor strength and reflexes , Romberg and finger-to-nose tests normal , Dix-Hallpike test subjectively positive
Data interpretation : Based on what you have learned from the history and physical examination, list up to 3 diagnosis that might explain this patient’s complaint(s) . List your diagnoses from most to least likely . For some cases , fewer than 3 diagnosis will be appropriate . the , enter the positive and negative findings form the history and the physical examination (if present) that support each diagnosis . Finally , list initial diagnostic (if any) you would order for each listed diagnosis (eg,restricted physical examination maneuvers, laboratory tests , imaging ECG , etc).
If the doctor asks you about anything other than these , just say “ no ,” or provide an answer that a normal patient might give.
You are a 45-tear-old man who comes to the emergency department with bloody vomiting
History of present illness
. Acute one of symptoms 2 hours ago . Burning epigastric pain (8/10 severity ) radiating t the back , immediately followed by vomiting with cupful of bright blood . Came to the emergency department following a second , similar episode 30 minutes ago . Associated symptoms include: - Dizziness/ lightheadedness - Dark black stools occasionally in the last month . History of heartburn for the last 2 years , worse in the last 2 months . Midepigastric pain 3-4 times a week after meals , especially when you also consume coffee or alcohol; symptoms last 10-15 minutes and are relieved with antacids
. Ask the doctor : “ Will I die for this bleeding ? Is it cancer ?”
Review of systems
. No fever or chills . No weight loss . No shortness of breath . No jaundice , diarrhea , or constipation . No urinary symptoms . Heavy work stress
Past medical / family / social history
. Hypertension . Tension headaches . No surgeries or hospitalization . Medications ; Hydrochlorothiazide 50mg daily , ibuprofen 400 mg 3 times a day as needed . No drug allergies . Father , mother , and 2 siblings are healthy . Married ,live with wife and 2 children . Occupation : Sale manager at a marketing company . Smoking : 2 pack a day for last 25 years . Alcohol : 2 beers a day for last 25 years . Recreational drugs : None
Physical examination
HEENT : . No jaundice or pallor . Oropharynx clear
Neck : . Supple without thyromegaly or lymphadenopathy
Lungs : . Clear to auscultation bilaterally
Heart : . Regular rhythm and rate . No murmurs , gallops, or rubs
Abdomen : . Non-tender , non-distended . Normative bowel sounds throughout . No hepatosplenomeagly . No bruits
—————
Case 40 sim. pt. checklist
Following the encounter , check which of the following items were performed by the examinee
History of present illness/ review of systems
. Asked about the inset and frequency of vomiting . Asked about the color of the vomit and quantity of blood vomited . Asked about any recent/ prior symptoms (eg , heartburn , coughing , retching) . Asked about associated abdominal pain ( location , radiation , quality , severity , aggravating / relieving factors) . Asked about other associated symptoms , especially : - Fever - Dizziness - Melena or bright red blood in stool . Asked about hematuria or any otters unusual bleeding /bruising
Past medical /family/social history
. Asked about similar episodes in the past . Asked about other medical issues (especially liver problems , stomach ulcers) . Asked about past hospitalizations and surgeries . Asked about current medications . Asked about medication allergies . Asked about family health . Asked about tobacco , alcohol , and recreational drug use . Asked about occupation
Examination
. Washed heads before examination . Examined without gown , not through gown . Examined eyes for pallor and jaundice . Examined mouth and pharynx . Palpated neck and supraclavicular region for lymph nodes . Examined heart and lungs . Examined abdomen (auscultation , superficial and deep palpation , percussion of liver) . Examined extremities
Counseling
. Explained physical findings and possible diagnosis . Explained further workup . Discussed smoking cessation (briefly)
Communication skills and professional conduct
. Knocked before entering the room . Introduced self and greeted you warmly . Used your name to address you . Paid attention to what you said and maintained good eye contact . Asked opened questions . Asked non-leading questions . Asked one question at a time . Listened to what you said without interrupting me . Used plain English rather than technical jargon . Used appropriate transition sentences . Used appropriate draping techniques . Summarized the history and explained physical findings . Expressed empathy and gave appropriate reassurances . Asked whether you have any concerns/questions
. CBC with differential count . Serum electrolytes (Na , K , HCO3 , Cl , BUN , creatinine) . Coagulation studies (PT, aPTT) . Upper GI endoscopy . Liver function tests
—————
Case 40 clinical summary
Clinical Skills Evaluation Case 40 Patient Note
The following represents a typical note for this patient encounter . the detail may vary depending on the information given by the simulated patient.
