-- 作者： JuanFe -- 發表時間： 2018/06/05 11:03pm [這篇文章最後由JuanFe在 2018/09/13 08:08am 第 7 次編輯] 1 Abdominal pain 2 Skin rash 3 Arm and leg weakness 4 Acute chest pain 5 Cough 6 fatigue and weight loss 7 diarrhea 8 sore throat 9 medication refill 10 constipation 11 importance 12 child fever 13 abdominal pain RUQ 14 prenatal visit ------------------------------------------------------------------- 15 shortness of breath 16 increase urination 17 jaundice 18 chest pain 19 abdominal pain RLQ 20 leg pain bilateral 21 vomiting 22 Acute chest pain 23 Frequent fall 24 Cough and chest pain 25 lower abdominal pain 26 Fatigue 27 hearing loss 28 Right knee pain 29 Blurred vision ------------------------------------------------------------------- 30 multiple bruises 31 burning during urination 32 difficulty swallowing 33 Refill medication for HIV 34 amenorrhea 35 right lower back and lower abdominal pain 36 insomnia 37 difficulty urination 38 panic attack 39 epigastric pain 40 hematemesis 41 dizziness 42 seizure 43 rectal bleeding -- 作者： JuanFe -- 發表時間： 2018/07/07 05:16am [這篇文章最後由JuanFe在 2018/11/03 01:04pm 第 1 次編輯] 1 Case 1 Scenario (abdominal pain) Doorway information The patient is a 30-year-old woman who comes to the clinic due to abdomen pain Vital signs . Temperature : 38.5’C (101.3 F) . Blood pressure : 120/75 mmHg . Pulse : 98 /min . Respiration : 22/ min Basic differential diagnosis Gastrointestinal . Appendicitis . Acute cholecystitis . Pancreatitis . Inflammatory bowel disease . Irritable bowel syndrome . Diverticulitis . Bowel obstruction . Acute gastroenteritis Urinary . Urinary tract infection / pyelonephritis . Renal colic Reproductive . Pelvic inflammatory disease . Pelvic abscess . Endometriosis . Ovarian cyst / torsion . Ectopic pregnancy . Spontaneous abortion Miscellaneous . Shingles . Aortic dissection ————— Case 1 sim. pt . instructions If the doctor ask you about anything other then these , just say “no” , or provide an answer that a normal patient might give. You are a 30-year-old women who comes to the clinic with abdomen pain. History of present illness . The pain started 12 hours ago . Started slowly , progressively increasing . “Sharp” pain ; 6-7/10 in severity . Felt all mover lower abdomen , but worst right below the umbilicus . Began after eating a large meal . Moving around makes it worse . No alleviating factors . Fever since yesterday, with occasional chills today . Intermittent nausea and vomiting . Passing urine more frequently and having burning on urination . No bowel problems Review of the systems . Last menstrual period was 3 weeks ago . No discharge or abnormal bleeding form vagina . Appetite and weight have not changed recently Past medical /family /social history . One urinary tract infection in the past ; was serious and required hospitalization . Current medications is an oral contraceptive pill only . No allergies . Immediate family members are all healthy . Occupation : Receptionist （接待員） . Sexually active with multiple men . Tobacco : no . Alcohol : 2-3 drinks on weekend . Recreational drugs: no Ask this question : “Doctor , is this appendicitis ?” ————— Case 1 checklist Following the encounter , check which of the following items were performed by examinee. History of present illness / review of system . Asked about the location of pain . Asked about the intensity of pain . Asked about the quality of pain . Asked about the onset and duration of pain . Asked about the course pf pain over time . Asked about any radiation of pain . Asked about any aggravating or relieving factors . Asked about associated symptoms , especially : 1 Vomiting 2 Fever 3 Urinary problems 4 Bowel problems 5 Vaginal bleeding / discharge . Asked about last menstrual period . Asked about appetite and changes in weight Past medical/ family / social history . Asked about similar episodes in the past . Asked about past medical issue , hospitalization , and surgeries . Asked about current medications . Asked about medication allergies . Asked about family health . Asked about tobacco, alcohol, and  drug use . Asked about sexual and reproductive history . Asked about occupation Examination . Examinee washed hands before examination . Examined without gown , not through gown . Auscultated abdomen . Palpated abdomen(superficial and deep) . Checked for rebound tenderness . Checked for costovertibral angle tenderness . Performed posts sign and obstructor sign Counseling . Explained physical findings and possible diagnosis . Explained further workup . Discussed safe sexual practices and sue of condom . Asked to perform rectal and vaginal 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 open-ended questions . Asked non leading questions . Asked one question at a time . Listened to what you said without interrupting . Used plain english rather than technical jargon . Used appropriate transition sentences . Used appropriate draping techniques . Expressed empathy and made appropriated reassurances . Asked whether you had any concerns/ questions Differential diagnosis . Pelvic inflammatory disease . Pelvic abscess . Urinary tract infection . Appendicitis . Ovarian torsion / rupture of cyst Diagnostic study/ studies . Rectal and vaginal examination . CBC with differential count . Urinalysis . Pregnancy test . Abdomen x-ray . Abdomen ultrasound ————— Case 1 clinical summary Clinical skill evaluation Case 1 patient note The following represents a typical note or this patient encounter . the details may vary depending on the information given by the simulated patient. History : Described the history you just obtained from this patient, Include only information (pertinent positive and negatives ) relevant this patient’s problem(s) . 30-yo remake with 12 hours of abdominal pain . Ate a heavy meal at a barbecue restaurant a day ago. . Developed acute-onset periumbilical abdomen 12 hours later; described as a sharp , lasting a few minutes at a time , radiating diffusely in the abdomen , made worse with movement , and relieved with rest. . Dysuria , increased urinary frequency , fever to 38.5’C (101.3F) , chills , nausea ,and an episode of non bloody and non bilious vomiting. ROS : No chest pain , shortness of breath , diarrhea , constipation PMHx: Previous UTI with possible pyelonephritis PSHx: None Meds: None Allergies : None FHx: noncontributory SHx: HAs had 2 sexual partners with unprotected intercourse in the past month Physical examination : 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 signsL Temperature , 38.5C (101.3F) ; blood pressure , 120/75 mmHg, pulse 98/min; and respiration’s , 22/min . Abdomen :Tenderness in the periumbilical , RLQ and LLQ regions . No abdomen dissension or guarding . Normative bowel sounds . Negative Murphy sign, Rovsing sign , posts sign , and obturator sign . No CVA tenderness . Lungs : Clear to auscultation . Heart : Normal heart sounds with no murmurs Data interpretation : Based on what you have learned form the history and physical examination, list up to 3 diagnoses that might explain this patient;s complaint(s) , List your diagnoses form most to least likely . For some cases , fewer than 3 diagnoses will be appropriate . Then , enter the positive or negative findings form the history and the physical examination (if present) that support each diagnosis. Lastly , list initial diagnostic studies (if any) you would order for each listed diagnosis (e,g, restricted physical examination maneuvers ,laboratory tests , imaging , ECG ,etc.). Diagnosis #1 : Appendicitis History findings . Diffuse , abdomen pain . Fever , chills . Nausea ,vomiting Physical Exam finding(s) . Diffuse abdomen tenderness . Fever Diagnosis #2 : UTI History findings . Dysuria . Increased urinary frequency . Fever Physical Exam findings . Fever Diagnosis #3 : Pelvic inflammatory disease History findings . Multiple sexual partners with unprotected intercourse . Nausea, vomiting Physical Exam findings . Diffuse abdominal tenderness . Fever Diagnostic Studies . Pregnancy test . Urinalysis with culture . CT scan of abdomen -- 作者： JuanFe -- 發表時間： 2018/07/07 05:19am [這篇文章最後由JuanFe在 2018/10/15 04:11pm 第 3 次編輯] 2 case 2 Scenario (rash) Doorway information about patient The patient is a 27-year-old woman who comes to the office due to a rash. Vital signs . Temperature : 36.8’C(98.3F) . Blood pressure : 120/75 mmHg . Pulse : 78/min . Respirations: 16/min Basic differential diagnosis . Infections - Bacterial (eg, cellulitis) - Viral (eg,herpes zoster/shingles) - Fungal (eg,tine corporis) - Parasitic (eg, scabies) . Psoriasis . Acne vulgaris . Rosacea . Immune / autoimmune (eg, systemic lupus erythematous , erythema multiforme) . Stasis dermatitis . Bullous disorders (eg , bullous pemphigoid , dermatitis herpetiformis) ————— Case2 sim. pt. instructions 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 27-year-old woman who comes to the office with a rash History of present illness . the rash began 1 week ago . Started after working in the garden . Located on the face and neck . Flat, with no bumps or blisters . No associated itching , burning , pain . Felt feverish but did not check temperature . Rash getting larger but not spreading to other areas of the body . Worse after going out on the sun, no alleviating factors . No recent travel or sick contacts . Also noticed joint pain and stiffness for about an hour in the morning , starting 4 days ago Review of the system . Last menstrual period was 2 weeks ago ; regular menses Past medical /family/social history . Intermittent joint pains in the past that resolve spontaneously ; never was evaluated by a doctor . no medications except aspirin 7 days ago for a headache . No surgeries . No pregnancies . Father is 55 and healthy ; mother is 54 and has “rheumatism” ; sister is28 and has hypothyroidism . Single . Works as a computer operator in a chemical manufacturing facility . 1 sexual partner in the last month ; regular condom use . Tobacco: No . Alcohol: no . Recreational drugs : No Physical examination . Skin: Multiple , well-circumscribed lesions on face and neck without vesicles ; no tenderness to touch ————— Case2 sim. pt checklist Following the encounter , check which of the following items were performed by the examinee History of present illness/review of system . Asked about the location of rash . Asked about whether the rash was initially flat or raised /blistered . Asked whether the rash has changed over time or involved new areas . Asked about any aggravating or relieving factors . Asked about any causative factors . Asked about associated symptoms , especially - Itching or burning - Pain - Breathing problems or chest pain . Asked about redness of eyes . Asked about any joint pains . Asked about fever . Asked whether any close contacts have similar rash . Asked about rennet travel . Asked about any animal contact . Asked about insect bites or outdoor activities in the recent past Past medical / family / social history . Asked about similar epodes of rash in the past . Asked about past medical issue , hospitalizations ,a dn surgeries . Asked about current medications . Asked about medication allergies . Asked about family health . Asked bout tobacco, alcohol , and drug use . Asked about sexual and reproductive history . Asked about occupation Examination . Examinee washed heads before examination . Examined without gown , not though gown . Looked inside mouth for oral ulcers . Examined hand joints . Auscultate heart and lungs . Examined face and neck for rash 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 open-ended questions . Asked non leading questions . Asked one question at a time . Listened to what you said without interrupting . Used plain English rather than technical jargon ————— Clinical Skills evaluation The following represents a typical note for this patient encounter . the details 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 positive and negatives ) relevant to this patient’s  problem(s) . 27-yo female with 1 week of rash, . Gardened for 3 hours a week ago and developed a rash on her face and neck a few hours later . . Rash has increased in size but dose not involve other areas of the body. . Morning joint pains and subjective fever. ROS: no chest pain , shortness of breath , diarrhea , constipation , sick contacts , or recent travel PMHx : Episodes of joint pain and stiffness in the past , with spontaneous resolution PSHx : None Meds : None Allergies : Noen FHx : Mother has possible rheumatoid arthritis. SHx: HAs 1 sexual partner and uses condoms Physical examination : Describe any positive and negative findings relevant to this patient’s [problem(s) . Be careful yo include only those parts of the examination performed i this encounter. . Vital signs : Temperature : 36.8’C (98.3F) , blood pressure : 120/75mmHg , Pulse : 78/min, respirations : 22/min . Face / neck : Multiple , well-circumscribes , erythematous macule without tenderness on palpation . Skin : No clines , vesicles , or cysts in rash area . . Joints : Normal range of motion in all joints without tenderness , edema , or erythema . HEENT : no pallor , jaundice or eye lesion . Lungs : CTA (C-lear T-o A-uscultate) bilaterally . Heart ; RRR without M/G/R Data interpretation: Based in what you have learned form the history and physical examination , lists up to 3 diagnosis that might explain this patient’s complaint(s) , List your diagnosis form most to least likely . For some cases , fewer than 3 diagnosis will be appropriate . then , enter the positive or negative diagnosis .Lastly , list initial diagnostic studies (if any) you would order for each listed diagnosis (eg , restricted physical exam maneuvers ,laboratory tests , imaging , ECG , eft.) . Diagnosis #1 : SLE History finding(s) . Cutaneous photosensitive rash . Fever . Joint pain Physical Examination finding(s) . Discoid lupus rash Diagnosis #2 : Rheumatoid arthritis History findings . Joint pain and morning stiffness . Fever . Family history Physical Exam findings . None Diagnosis #3 : Photodermatitis History finding(s) . History of sun exposure followed by rash Physical Exam finding(s) . Photosensitive rash on face and neck . No progression of rash to other areas Diagnosis Studies . ANA and anti-ds DNA . Rheumatoid factor and ESR . Skin biopsy -- 作者： JuanFe -- 發表時間： 2018/07/07 05:20am 3 Case 3 Scenario (arm and leg weakness) Doorway information about patient The patient is a 65-year-old woman who comes to the emergency department due to are and leg weakness. Vital signs . Temperature . Blood pressure : 160/90 mmHg . Pulse : 78/min . Respirations : 22 /min Basic differential diagnosis Neurologic . Stroke . Transient ischemic attack (TIA) . Subarachnoid hemorrhage , Subdural hematoma . Intracranial mass . Guillain -Barre syndrome . Spinal cord lesion . Complex migraine Metabolic . Hypoglycemia . Hypothyroidism . Adrenal insufficiency . Electrolyte disorders Musculoskeletal . Myopathy Miscellaneous . Conversion disorder . Heart-Reflated illness ————— Case 3 sim. pt. instructions 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 65-year-old woman who comes to the emergency department with 1 hour of right arm and leg weakness. History of illness . The symptoms started an hour ago with weakness in the right  arm and leg . Gradually increasing numbness . Moderate (5/10 in severity) headache that felt”all over “ the head . Nausea but no vomiting . No slurred speech or difficulty swallowing . No blurred or double vision. . No recent fall or loss consciousness . no symptoms like this in the past. Review of systems . No fever . No chest pain or palpitations . No diarrhea . No urinary symptoms . No seizures Past medical/family/social history . High blood pressure for 25 years . High cholesterol . Heart attack 6 years ago; heart bypass surgery at that time . Medications : Simvastatin 20 mg daily, aspirin 81mg daily, atenolol 50 mg daily . Medication allergies : None . Both parents had hypertension and died in their 60s of heart attacks . Widow (husband died 8 years ago); lives alone . Bought to the hospital by neighbor (“Steve”) who si closet contact and is “Like a son to me” . Tobacco: 2 pack of cigarettes a day for 35 years and quit 6 years ago . Alcohol : 1-2 drinks , once a month . Recreational drugs : None Physical examination Neurological: . Weaker on the right side of the body . Unable to lift right leg or arm without assistance . Unable to stand . Cranial nerves are normal . Reflexes are slightly exaggerated on the right . Babinski: Upping on right and downgoing on the left . Sensation is normal on both sides of body The rest of the examination is normal Ask this question : If the examinee dose not discuss the possibility of a stroke , ask , “Doctor , is it a stroke?” ————— Cases3 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 weakness . Asked where the weakness is felt . Asked if the weakness is changing over time . Asked how you felt prior to onset of the weakness . Asked about associated symptoms - Sensory changes or numbness - Loss of consciousness - Seizures/jerky movements - Fever - Nausea/vomiting - Chest pain, palpations - Problems with speech or swallowing - Visual changes (eg , blurred vision, double vision) - Incontinence / Bowel or bladder dysfunction . Asked about a history of frequent fall/spells . Asked about any history if recent head trauma Past / family/ social history . Asked about similar symptoms in the past . Asked about past/other medical issues (especially hypertension, diabetes mellitus , hypercholesterolemia, myocardial infarction, strokes ,migraine headaches) . Asked about previous hospitalizations and surgeries . Asked about current medications . Asked about medication allergies . Asked about any family history of stoke , heart attacks , or aneurysms . Asked about alcohol intake . Asked about living situation Examination . Examinee washed hands before examination . Examined without gown , not though gown . Checked cranial nerves II-XII . Tested muscle power bilaterally . Checked deep-tendon reflexes in bother the upper / lower extremities . Checked for sensory modalities proximally and distally . Checked coordination and gait . Listened for carotid bruits . Checked for neck stiffness . Auscultated heart Counseling . Explained the 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 open-ended questions . Asked non-leading questions . Asked one question at a time . Listened to what you said without interrupting . Used plain English rather than technical jargon . Used appropriated transition sentences . Used appropriate draping techniques . Expressed empathy and made appropriate reassurances . Asked whether you had any concerns./questions Differential diagnosis . Stroke . Transient ischemic attack . Subarachnoid hemorrhage Diagnosis study . CBC with differential . Basic metabolic panel (or glucose and electrolytes) . CT scan of the head without contrast . Doppler ultrasound of the carotid arteries . ECG . Transesophageal echocardiogram ————— Clinical Skill Evaluation Case 3 Patient Note The following represents a typical note for this patient encounter .  the details may vary depending on the information given by the simulated patient. History: Describe the history you just obtained from this patient. Include only information (patent positives and negatives) relevant to this patient’s problem(s) . 