History : Describe the history you just obtained form this patient . Include only information (Pertinent positives and negatives) relevant to this patient’s problem(s).
. 45-yo man with acute onset of 2 episodes of hematemesis with a cup of bright red blood and dizziness . Midepigastric pain radiating to the back . 2 years of heartburn and chronic midepigastric pain after meals , last 15-20 minutes and relieved with antacids. . Symptoms worse with caffeine and alcohol intake . Occasional black stools in the past month
ROS : No jaundice , fever, chills , shortness of breath , weight los, urinary symptoms , diarrhea , or constipation PMHx : HTN , tension headaches PSHx : None Meds ; Hydrochlorothiazide 50mg daily , ibuprofen 400 mg 3 times daily as needed Allergies ; None FHx : Father , mother , and sibling s are ha;thy SHx : 2 PPD smoker for 25 years ,2 beers a day for 25 years
Physical examinations : Describe any positive and negative findings relevant to this patient’s problem(s) . be careful to include only those parts of the examination performed in this encounter.
. Vital signs : Temperature , 36.7’C (98.1F) ; blood pressure , 100/60mmHg; pulse , 90/min ; and respirations , 18/min . HEENT : No jaundice or pallor , oropharynx clear . Neck : Supple without thyromegaly or lymphadenopathy . Lung s; Clear to auscultation bilaterally . Heart ; RRR without murmurs , gallops, or rubs . Abdomen : Non-tender , non distended , normative bowel sounds throughout , no hepatosplenomegaly , no bruits
Data interpretation : Based on what you have learned from the history and physical examination, list up to 3 diagnosis that might explain this patient’s complaint(s) . List your diagnoses from most to least likely . For some cases , fewer than 3 diagnosis will be appropriate . the , enter the positive and negative findings form the history and the physical examination (if present) that support each diagnosis . Finally , list initial diagnostic (if any) you would order for each listed diagnosis (eg,restricted physical examination maneuvers, laboratory tests , imaging ECG , etc).
Diagnosis #1 : Bleeding gastric ulcer
History finding(s) . Hematemesis . Midepigastric pain . Occasional black stools . NSAID use
Physical examination finding(s) . Hypoetsnion
Diagnosis #2 : Gastritis
History finding(s) . Hematemesis . Midepigastric pain . History of NSAID use
Physical examination finding(s) . None
Diagnosis #3 : Esophagitis
History finding(s) . History of heartburn . Hematemesis . Chronic tobacco / alcohol use
Physical examination finding(s) . None
Diagnostic studies
. CBC with differential . Upper GI endoscopy . PT, aPTT . Basic metabolic panel
JuanFe
發表於： 2018/09/13 08:02am
[這篇文章最後由JuanFe在 2019/05/23 08:10pm 第 1 次編輯]
39 Case 39 scenario
Doorway information about patient ( epigastric pain )
The patient is a 53-year-old man who comes to the emergency department due to epigastric pain
. Peptic ulcer . Gastritis . Esophagitis(GERD) . Carcinoma of esophagus , stomach , or pancreas . Acute or chronic pancreatitis . Cholecystitis . Hepatitis . Acute coronary event
—————
Case 39 sim.pt. instruction
If the doctor asks you about anything other than these , just say “ no ,” or provide an answer that a normal patient might give.