65-yo female with an hour of acute-onset , right -sided weakness and headache. . Gradually progressing symptoms over the pats hour. . Nausea without vomiting. . No history of fall or syncope. ROS: no fever , chest pain , shortness of breath , vision changes , dysarthria , seizures Max : HTN , hypercholesterolemia , CAD PSHx : CABG 6 years ago Meds : Aspirin , simvastatin , atenolol Allergies : None FHx : Mother and father had HTN and died of MI , Brother has HTN and hypercholesterolemia SHx : Smoked 2 PPD for 35 years but quit 6 years ago Physical examination : 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 : 36.8’C (98.2 F) , Blood pressure : 160/90 mmHg , pulse : 78 /min , respirations : 16/min. . Lungs :  CTA bilaterally . Heart : RRR without M/G/R . Neurological ; A&Ox3 , CN 2-12 intact , motor 5/5on LUE and LLE but 3/5 in RUE and RLE , sensory grossly intact , DTR 2+ on left but 3+ in RUE and RLE , upping toes on right and downing on left , gait unable to be assessed. Data interpretation: Based on what you have learned from the history and physical examination ., .lsit up to 3 diagnosis that might explain this patients complaint(s) , list your diagnosis form most to least likely . for some cases , fewer than 3 diagnosis will  be appropriate . then , enter the positive or negative findings form the history and physical examination (if present) that support each diagnosis . lastly ,list initial diagnostic studies (if any ) you would order for each listed diagnosis (eg , restricted physical examination maneuvers , laboratory tests , imaging , ECG , etc.). Diagnosis #1 ; Evolving stroke History finding(S) . Acute -onset weakness . Gradually progressing symptoms Physical Exam finding(s) . Right hemiparesis . Eight-side hyperflexia . Right Babinski rifles present Diagnosis #2: TIA or reversible ischemic neurological deficit History finding(s) . Acute-onset weakness Physical Exam finding(S) . Right hemiparesis . Right-sided  hyperreflexia . Right Babinski reflex present Diagnosis #3 : Subarachnoid hemorrhage History finding(s) . Headache . Nausea . Acute-onset weakness Physical Exam finding(s) . Right hemiparesis . Right-sided hyperreflexia . Right Babinski reflex present Diagnosis Studies . CT scan of head without contrast . Transesphageal echocardiogram . Carotid Doppler . CBC with differential -- 作者： JuanFe -- 發表時間： 2018/07/31 03:21am [這篇文章最後由JuanFe在 2018/08/15 03:39pm 第 1 次編輯] 4 Case 4 scenario (acute chest pain) Doorway Information About patient The patient is a 29-year-old woman with known sickle cel anemia who comes to the emergency department due to chest pain Vital signs . Temperature : 38.5’C (101.3F) . Blood pressure: 120/75 mmHg . Pulse : 110/min . Respirations : 22/min Clinical images Electrocardiogram T-S slightly upward ? Basic differential diagnosis Hematologic . chest syndrome due to sickle cell anemia Cardiovascular . Pericarditis . Acute coronary syndrome Pulmonary . Pneumonia . Pulmonary thromboembolism Musculoskeletal . Costochondritis . Salmonella osteomyelitis Other . Panic attack ————— Case 4 sim pt. instructions 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 29-year -old women who comes to the emergency department with chest pain. History of present illness . Pain started 12 hours ago . Pain located in the middle of the chest and dose not move. . Pain started slowly bit is increasing and is now 7-8/10 in severity. . Pain worse with any movement or deep breathing. . Took acetaminophen , which reduced the pain slightly. . Fever as high as 38.3’C (101F) . caught with green sputum , and imild shortness of breath for the last 3 days. . No blood in the sputum or recent chest trauma. Review of the systems . No used , vomiting , diarrhea , or abdominal pain. . No leg pain or swelling . No back pain . No urinary symptoms . Last menstrual period was 2 weeks ago Past medical / family / social history . Sickle cell anemia: Diagnosed in childhood ; had mild pain episodes at that time. 1 transfusion(age 18). Admitted once for abdominal pain 5 years ago that resolved with supportive care in hospital. . No surgires . No pregnancies . Medications : Birth control pill , acetaminophen as needed . Allergies ; No drug allergies . Mother also has sickle cell anemia; brother and father are healthy . Occupation ; Teacher . Single , sexual active with 1 boyfriend and use condoms regularly . Tobacco : No . Alcohol : No . Recreational drugs : No Physical examination Head and neck: . No redness or exudates in the mouth /pharynx . No enlarged lymph nodes Chest/lungs: . No tenderness to palpation of the chest wall . Clear to auscultation bilaterally Heart; . Regular rhythm with borderline tachycardia . No murmurs Abdomen: . Nontender , non distended . Normative bowel sound throughout . Tympanic to percussion . No hepatosplenomegaly Extremities: . No cyanosis . No tenderness in the legs You should also try to breath a little faster than normal to rate near 20/min . the rest of the examination is normal. ————— Case 4 sim. pt. checklist Following the encounter , check which of the following items were performed by the examinee. History of present illness/ review of the system . Asked about the location of pain . Asked about the intensity of pain . Asked about the quality of pain . Asked about the origin and duration off pain . Asked about the progression of pain . Asked about any radiation of pain . Asked about any radiation of pain . Asked about the aggravating/ relieving factors . Asked about associated symptoms , especially: - Nausea - Fever - cough - Shortness of breath . Asked about precipitating gators of sickle cell crisis (eg, diarrhea a, dehydration , stress) . Asked boy history of chest trauma . Asked about nay leg pain / swelling / redness . Asked about blood in the urine . Asked bout prior blood transfusion Past medical / family / social history . Asked about any similar problems in the past . Asked about other past medical issues . Asked about previous hospitalizations and surgeries . Asked about menstrual / reproductive history . Asked about current medications (prescription and over the counter) . Asked about any medication allergies . Asked about family history of sickle cell anemia , heart problems , and blood clots . asked about tobacco , alcohol , and drug use . Asked about occupation Examination . Examinee chased hands before examination . Examined without gown , not through gown . Examined the oral cavity . Examined for enlarged lymph nodes . Performed inspection and palpation of the chest . Performed palpation of area . Auscultated the lungs and heart . Palpated abdomen (superficial and deep) . Examined hands and fingers . Examined legs for tenderness Counseling . Explained the physical findings and possible diagnosis . Explained the complications of sickly cell disease (infections , hypoxia can precipitate pain) . Exclaimed further workup . Discussed the importance of avoiding hypoxemia and maintaining hydration 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 het you said and maintained good eye contact . Asked few open-ended questions . Asked non-leading questions . Asked one question at a time . Listened to what you said without interrupting . Used plain English rather than technical jargon . Used appropriate transition sentences . Used appropriate draping techniques . Expressed empathy and made appropriate reassurances Different diagnosis . Chest syndrome due to sickle cell anemia . Pneumonia . Costochondritis . Pericarditis . Pulmonary thromboembolism . Salmonella osteomyelitis Diagnostic study / studies . CBC with differential . Urinalysis . Sputum Gram and culture . Blood cultures . Chest x-ray . ECG (provided with doorway information) ————— Case 4 clinical summary Clinical Skill Evaluation Case 4 Clinical Note The following represents a typical note for this patient encounter. The details may vary depending on the information given by the simulated patient. History ; Describe the history you just obtained form this patient o. Include only information (pertinent positive and negatives) relevant to tis patient’s problem(s). . 29-yo female with history of sickle cell anemia and 12 hours of acute -onset chest pain. . Grade; increase in pain to 7-8 on a scale of 10 over the past 12 hours. . Pain is worse with movement and respiration and improved with acetaminophen. . 3 days of fever to 38.3’C (101F) , cough productive of green sputum , and mild shortness of breath. ROS: No nausea , vomiting, trauma to chest , dysuria , diarrhea , leg swelling , or leg pain. PMHx : Admitted once 5 years ago for abdominal pain that resolved PSHx : None Meds : Birth control pills , Tylenol PRN Allergies : Noen FHx : Mother has sickle cell anemia SHx : Denies use of tobacco, alcohol , and elicit drugs , Had a blood transfusion as a child. ECG shows sinus tachycardia with no diagnostic abnormalities Physical examination: 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 , 38.5’C (101’3F); blood pressure , 120/75 mmHg; pulse , 110/min; and respirations , 2/min . HEENT : Oropharynx without erythema or exudates . Neck : No cervical lymphadenopathy , trachea midline . Lungs : CTA bilaterally , no chest tenderness to palpation . Heart : RRR without M/R/G . Abdomen : Contender , non distended , normative bowel sounds thought ; tympanic to percussion , no hepatosplenomegaly . Extremities : No cyanosis, clubbing , or edema ; no swelling or tenderness in the legs Data interpretation; Based on what you have learned form the history and physical examination, List up to 3 diagnosis that might explain this patient’s complaints(s). List your diagnosis form poset to least likely . For some cases , fewer than 3 diagnosis will be appropriated  then , enter the positive ro negative findings form the history and the physical examination (if present) that support each diagnosis . Lastly ,list initial diagnostic studies (if nay) you would order for each listed diagnosis(e.g., restricted physic examination maneuvers, laboratory testes , imaging , ECG, etc) Diagnosis #1 : Acute chest syndrome History finding(s) . Acute -onset chest pian . Shortness of breath . History of sickle cell anemia Physical Exam finding(s) . No chest pain or palpation . Fever Diagnosis#2 : Pneumonia History finding(s) . Fever . Cough productive of green sputum . Shortness of breath Physical Exam finding(s) . Fever . Tachypnea Diagnosis#3 ; Pulmonary embolism History finding(s) . Pleuritic chest pain . Fever . Shortness of breath . Birth control pills Physical Exam finding(s) . Fever . No chest tenderness ot palpation Diagnostic Studies . chest x-ray . ABG . Blood cultures . CBC with differential -- 作者： JuanFe -- 發表時間： 2018/07/31 03:22am [這篇文章最後由JuanFe在 2018/08/15 04:00pm 第 2 次編輯] 5 Case 5 scenario (cough) Doorway information about patient The patient is a 35-year -old man who comes to the office due to cough Vital signs . Temperature : 38.5’C(101.3F) . Blood pressure : 120/75 mmHg . Pulse : 98/min . Respirations :  20/min Basic differential diagnosis . Common cold . Acute sinusitis . Allergic rhinitis . Acute bronchitis . Pneumonia . Pertussis . Pulmonary embolism . Drugs (ACE inhibitors) . Asthma . Congestive heart failure . Chronic obstructive pulmonary disease (COPD) exacerbation ————— Case 5 sim. pt. instructions f the patient asked you about anything other than these , just say “ no “ , for provide an answer that a normal patients might give. You are a 35-tear-old man who  comes to the office with a cough. History of present illness: . the cough started 5 days ago . Yellow sputum (“ teaspoon size” at a time) . Cough is worse at n eight and is keeping you awake. . Other symptoms include sore throat , sinus congestion , running nose, mild frontal headache . No blood in the sputum , chills m night sweats , chest pain , shortness of breath, or wheezing . Symptoms slightly better with over-the -counter cough medicine (guaifenesin/dextromethorphan) . Temperature at home was 37.9’C(100.2F) . 8 year-old son was recently sick with similar symptoms Past medical/family/social history: . Asthma l had it since childhood with mild intermittent symptoms . Seasonal allergies; mainly in the fall and spring . No surgieres . Medications ; Albuterol inhaler as needed (2-3 times a month) . Allergies : No medication allergies , but allergic to cats . Father is 60 and has asthma ; mother is 59 and is healthy ; no siblings . Married , live with spouse and 2 children . Occupation : Paramedic . Tobacco : 1 pack per day for 10 years . Alcohol : 1-2 drinks on social occasions . Recreational drugs : None Physical examination Head and neck : . No redness or exudates in the mouth . No sinus tenderness to percussion . No enlarged lymph nodes Chest/lungs: . Clear to auscultation bilaterally heart: . Regular rate and rhythm; No murmurs You should also try to breath a little faster to a rate near 20 /min . the rest of the examination is normal ————— Case 5 sim. pt. checklist Following the encounter , check which of the following itms were performed buy the examinee. History of present illness/ review of systems . Asked about the onset of cough . Asked about the duration of cough . Asked about whether cough is dry or productive . Asked for descriptions of  sputum(color, quantity) . Asked about any problem with breathing . Asked about wheezing . Asked about associated symptoms , especially: - Chest pain - Fever and chills - Sinus congestion/pain - Running nose - Sore throat . Asked about contacts with ill persons(workplace and home) Past medical / family / social history . Asked about similar episodes in the past . Asked about past medical issues(asthma , chronic allergies) . Asked about previous hospitalization and surgeries . Asked about medications (prescription and over the counter) . Asked about allergies . Asked about family health . Asked about occupation . Asked about tobacco , alcohol, and drug use Examination . Examinee washed hands . Examined without gown , not though gown . Examined nose and throat . Checked neck for lymph nodes . Palpated sinus . Listened to lungs - Asked you to say 99 repeatedly(palpated for tactile vocal fremitus). . Tapped on lungs (percussion) . Auscultated heart Counseling . Explained physical findings and possible diagnosis. . Emplane the further workup . Discussed quitting smoking . Discussed simple measures for comfort (eg, over the counter medications, fluids , humidifier air) 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 few open-ended questions . Asked non-leading questions . Asked one question at a time . Listened to what you said without interrupting . Used plain english reader 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 had any concerns / questions Differential diagnosis . Common cold . Acute sinusitis . Acute bronchitis . Pneumonia Diagnostic study/studies . CBC with differential count . Sputum Gram stain and culture . Chest x-ray (posterior anterior and lateral view) ————— Case 5 clinical summary Clinical Skills Evaluation Case 5 Patient Note The following represents a typical note for this patient encounter . the details 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 male with 5 days of worsening cough . Sore throat, fever , rhinorrhea, and frontal headache. . Cough productive of approximately 1 tsp of yellow sputum without hemoptysis . recent sick contact : 8-yo son. ROS : No chills , night sweats , chest pain , shortness of breath , wheezing , or abdominal pain PMHxL Mild asthma, seasonal allergic  rhinitis. PSHx: None Meds ; Albuterol MDI PRN Allergies: Cats FHx : Father has asthma SHx : has smoked 1 PPD for past 10 years and drinks occasionally Physical examination : Describe any positive and negative findings relevant to this patient’s problem(s). be careful in include only those parts of the examination performed in this encounter. . Vital designs: Temperature , 38.3’C(101F) ; blood pressure , 120/75 mmHg ; pulse, 98/min ; restorations , 20/min . HEENT : Oropharynx without erythema or exudates. no sinus tenderness to percussion . Neck : No cervical lymphadenopathy , trachea midline . Lungs; CTA bilaterally . Heart : RRR without M/R/G Data interpretation: Based on what you have learned form the history and physical examination, list up to 3 diagnosis that might explain this patient’s complaint(s). List your diagnosis from most to least likely . for some cases , fewer than 3 diagnoses will be appropriate . Then , enter the positive or negative findings form he history and the physical examination (if present) that support each diagnosis. Lastly , list initial diagnostic studies (if nay) you would order for each listed diagnosis (e.g.,restricted physical exam maneuvers , laboratory tests, imaging , ECG , etc.). Diagnosis #1 : Acute sinusitis History finding(s) . History of allergic rhinitis . Frontal headache . Fever Physical Exam finding(s) . Fever Diagnosis # 2 : Pneumonia History finding(s) . Fever . Cough productive of yellow sputum . Smoking history Physical Exam finding(s) . Fever . Tachypnea Diagnosis # 3 : Acute bronchitis History finding(s) . Cough . Fever . Smoking history Physical Exam finding(s) . Fever Diagnostic Studies . Chest x-ray . Sputum Gram stain and cultures . CBC with differential -- 作者： JuanFe -- 發表時間： 2018/08/15 03:22pm 6 Case 6 scenario (fatigue and weight loss) Door way information about patient The patient is a 50-year-old man who comes to the office due to fatigue and weight loss. Vital signs . Temperature : 36.7’C (98.1F) . Blood pressure : 120/76 mmHg . Pulse : 78 /min . Respirations : 18 /min Basic differential diagnosis Infection . HIV . Tuberculosis Metabolic disorders . Diabetes . Thyroid disorder . Adrenal insufficiency Malignancy . Solid tumor . Hematologic malignancy Gastrointestinal . Hepatitis . Malabsorption Other . Depression . Eating disorder . Medication side effect ————— Case 6 sim. pt. instruction If the doctor asks you about anything otters than these , just say “no,” or provide an answer that a normal patient might give. You are a 50-year-old man who comes to the office with fatigue History of present illness . The symptoms stated 5 months ago . Symptoms were initially mild but have been worse over the last 3 months . Generalized weakness but no focal weakness . Symptoms are associated with intermittent “ gas pain “ around the umbilicus . Feel full after eating only small meals (Include the following information only of asked what may have caused / trigged your symptoms.) . Symptoms got worse after your spouse died 3 months ago . Decreased appetite with a 13.6-kg(30-lb) weight loss . Decreased interest in activities . Difficulty falling asleep at night ; also waking up frequently at night and unable to get back to sleep . No thoughts about suicide , but have feelings of guilt . Difficulty concentrating on tasks . Thinking that your family dose not understand what you are going though and feeling isolated form many of your friends Review of systems . No fever , chills . No nausea, vomiting , diarrhea , or constipation . No chest pain, or shortness of breath . No jaundice . No numbness, tingling , or tremor Past medical / family / social history . No prior medical problems . No surgeries . No medications . No drug allergies . Mother died at age 60 of pancreatic cancer ; after died at age 55 of heart attack ; no siblings . Widower, living aloe . 2 children (ages 28, 25) . Occupation : restaurant manager . Tobacco: No . Alcohol : 2-3 drinks on social occasions . Recreational drugs: No Physical examination Head and neck: . No readiness or exudates in the mouth . No enlarged lymph nodes . No thyromegaly Chest / Lungs : . No tenderness to palpation of the chest wall . Clear to auscultation bilaterally Heart: . Regular rate and rhythm . No murmurs Abdomen: . Non tender, non distended . Normative bowel sounds throughout . Tympanic to percussion . No hepatoslenomegaly . No jaundice Extremities: . No cyanosis , clubbing , edema Neurological: . Normal motor strength and deep-tendon reflexes ————— Case 6 sim. pt. check list Following the encounter , check which  of the following items were performed by the examinee History of present illness/review of the system . Asked  about the onset and progression of weakness. fatigue (open-ended question) . Asked about associated symptoms , especially: - Fever , chills , night sweats - Enlarged lymph nodes - Temperature intolerance (hot or cold) - Chest pain, cough , and shortness of breath - Nausea and vomiting - Change in appetite and weight - Difficulty swallowing - Abdominal pain - Jaundice - Blood in stools or black stools - Insomnia/sleep . Enquired about any precipitating factors . Asked about mood/emotional state . Asked about interest in life . Asked about any guilt feelings . Asked about any ideas , plans , attempts for suicide Past medical / family / social history . Asked about similar episodes in the past . Asked about past medical issue . Asked about previous hospitalization and  surgeries . Asked about medications . Asked about medication allergies . Asked about family health . Asked about occupation . Asked about tobacco, alcohol, and drug use Examination . Examinee washed hands . Examined without gown , not though gown . Examined eyes . Examined oral cavity . Examined neck for thyromegaly and lymphadenopathy . Auscultated test (heart and lungs) . Palpated abdomen , both superficially and deeply . Checked leg for edema . Check muscle power . Looked for ankle jerk / reflex Counseling . Explained the physical findings and possible diagnosis . Explained further workup . Inquired regarding need for any additional emotional 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 open-ended questions . Asked non leading questions . Listened to what you said without interrupting . Used plain English rather than technical jargon . Used appropriate draping techniques . Summarized the history and explained physical findings . Expressed empathy and gave appropriate reassurances . Asked whether you had any concerns/ questions Differential diagnosis . Occult malignancy . Hyper/hypothyroidism . Depression Diagnostic study/ studies . Rectal examination and stool examination for occult blood . CBC with differential . Glucose and electrolytes . TSH . Liver function tests ————— Case 6 clinical summary Clinical Skill Evaluation Case 6 Patient Note The following represents a typical note for this patient encounter . the details may vary depending on the information given by simulated patient History : Describe the history you just obtained form this patient. Include only information (pertinent positive and negatives) relevant to this patient’s problem(s). . 