You are a 53-year-old man who abdominal pain
History of present illness
. Intermittent abdominal pain for the past 2 years . Located in midepigastric area and sometimes radiates to back . Sharp quality ; 7/10 severity at worst . Worse with meals and sometimes relieved with antacids; the pain also occurs in the middle of the night . Associated symptoms : - Decreased appetite with 6.8-kg(15-lb) weight loss in the last 6 months - Abdominal bloating and feeling of fullness - Occasional black stools
. Asked the doctor : ” Can you please stop this pain ? Is it durable?”
Review of systems
. No fever or chills . No jaundice . No shortness of breath . No nausea , vomiting , diarrhea , or constipation
Past medical / family / social history
. Osteoarthritis of the knee for past 10 years . Surgeries : None . Medications : Ibuprofen 600 mg 3 times a day as needed , over-the-counter antacids as needed . No drug allergies . Father is healthy , mother died of pancreatic cancer at age 60, broth is healthy . Occupation ; stockbroker . Married , live with wife and 2 children . Tobacco : No
Physical examination
Neck : . Supple without thyromegaly or lymphadenopathy
Abdomen : . Soft , non-tender, non-disveended . Normative bowel sounds throughout . No hepatosplenomegaly . No bruits
—————
Case 39 sim. pt. checklist
Following the encounter , check which of the following items were performed by the examinee
History of present illness/ review of systems
. Asked about the onset of pain . Asked about the course over time . Asked about the location and radiation of pain . Asked about the quality and intensity of pain . Asked about any aggravating or relieving factors (especially with relation of food) . Asked bout associated symptoms , especially : - Nausea - Vomiting - Heartburn - Black stools or red blood in stools - Jaundice - Changes in appetite or weight . Asked about dietary and bowel habits . Asked about postprandial fullness or early satisfy
Past medical /family/social history
. Asked about similar episodes in the past . Asked about previous medical issues , hospitalizations ,and surgeries . Asked about current medications . Asked bout medication allergies . Asked bout family health . Asked bout tobacco , alcohol , and recreational drug use . Asked about occupation
Examination
. Washed heads before examination . Examined without gown , not through gown . Examined heart and lungs . Examined abdomen (auscultation , superficial and deep palpation) . Palpated axilla and above clavicle for lymph nodes
Counseling
. Explained physical findings and possible diagnosis . Explained further workup
Communication skills and professional conduct
. Knocked before entering the room . Introduced self and greeted you warmly . Used your name to address you . Paid attention to what you said and maintained good eye contact . Asked opened questions . Asked non-leading questions . Asked one question at a time . Listened to what you said without interrupting me . Used plain English rather than technical jargon . Used appropriate transition sentences . Used appropriate draping techniques . Summarized the history and explained physical findings . Expressed empathy and gave appropriate reassurances . Asked whether you have any concerns/questions
. CBC with differential count . Upper GI endoscopy . Serum amylase and lipase . Liver function tests (albumin , bilirubin, AST , ALT , alkaline phosphatase) . Fecal occult blood test . Abdomen ultrasound or CT scan
—————
Case 39 clinical summary
Clinical Skills Evaluation Case 39 Patient Note
The following represents a typical note for this patient encounter . the detail may vary depending on the information given by the simulated patient.
History : Describe the history you just obtained form this patient . Include only information (Pertinent positives and negatives) relevant to this patient’s problem(s).
. 53-yo man with 2 years of episodic midepigastric pain worse with food and sometimes relieved with antacids . Pain also occurring at night and sometimes radiating to the back . Pain is 7/10 severity . Decreased appetite , feeling of a full stomach . abdominal bloating , occasional back stools , and a 6.7-kg(15-lb) weight loss in the past 6 months.
ROS : No jaundice , fever ,chills, vomiting , shortness of breath , diarrhea , or constipation PMHx : Osteoarthritis of the knee for past 10 years PSHx : None Meds : Over-the -counter antacids as needed , ibuprofen 600mg 3 times a day as needed Allergies : None FHx : Father healthy , mother died at age 60 of pancreatic cancer SHx : No tobacco use ; 2 beers day for 25 years
Physical examinations : Describe any positive and negative findings relevant to this patient’s problem(s) . be careful to include only those parts of the examination performed in this encounter.