50-yo male with 5 months of increased fatigue. . Spouse died 3 months ago and symptoms have worsened since then. . 13.6-kg (30-lb) weight loss, decreased appetite , periumbilical abdominal pain , early satiety. . Loss of interest in activities and terminal insomnia but not suicidal ROS: No dysphagia , fever , chills , night sweats , chest pain , shortness of breath, or cough PMHx: None PSHx: None Meds: None Allergies: None FHx: Mother died at age 60 form pancreatic cancer , after died at age 55 form heart attack SHx: Denies tobacco use Physical examination: 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 (98F) ; blood pressure , 120/76 mmHg ; pulse , 78/min : and respirations , 18/min . Head / neck : No redness or exudates in the mouth , no enlarged lymph nodes , no jaundice , no thyromegaly . Chest /lungs: No tenderness to palpation of the chest wall , clear to auscultation bilaterally . Heart : RRR . Abdomen : Non tender , non distended , normative bowel sounds throughout ; tympanic to percussion ; no hepatosplenomegaly . Extremities : No cyanosis , clubbing, or edema . Neurological : Motor 5/5 throughout , DTR 2+ bilaterally Data interpretation : Based on what you have learned form the history and physical examination, list up to 3 diagnosis that might explain this patient’s complaint(s). List your diagnosis form most to least likely. For some cases , fewer than 3 diagnosis will be appropriate . then , enter the positive or negative findings form the history and the physical examination (if present) that support each diagnosis. Lastly , list initial diagnostic studies(if any) you would order for each listed diagnosis (e.g., restricted physical exam maneuvers , laboratory tests, imaging, ECG, etc.). Diagnosis #2 : Depression history finding(s) . Fatigue . Weight loss . Death of spouse . Terminal insomnia Physical Exam finding(s) . None Diagnosis #1 : GI malignancy (eg , colon cancer, Gastric cancer ) History finding(s) . Fatigue . Weight loss . Early satiety Physical exam finding(s) . None Diagnosis #3 : hyperthyroidism History finding(s) . Weight loss . Fatigue Physical Exam finding(s) . None Diagnosis Studies . TSH and T4 . CBC with differential . Rectal examination with FOBT . Colonoscopy . CT scan ion the abdomen -- 作者： JuanFe -- 發表時間： 2018/08/15 03:23pm 7 Case 7 & scenario (diarrhea) Doorway information about patient The patient is a 35-year-old man who comes to the office due to acute diarrhea. Vital signs . Temperature: 36.7’C(98.1F) . Blood pressure: 110/65 mmHg . Pulse : 100 /min . Respirations: 18/min Basi differential diagnosis . Viral gastroenteritis . Bacterial gastroenteritis & food-borne pathogens . Medication induced . Giardiasis . Clostridium difficle colitis . Inflammatory bowel disease . Irritable bowel disease . Malabsorption . HIV ————— Case 7 sim. pt. instructions If the doctor asks you about anything otters than these . just say “no” , or provide an answer that a normal patient might give. You are a 35-year-old man who has diarrhea. History of present illness . Onset 1 day ago , 6-8 hours after meal . Ate salad and shrimp at a local seafood restaurant . Loose , watery stop,s with no blood or mucus . 6 or 7 bowel movements in 24 hours . Associated symptoms: - Diffuse abdominal cramps - Nausea and vomiting - Difficulty keeping down solids or liquids - no fever or chills . Nothing seems to make it worse , and you have not tried any over-the-counter treatments . 2 friends who ate with you have similar symptoms . No recent travel Review of system . Sinus infection 2 weeks ago , treated with amoxicillin (last dose 2 days ago) . No chest pain or shortness of breath . No urinary symptoms . No back pain Past medical / family / social history . No significant past medical problems or surgeries . No other medications (otters than amoxicillin) . No medication allergies . Bother parents and siblings (2 brothers) are healthy . Single , live  alone . Occupation : Software engineer . Smoking : No . Alcohol : no . Recreational drugs: No Physical examination Head and neck: . No erythema or exudates in the mouth / pharynx . Dry mucous membranes . No enlarged lymph nodes Skin: . No jaundice Chest/lungs: . Clear to auscultation bilaterally Heart : . regular rhythm without murmurs , gallops , or rubs Abdomen: . Non tender, non distended . Normative bowel sounds throughout . Tympanic to percussion . No hepatosplenomegaly ————— Case 7 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 characteristics of diarrhea - Increased frequency ? Increased volume ? Altered consistency ? . Asked about the frequency of diarrhea . Asked about associated symptoms (eg,vomiting , fever , abdominal pain, anorexia, prior constipation , myalgia , tenesmus) . Asked about any blood or mucus in stools . Asked about any recent travel . Asked whether any otters family members or other contacts are sick . Asked about exposure to suspicious foods (eg, unpasteurized /undercooked food , unusual foods , dairy products , seafood) Past medical / family/ social history . Asked about prior episodes of diarrhea and gastrointestinal illness . Asked about otters medical issue . Asked  bout medications (especially antibiotics) and medication allergies . Asked  about recent and previous hospitalizations . Asked boy any  abdomen surgeries . Asked bout occupation . Asked boy tobacco , alcohol , and drug use . Asked about family history (especially gastrointestinal disease) Examination . Examinee washed heads . Examined without gown , not though gown . Auscultated abdomen . Palpated abdomen superficially . Palpated abdomen deeply . Examination of skin for any rashes . Examination of oral cavity . Respiratory examination . Cardiac auscultation Counseling . Explained the physical findings and possible diagnosis . Explained further workup . Discussed need for rectal examination . Discussed fluids and otters basic interventions 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 heat you said and maintained good eye contact . Asked open-ended questions . Asked non-leading questions . Asked one question at a time . Listened to what you said without interrupting . Used plain English rather than technical jargon . Used appropriate transition sentences . Used appropriate draping techniques . Summarized the history and explained physical findings . Asked whether you have any concerns / questions Differential diagnosis .Viral gastroenteritis . Bacterial gastroenteritis . Clostridium difficile diarrhea Diagnostic study/ studies . Rectal examination . Fecal occult blood test . CBC with differential count . Basic metabolic panel (electrolytes , BUN , creatinine, glucose) . Stool for C. difficile toxin . Stool for fecal leukocytes ————— Case 7 clinical summary Clinical Skills Evaluation Case 7 Patient Note The following represents a typical note for this patient encounter . the details amy vary depending on the information given by the simulated patient. history : Describe the history you jus obtained for  this patient . Include only information (permanent positives and negatives) relevant to this patient’s problem(s) . 35-yo male with 1 day of diarrhea with 6-7 loose BM/day without blood or mucus. . Ate seafood and salad at restaurant 6-8 hours before symptom onset. . Recent sinus infection treated with amoxicillin , last dose 2 days ago. . Diffuse crampy abdominal pain , nausea , vomiting , decreased PO intake. , Two otters friends who ate at the restaurant have the same symptoms, ROS : No fever , chills , chest pain , shortness of breath , burning with urination , rennet travel , or back pain. PMHx : None PSHx : None Meds : None Allergies : None FHx : Noncontributory SHx : Denies tobacco and alcohol use Physical examination ; 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. . Viral signs: Temperature , 36.7’C (98F) ; blood pressure , 110/65 mmHg : pulse , 100/min ; and respirations , 18/min. . Head / neck : Oropharynx with dry mucous membranes but no erythema or exudates , no enlarged lymph nodes , no jaundice . Chest /lungs : Clear to auscultation bilaterally . Heart : RRR without M/G/R . Abdomen : Contender , non distended , normoactive bowel sounds thought ; tympanic on percussion ; no hepatosplenomegaly Data interpretation : Based on what you have learned form the history and physical examination , List up to 3 diagnosis that might explain this patient’s complaint(s). List your diagnosis form most to least likely . For some cases , fewer than 3 diagnosis will be appropriate . Then , enter the positive or negative findings forth history and the physical examination (if present) that support each diagnosis . Lastly , list initial diagnostic studies (if any) you would order for each listed diagnosis (e,g,,restricted physical exam maneuvers , laboratory test, imaging , ECG , etc.). Diagnosis #1 : Viral gastroenteritis History finding(s) . Diarrhea without fever . No blood in stool . Other sick friends who also ate at same place Physical Exam finding(s) . No fever Diagnosis #2 : Bacterial gastroenteritis History finding(s) . Symptom onset 6-8 hours after eating at a restaurant . Nausea , vomiting Physical Exam finding(s) . None Diagnosis #3 : Clostridium difficile colitis History finding(s) . Symptoms starting 2 days after rennet amoxicillin use . No blood in stool Physical Exam finding(s) . None Diagnostic Studies . Stool for leukocytes . Stool for Clostridium difficile . Rectal examination with FOBT -- 作者： JuanFe -- 發表時間： 2018/08/15 03:25pm 8 Case 8 scenario (sore throat) Doorway information about patient The patient is a 25 -year-old woman who comes to the clinic sue to a sore throat Vital signs . Temperature : 13.3’C (101F) . Blood pressure : 120/70 mmHg . Pulse : 90 /min . Respirations : 22/min Basic differential diagnosis . Viral pharyngitis . Bacterial pharyngitis - Group A streptococcal pharyngitis - Mycoplasma pneumonia - Neisseria gonorrhea . Epstein-Barr virus mononucleosis . Allergies rhinitis / postnasal drip . Chronic tonsillitis . Primary HIV ————— Case 8 cim. pt. instructions if the doctor sales you about anything other than these ,just say “no,” or provide an answer that a normal patient might give. you are a 25 -year-old woman who comes to the office with a sore throat History  of present illness . Onset 3 days ago . Pain with swallowing food . Associated symptoms: - Headache - Body ache - Nasal congestion - Dry cough - Fever to 38.1’C(100.5F) . Symptoms partially relieved with Tylenol/acetaminophen . Boyfriend had similar symptoms 2 weeks ago but now better Review of system . No abdominal pain , pelvic pain , rash , chills , chest pain , or shortness of breath . Last menstrual period was 2 weeks ago Past medical / family/ social history . Frequent episodes of tonsillitis in childhood . 2 upper respiratory illnesses in the past 2 years . No pregnancies . No past surgeries . No current medications . No medication allergies . Parents and sister are healthy . Occupation : College student . Sexually active with boyfriend (condoms for birth control) . Smoking : No . Alcohol : No . Recreational drugs : No Physical examination Head and neck : . Oropharynx with tonsillar exudates . Tympanic membranes clear bilaterally . No sinus tenderness . No enlarged lymph nodes Chest/lungs: . Clear to auscultation  bilaterally Heart : . Regular rhythm without murmurs, gallops , or rubs Abdomen ; . Non tender , non distended . Normative bowel sounds throughout . Tympanic to percussion . No hepatospenomegaly ————— Case 8 sim. pt. check list Following the encounter , check which of the following items were performed by the examinee History of present illness / review or system . Asked about the onset of sore throat . Asked about the course of symptoms over time . Asked about pain during swallowing . Asked  about associated symptoms - Coughing and breathing problems - Nasal discharge/ congestion - Sinus pain and postnasal drip - Headache - Fever and chills - Nausea and vomiting - Joint pains and muscle aches - Swollen neck glands - Abdominal pain (especially left upper quadrant and pelvic pain) - Rash - Vaginal discharge . Asked about contacts with ill person Past medical /family/social history . Asked about similar episodes in the past . Asked about otters past medical issues . Asked about current medications . Asked about medication allergies . Asked about family health problems . Asked  about occupation . Asked about tobacco , alcohol , and recreational drug use . Asked about sexual and reproductive history Examination . Washed hands before examination . Examined without gown , not though gown . Looked inside mouth . Palpated cervical lymph nodes . Examined both ears . Palpated spleen and liver . Palpated abdomen (superficial and deep) . Auscultated heart . Auscultated lungs . Examined skin for rash 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 open-ended questions . Asked non;eating questions . Asked one question at a time . Listened to what you said without interrupting . 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 Differential diagnosis . Infectious mononucleosis . Viral pharyngitis . Bacterial (streptococcal) pharyngitis Diagnostic study/workup . CBC . Monospot test . Rapid streptococcal antigen test ————— Case 8 clinical summary Clinical Skills Evaluation Case 8 Patient Note The following represents a typical note for this patient encounter . the details amy 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). . 25-yo female with 3 days pop sore throat. . Initially , sore throat , sinus congestion , runny nose , fever , and dry cough . Sore throat has worsened with pain when swallowing. . Sick contact (boyfriend) had similar symptoms that resolved ROS : No chills , chest pain ,shortness of breath , nausea , vomiting m or abdominal pain PMHx : None PSHx : None Meds : None Allergies : None FHx : Noncontributory SHx : Denies tobacco and alcohol use Physical examination: 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 (101F); blood pressure , 120/70 mmHg; pulse , 90/min ; and respirations , 16/min . HEENT : Oropharynx with tonsillar exudates , TM clear bilaterally . Neck : no enlarged lymph nodes . Chest / lungs ; clear to auscultation bilaterally . Heart : RRR without M/R/G . Abdomen : non tender , non distended , normative bowel sounds thought ; tympanic to percussion ; no hepatosplenomegaly. Data interpretation : based on what you have learned form the history and physical examination, list up to 3 diagnosis that might explain this patient’s complaint(s) . List your diagnosis form most to least likely . for some cases , fewer than 3 diagnosis will be appropriate . then , enter the positive or negative findings form the history and the physical examination (if present) that support each diagnosis . Lastly , list initial diagnostic studies (if any) you would order for each listed diagnosis (e,g,, restricted physical exam maneuvers , laboratory tests , imaging , ECG , etc.). Diagnosis #1 : Bacterial pharyngitis History finding(s) . Sore throat . Fever Physical examination finding(s) . Fever . Tonsillar exudates Diagnosis #2 : Viral pharyngitis History finding(s) . Fever . Sore throat . Boyfriend with similar illness that resolved Physical examination finding(s) . Fever Diagnostic studies . Rapid strep test . Throat culture if rapid strep test is negative -- 作者： JuanFe -- 發表時間： 2018/08/15 03:26pm 9 Case 9 scenario (medication refill) Doorway information about patient The patient is a 56-year-old man who comes to the office for a blood pressure check and medication refill Vital signs . Temperature : 36.1’C (97F) . Blood pressure ; 150/90 mmHg . Pulse : 80 /min . Respirations : 16/min Basic differential diagnosis When patient come for follow-up of known conditions , the primary diagnosis is known . However, you should be aware of complications and associated conditions. . Congestive cardiac failure . Coronary artery disease (angina) . Peripheral vascular disease . Retinopathy . Side effects of the medications ————— Case 9 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 56-year - old man who needs a blood pressure recheck and medication refill. history of present illness . Diagnosed with hypertension and high cholesterol 10 years ago . Taking medications regularly . Currently medications include hydrochlorothiazide and simvastatin . DO not volunteer this information unless asked specifically abut past treatment: You were initially treated with lisinopril , but that was stopped due to a dry cough ; You were then treated with atenolol but developed erectile dysfunction . Not exercising regularly and not always following dietary recommendations . Checking blood pressure at home ranges form 140-150 systolic and 80-90 diastolic . No headaches , palpations , blurry vision , chest pain , shortness of breath , nosebleeds , dizziness , or leg swelling. Past medical / family / social history . Medical history otherwise negative . No surgeries . No other medications . No medication allergies . Father has hypertension and  mother has diabetes . Occupation : Accountant . Smoking ; 1 pack /day for 30 years . Alcohol ; 1 glass of wine on social occasions . Recreational drugs : None Physical examination HEENT: . Pupils are equally round and reactive to light and accommodation (PERRLA) . Extra ocular movement are intact (EOMI) . Funduscopic examination shows no papilledema , exudates or AV nicking Neck: . No enlarged lymph nodes . No bruits . Carotid pulse 2+ bilaterally Chest/lungs: . Clear to auscultation bilaterally Heart : . Regular rhythm without murmurs , gallops , or rubs Extremities : . No cyanosis , clubbing , or edema . Radial and posterior tibial pulses 2+ ————— Case 9 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 when you diagnosed with high blood pressure . Asked what medications you are taking and of you take them as prescribed . Asked about any side effects or other issues with medications . Asked about prior treatment and why it was changed . Asked about symptoms that might indicate a problem , including: - Headache - Dizziness - Nosebleeds - Dyspnea , orthopnea, paroxysmal nocturnal dyspnea - Palpations - Chest pian - Pedal edema . Asked about home blood pressure checks . Asked about diet and exercise habits Past medical / family / social history . Asked about otters medical issues , hospitalizations , and surgeries . Asked about other medications . Asked about medication allergies . Asked about family health (especially cardiovascular daises) . Asked about tobacco . alcohol , and recreational drugs use . Asked about occupation Examination . Washed hands before examination . Examined without gown , not through gown . Measured blood pressure in both arms . Examined eyes with ophthalmoscope . Check carotid arteries (pulses and bruits) . Checked jugular venous pressure . Auscultated heart . Auscultated lungs . Palpated peripheral pulses Counseling . Complemented you for using medications as prescribed . Complemented you for checking home blood pressure regularly . Explained further workup . Explained the importance of diet and regular exercise . Explained likely complications of uncontrolled blood pressure Communication skills and professional conduct . Knocked beef entering the room . Introduced self and greeted you warmly . Used your name to address you . Paid attention to what you said and maintain good eye contact . Asked open-ended questions . Asked non-leading questions . Asked one question at a time . Listened to what you said without interrupting . 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 Differential diagnosis . Essential hypertension Diagnostic study/studies . Urinalysis . Lipid profile . Electrolytes . BUN and creatinine . Glucose . ECG ————— Case 9 clinical summary Clinical Skill evaluation Case 9 Patient Notes The following represent a typical notes 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 problems(s) . 