. Vital signs : Temperature , 36.1C (97F) ; blood pressure , 120/70 mmHg; pulse , 84/min; and respirations ,16/min . Neck : Supple without thyromegaly or lymphadenopathy . Heart : RRR with no murmurs . Lungs : Clear to auscultation and percussion . Abdomen : Non0tender , non-distended , normative bowel sounds throughout , no hepatosplenomegaly , no bruits
Data interpretation : Based on what you have learned from the history and physical examination, list up to 3 diagnosis that might explain this patient’s complaint(s) . List your diagnoses from most to least likely . For some cases , fewer than 3 diagnosis will be appropriate . the , enter the positive and negative findings form the history and the physical examination (if present) that support each diagnosis . Finally , list initial diagnostic (if any) you would order for each listed diagnosis (eg,restricted physical examination maneuvers, laboratory tests , imaging ECG , etc).
Diagnosis #1 : Peptic ulcer disease
History finding(s) . Midepigastric pain . Relief with antacids . History of NSAID use
Physical examination finding(s) . None
Diagnosis #2 : Chronic pancreatitis
History finding(s) . Chronic midepigastric pain . Pina radiating to back . History of alcohol use
Physical examination finding(s) . None
Diagnosis #3 : Gastric cancer
History finding(s) . Midepigastric pain increased with food . Nocturnal pain . Weight loss
Physical examination finding(s) . None
Diagnostic studies
. Abdominal X-ray (is normal) . CBC with differential . Serum amylase and lipase . Upper GI endoscopy . Liver function tests
JuanFe
發表於： 2018/09/13 08:02am
38 Case 38 scenario ( anxiety )
Doorway information about patient
The patient is a 35-year-old woman who comes to the emergency department due to breathlessness and anxiety.
. Anxiety secondary to medical condition (eg, hyperthyroidism, arrhythmias) . Substance abuse . Panic disorder . Generalized anxiety disorder . Adjustment disorder with anxious mood . Acute stress disorder or post-traumatic stress disorder . Hypochondriasis
—————
Case 38 sim.pt. instruction
If the doctor asks you about anything other than these , just say “ no ,” or provide an answer that a normal patient might give.
You are a 35-year-old woman experiencing shortness of breath
History of present illness
. Episodic shortness of breath for 3 months ; slight problems previously but never this severe . Episodes last 30 minutes and are associated with palpitations , sweating ,and feeling that you are going to die . Episodes occur about 2 or 3 times a week at any time but are worse in crowded places outside the house , and you have stopped going to outdoor activities to avoid triggering symptoms . Symptoms seem to improve with sloe breathing and relaxation . Multiple emergency department evaluations for the same symptoms ; all test have been normal/nondiagnostic . Ask the doctor : “ Do you think that this is anxiety like my mother has?”
Review of systems
. No chest pain . No headaches or tremors . Occasional diarrhea alternating with constipation . No nausea , vomiting , or abdominal pain
Past medical / family / social history
. No prior medical issues , surgeries , or hospitalizations . No medications . Allergies : Penicillin causes a rash . Father is healthy , mother has generalized anxiety disorder, sister is healthy . Married , live with husband and 2 children . Occupation : Homemaker . Tobacco : No . Alcohol : Wine on social occasions only . Recreational drugs : Used marijuana occasionally in college but non since then . Caffeine : 1 cup of coffee daily
Physical examination
Neck: . Supple without thyromegaly or lymphadenopathy
Lungs : . Clear to auscultation
Heart : . Regular rhythm . No nurtures, rubs, or gallops
Neurologic : . No treor in extremities
Psychological : . Alert and oriented . Affect mildly anxious but otherwise appropriate . Speech clear
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Case 38 sim. pt. checklist
Following the encounter , check which of the following items were performed by the examinee
History of present illness/ review of systems
. Asked about the initial onset of symptoms and course over time . Asked about the frequency and duration of attacks . Asked about associated symptoms . especially : - Chest pain - Swelling in neck - Fear/apprehension, sense of impending doom - Palpitations - Dizziness - Tremor - Sweating . Asked about aggravating and relieving factors . Asked about impact of symptoms on relationship and normal activities
Past medical /family/social history
. Asked about similar episodes in the past . Asked about past medical issues (especially thyroid and psychological disorders) . Asked about previous hospitalizations and surgeries . Asked about current medications . Asked about medication allergies . Asked about family health . Asked about occupation . Asked bout tobacco , alcohol , and recreational drugs
Examination
. Washed heads before examination . Examined without gown , not through gown . Palpated neck for swelling . Examined hands for tremor . Examined heart and lungs . Examined cranial nerves , motor strength , and reflexes
Counseling
. Explained the physical findings and possible diagnosis . Explained further workup (if any)
Communication skills and professional conduct
. Knocked before entering the room . Introduced self and greeted you warmly . Used your name to address you . Paid attention to what you said and maintained good eye contact . Asked opened questions . Asked non-leading questions . Asked one question at a time . Listened to what you said without interrupting me . Used plain English rather than technical jargon . Used appropriate transition sentences . Used appropriate draping techniques . Summarized the history and explained physical findings . Expressed empathy and gave appropriate reassurances . Asked whether you have any concerns/questions
. ECG . Electrolytes and glucose . TSH . Urine drug screen
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Case 38 clinical summary
Clinical Skills Evaluation Case 38 Patient Note
The following represents a typical note for this patient encounter . the detail may vary depending on the information given by the simulated patient.
History : Describe the history you just obtained form this patient . Include only information (Pertinent positives and negatives) relevant to this patient’s problem(s).
.35-yo woman with 3 months of episodic shortness of breath , palpitations , diaphoresis, and feeling of impending death . Episodes lasting 30 minutes and occurring more frequently outside of house in crowded places . Symptom improvement with slow breathing and relaxation . Multiple ED trips with normal investigations and no definitive diagnosis
ROS : Occasional diarrhea alternating with constipation ; no chest pain, headache nausea , vomiting , tremors , neck swelling , or abdominal pain PMHx : None PSHx : None Meds : None Allergies : Penicillin (rash) FHx : Father is healthy ; mother has generalized anxiety disorder SHx ; No tobacco use , occasional glass of wine
Physical examinations : Describe any positive and negative findings relevant to this patient’s problem(s) . be careful to include only those parts of the examination performed in this encounter.
. Vital signs ; Temperature ,36.1’C(97F); blood pressure , 130/80/mmHg; pulse ,94/min; and respirations , 22/min . Neck : Supple without thyromegaly or lymphadenopathy . Lung : Clear to auscultation . Heart : Regular rhythm without murmurs , rubs, gallops . Neurologic ; No tremor in extremities
Data interpretation : Based on what you have learned from the history and physical examination, list up to 3 diagnosis that might explain this patient’s complaint(s) . List your diagnoses from most to least likely . For some cases , fewer than 3 diagnosis will be appropriate . the , enter the positive and negative findings form the history and the physical examination (if present) that support each diagnosis . Finally , list initial diagnostic (if any) you would order for each listed diagnosis (eg,restricted physical examination maneuvers, laboratory tests , imaging ECG , etc).
Diagnosis #1 : Panic disorder
History finding(s) . Episodes of palpitations with dyspnea . Family history of anxiety . Symptoms worse in crowded places . Symptoms relieved wth slow breathing
Physical examination finding(s) . None
Diagnosis #2 : Hyperthyroidism
History finding(s) . Episodes of palpitations . Shortness of breath and diaphoresis
Physical examination finding(s) . None
Diagnosis #3 : Cardiac arrhythmia
History finding(s) . Palpitations . Shortness of breath and diaphoresis
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