56-yo man here for BP check and medical refill. . BP ranges form 140-150 systolic and 80-90 diastolic at home 3x/week in morning and evening . Not compliant with low salt diet , no regular exercise . Compliant with medications. . Cough with ACE inhibitor , ED with beta blocker ROS : no headache , palpations, blurry vision , chest pain , shortness of breath , nose bleeds, dizziness , or leg swelling PMHx : Hypertension and hypercholesterolemia for past 10 years . PSHx: None Meds : Hydrochlorothiazide 50 mg daily , simvastatin 20 mg daily Allergies ; None FHx ; father has hypertension , mother has diabetes SHx: Smokes 1 PPD for 30 years . drinks occasionally Physical examination : Describe nay 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’C (98.6F) ; blood pressure , 150/90 mmHg in both arms ; pulse , 90/min; and respirations , 16/min . HEENT : PERRLA , EOMI , fund without papilledema , exudates , or AV nicking . Neck : No enlarged lymph nodes , no bruits . Chest /lungs : Clear to auscultation bilaterally . Heart : RRR without M/G/R . Extremities : No cyanosis , clubbing , or edema ; pulse 2+ bilaterally in carotid , radial , and posterior tibialis Data interpretation : based on what you have learned from the history and physical examination , list up to 3 diagnoses that might explain this patient’s compliant(s) .List your diagnosis form most to least likely . For  some cases , fewer than 3 diagnosis will be appropriate . then enter the positive or negative findings form the history and the physical examination (if present) that support each diagnosis . Lastly , list initial diagnostic studies (if any ) you would order for each listed diagnosis (eg , restricted physical examination maneuvers , laborite tests , imaging ECG) Diagnosis #1 : essential hypertension , sub optimally controlled history finding(s) . Hypertension . Poor dietary complicate . No regular exercise Physical examination finding(s) . Elevated blood pressure to 150/90 mmHg . No neck bruits . Symmetrical peripheral pulses . Normla funduscopic examination Diagnostic studies . Serum electrolytes and creatinine . Lipid panel -- 作者： JuanFe -- 發表時間： 2018/08/15 03:27pm 10 Case 10 scenario (constipation) Doorway information about patient The paint is a 66-year-old man who comes to the clinic due to constipation Vital signs . Temperature ; 36.7’C (98F) . Blood pressure : 120/70 mmHg . Pulse : 70 /min . Respirations : 16/min Basic differential diagnosis . Functional constipation . Obstructive lesions (eg , bowel obstruction , carcinoma f colon) . Metabolic disturbances (eg , hypothyroidism, diabetes mellitus , hypercalcemia) . Neurologic dysfunction (eg , stroke , autonomic neuropathy , final cord trauma , multiple sclerosis, Parkinson disease) . Medication-induced (eg , iron preparations , opiates , anticholinergics) ————— Case 10 sim. pt. instructions If the doctor asks you about anything other than ashes , just say “no,” or provide na answer that a normal patient might give. You are a 66-year -old man with constipation. history o present illness . Onset 5 months ago . Worse over the last 2 months . Previously 1 film bowel movement a day , now every otters day . Stool now become harder . Straining , difficulty passing stool , sense of incomplete evacuation . Occasional black stools; no red blood in stools . eating fruits and vegetables regularly and have not changed diet recently Review of systems . Fatigue . 10-lb weight loss over the last 2 months . No fever , chills , night sweats . No diarrhea , nausea , vomiting . No urinary symptoms Past medical / family / social history . Arthritis of the right knee . Hashimoto thyroiditis ; had normal blood work 1 year ago . Never had colonoscopy but rectal examination was normal 2 years ago . No surgeries . Medications: - Levothyroxine 100 mcg/day - Hydrocodone/acetaminophen 5mg/650mg 1 pill 3 times /day 9started 2 months ago for knee pain . No medication allergies . After died of colon cancer at age 67 and mother is healthy . Occupation; Supervisor at pharmaceutical company . Tobacco : No . Alcohol : 2-3 glasses of wine a week . Recreational drug : No Physical examination HEENT : . No pallor icterus Neck : . No enlarges lymph nodes Chest /lungs : . Clear to auscultation bilaterally Heart : . Regular rhythm without murmurs , gallops , or rubs Abdomen : . Non-tender, non-distended . Hypoactive bowel sounds thought . No hepatosplenomegaly Neurologic : . Muscle strength 5/5 throughout . Reflexes 2+ symmetric ————— Case 10 sim. pt. checklist Following the encounter , check which for the following itms were performed by the examinee. history of present illness / review of systems . Asked an open-ended questions What do you mean by constipation) . Asked about the onset of constipation . Asked about the frequency of bowel movements . Asked about amount and caliber of stool passed . Asked about consistency of stool . Asked about pain during defecation . Asked about any blood in stools of black stools . Asked about episodes of diarrhea . Asked about nay nausea and vomiting . Asked about abdominal pain or cramps . Asked about urinary issue (polyuria, dribbling) . Asked about intolerance to hot or cold temperatures . Asked about loss of appetite and weight loss . Asked about diet (especially fluids and dietary fiber) Past medical / family /social history . Asked about similar episodes in the past . Asked about other medical issues . Asked about previous hospitalizations and surgeries . Asked about regular screening procedures (especially colon conner screening) . Asked about current medications . Asked about medication allergies . Asked about family health (especially colon cancer) . Asked about tobacco , alcohol , and recreational rug use . Asked about occupation Examination . Washed hands before examination . Examined without gown , not though gown . Examined eyes for pallor . Auscultated abdomen . Palpated abdomen (superficial and deep) . Checked muscle power and reflexes inlayer extremities Counseling . Explained the physical findings and possible diagnosis . Explained further workup (include 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 Differential diagnosis . Medication -induced . Carcinoma of colon . Uncontrolled hypothyroidism . Functional constipation . Undiagnosed diabetes Diagnostic study/studies . Rectal examination and stools for occult blood . CBC with differential . TSH . Fasting blood sugar and /or hemoglobin A1c . Colonoscopy ————— Case 10 clinical summary Clinical Skills Evaluation Case 10 Patient notes The following represents a typical note for this patient encounter . the details 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). . 66-yo man here for constipation for 5 months with worsening over past 2 months . Fatigue , 4.5-kg (10-lb) weight loss . Change in bowel movement form 1 /day to 1 every other day . Occasional black stools ROS : No diarrhea , abdominal pain , nausea , vomiting , fever , chills , night sweats , or urinary problems PMHx: Hashimoto’s thyroiditis , severe DJD of right knee PSHx: None Meds : Levothyroxine , hydrocodone / acetaminophen (started 2 months ago) Allergies : None FHx : Father died at age 67 of colon cancer SHx : no smoking but drinks 1-3 glasses of wine /week 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 preformed in this encounter. . Vital signs: Temperature, 36.7’C(98F); blood pressure , 120/70 mmHgin both arms; pulse , 70/min; respirations , 16/min . HEENT : No pallor or jaundice . Neck : No enlarge lymph nodes . Chest / lungs : clear to auscultation bilaterally . Heart : Regular rate and rhythm without M/G/R . Abdomen : Non-tender , non-distended , hypoactive bowel sounds thought , no hepatosplenomegaly . Neurologic : Muscle strength 5/5 throughout , DTR 2 + bilaterally and symmetrical 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 : Colon cancer history findings(s) . Worsening constipation . Fatigue . Weight loss . Black stools Physical examination finding(s) . hypoactive bowel sounds Diagnosis #2 : Functional constipation form medications History finding(s) . New drug (Lortab) started , with worsening of constipation physical examination finding(s) . Hypoactive bowel sounds Diagnosis #3 : Hypothyroidism with suboptimal control History finding(s) . Fatigue . Constipation Diagnostic studies . Rectal examination with stool for occult blood . CBC with differential . Serum TSH . Colonoscopy . Serum calcium -- 作者： JuanFe -- 發表時間： 2018/08/15 03:28pm 11 Case 11 scenario (importance) Doorway information about patient The patient is a 50-year-old man who comes to the clinic due to importance Vital signs . Temperature : 36.7’C (98F) . Blood pressure : 150/80 mmHg . Pulse : 80/min . respirations ; 16/min Basic differential diagnosis Cardiovascular . Atherosclerotic vascular disease Metabolic /endocrine . Diabetes . Hypogonadism . Hyperprolactinemia Neurotic . Spinal cord disorders Psychological . Anxiety . Depression . Alcohol or otters substance abuse Other . Medications (eg, antihypertensives) ————— Case 11 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 50-year-old man who has erectile dysfunction History of present illness . Onset 3-4 months ago . Gradually increasing difficulty getting an erection . Normal interest unisexual activity . Increased stress over last 6 months due to financial problems Do not volunteer this information unless asked : You have awakened with a nocturnal erection for several months. Review of systems . Mild fatigue . No headaches or visual changes . No pain in the extremities . No nausea , vomiting , or abdomen pain Past medical history . Diabetes for 10 years (home glucose ranges 150-200 mg/dL) . Hypertension . Generalized anxiety disorder . Surgeries : None . medications : Atenolol 50 mg , daily (started 4 months ago), lisinporil 20 mg daily, metformin 500 mg twice daily , glyburide 10 mg daily, fluoxetine 20 mg daily . Allergies : None . Immediate family members are healthy . Occupation : truck driver . Married, live with wife . Tobacco 1-2 cigarettes week 9only when gong out with friends) . Alcohol : 2-3 beers a day for 25 years . Recreational drugs : No Physical examination HEENT: . PERRLA . EMOI Abdomen . Non-tender, Non-distended . Normative bowel sounds throughout . No hepatosplenomegaly . No bruits Extremities . Posterior tibial and dorsals pedis pulse 2+ in both lower extremities ————— Case 11 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 symptoms . Asked whether out is continuous or intermittent . Asked whether it is getting worse . Asked about any changes in sexual desire . Asked about any problems with ejaculation . Asked detailed sexual history including the number of sexual partners (if multiple , ask follow-up questions : Dose the dysfunction occur with one partner and not another?) . Asked about nocturnal erections . Asked about aggravating to triggering factors . Asked about nay pain in the legs(claudication) . Asked about anxiety and depression . Asked about headache (pituitary tumors) . Asked about trauma Past medical /family/social history . Asked about otters medical issue (especially hypertension , diabetes mellitus , sickle cell disease , pulmonary vascular disease),hospitalization , and surgeries . Asked about current medications . Asked about medication allergies . asked about family health . Asked about tobacco, alcohol, and drug use . Asked about occupation Examination . Washed hands before examination . Examined without gown , not though gown . Palpated abdomen and listened for bruit . Examined pulsations in lower limbs Counseling . Explained the physical findings aden possible diagnosis . Explained the need for additional workup(include genitourinary examination) . Discussed quoting smoking and reducing alcohol intake 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 Differential diagnosis . Medication induced . Diabetes neuropathy . Atherosclerotic vascular disease . Anxiety Diagnostic study/studies . Genital examination . Fasting blood sugar and hemoglobin A1c . Complete blood count . TSH , Serum prolactin , and testosterone ————— Case 11 clinical summary Clinical Skills Evaluation Case 11 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). . 50-yo man with 4 months of worsening erectile dysfunction. . New blood pressure medication (atenolol) started 4 months ago. . Increased stress for past 6 months , mild fatigue. . Poorly controlled diabetes with glucose near 200 mg/dl most of the day. ROS : No headaches , leg pain , visual disturbances , nausea , vomiting , or abdominal pain PNHx: Diabetes ,hypertension, anxiety Meds ; Metformin, glyburide, fluoxetine , atenolol (started 4 months ago) Allergies : None FHx : Parents and siblings are healthy SHx : Occasionally smokes and has had 2 or 3 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, 36.7’C (98F) ; blood pressure , 150/80 mmHg ; pulse , 80/min ; respirations , 16/min . HEENT : PERRLA, EOMI . Abdomen : Non-tender , non-distended, normative bowel sounds throughout , no hepatosplenomegaly or bruits . Extremities : Pulses 2+ in the bilateral lower 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 : Medication-induced ED History finding(s) . Started beta blocker 4 months ago . No nighttime erection . Difficulty having daytime erection Physical examination finding(s) . None Diagnosis #2 : testosterone deficiency History finding(s) . Fatigue . Erectile dysfunction Physical examination finding(s) . None Diagnosis #3 : Anxiety History finding(s) . History of anxiety . Increased stress over past 6 months Physical examination finding(s) . No focal findings on examination Diagnostic studies . Serum glucose and hemoglobin A1c . Serum testosterone and TSH -- 作者： JuanFe -- 發表時間： 2018/08/15 03:30pm 12 Case 12 scenario (child fever) Doorway information about patient You will be speaking with the mother of a 1-year-old with fever Basic differential diagnosis . Respiratory tract infection . Ear infection . Exanthematous disease . Meningitis . Urinary tract infection . Gastroenteritis ————— Case 12  sim.pt. instruction This is a telephone encounter with the doctor , who is asking you questions on the phone input the child . 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 28-year-old woman who calls for evaluation of fever in your 1-year-old child History of present illness . Onset of fever 2 days ago . Fever to 38.9’C (102F) . Associated symptoms include dry cough , picking at the right ear , and vomiting ingested food without diarrhea . Had 1 episode of rhythmic jerking in both arms , with loss of urine ; afterward was silent and irritable for few minutes an then slept . Dose met appear drowsy or lethargic but has not been feeling well . Acetaminophen decreases the fever to 37.2’C (99F) transiently ; tepid sponge bathes also provide some relief . 3 year old sibling has no symptoms . No recent travel Review of systems . No rash . Passing normal yellow urine but cries while urinating Past medical history . No prior medical conditions , surgeries , or hospitalizations . Full-term delivery without complications . Breastfed until 2 months old , then changed to formula . Able to stand , hold objects in the hand , and say “Mama” and “ Dada” . Childhood vaccinations are up to date . At 9-month well-child visit , was at 75 percentile for height and 60 percentile for weight . Chile lives at home with mother , father , and 3-year-old sibling . Medications : Acetaminophen , liquid as needed . Allergies : None . Parents and siblings are all healthy ————— Case 12 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 and severity of fever . Asked whether the fever is continuous or intermittent with spontaneous return to baseline . Asked  whether the fever responds to any medications . Asked about associated symptoms , including: - Cough - Ear discharge - Nasal congestion / discharge - Pain - vomiting and diarrhea / bowel symptoms - Urinary symptoms - Rash . Asked about association with seizures (and further details including description , onset , associated incontinence or urine / bowel) . Asked about what happened after seizure : whether the child was irritable and if any body part was paralyzed . Asked about any exposure to infected individuals and history of travel Past medical /family/social history . Asked about similar episodes i the past . Asked about current medications and allergies . Asked about past medical issues (ear infections , convulsions, urinary tract infections),surgeries , and hospitalizations . Asked about motor and social development . Asked about prenatal and perinatal history . Asked about feeling habits . Asked about family health (especially seizures) Counseling . Explained the possible diagnosis . Explained further workup . Advised to give fluid and antipyretic . Discussed the need for a clinic visit for examination and testing Communication skills and professional conduct . 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 . Expressed empathy and gave appropriate reassurances . Asked whether you have any concerns/questions Differential diagnosis . Febrile seizures . Meningitis . Acute otitis media . Urinary tract infection Diagnostic study/studies . CBC with differential count and erythrocyte sedimentation rate . Urinalysis . Lumber puncture ————— Case 12 clinical summary Clinical Skills Evaluation Case 12 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). . Telephone encounter with motor of 1-yo child with 2 days of fever to 38.9’C (102F),cough , and pulling at the right ear . 2 episodes of vomiting but no diarrhea. . 1 episodes of vomiting but no diarrhea. . Crying when passing yellow urine . No lethargy . No previous infections or hospitalizations . No sick contacts; sibling has no symptoms . Birth history remarkable, normal developmental milestones. . Immunizations up to date. ROS : No recent travel or rashes PMHx : None PSHx : None Meds : Acetaminophen Allergies : None FHx : Parents and sibling are healthy 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. . Not done as this is a telephone encounter 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 : Acute otitis media History finding(s) . Fever . Pulling at right ear Physical examination finding(s) . None Diagnosis #2 : Urinary tract infection History finding(s) . Fever . Pain with urination Physical examination finding(s) . None Diagnosis #3 : Febrile seizure History finding(s) . Fever . Rhythmic tremor with fever that subside . Shaking movements while passing urine Physical examination finding(s) . None Diagnostic studies . Office visit for ear examination . Urinalysis . CBC with differential -- 作者： JuanFe -- 發表時間： 2018/08/15 03:31pm 13 Case 13 scenario (abdominal pain RUQ) Doorway information about patient The patient is a 45-year-old woman who comes to the office due to acute right upper quadrant abdominal pain. Vital signs . Temperature ; 38.3’C (101F) . Blood pressure : 130/80 mmHg . Pulse ; 100/min . respirations : 20/min Basic differential diagnosis Gastrointestinal . Acute cholecystitis . Biliary colic . Acute hepatitis . Peptic ulcer (perforation) . Acute pancreatitis (biliary pain) Pulmonary . Right lower lobe pneumonia Cardiovascular . Myocardial infarction . Heart failure with hepatic congestion Miscellaneous . Herpes zoster (shingle) ————— Case 13 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 45-year-old woman with acute abdominal pain History of present illness . Sudden onset 2 hour ago , 30 minutes after eating . Progressively worsening . Right upper abdomen with radiation to back and right shoulder . Severity 8-9/10 . “Stabbing” sensation . Worse with deep breathing , not relieved with antacids . Associated symptoms : - Nausea and vomiting without blood or bile; feel warm , but you idid not check temperature - No diarrhea . Similar pain 3-4 times over the last 5 months ; usually after meals and sometimes better with antacids Do not volunteer this information unless asked about diet or fatty foods : You eat a lot of fast food because you are busy at work and do not have time to cook. Review of systems . No jaundice , cough , shortness of breath , itching , or chest pain Past medical history . No prior medical problems . C-section 20 years ago . Medications : Over -the -counter antacids . Allergies : None . Immediate family members are healthy . Occupation ; Accountant . Married , live with husband and 1 child . Tobacco : 1 pack of cigarettes a day for 25 years ; trying to cut down . Alcohol ; 2-3 beers a day for 15 years . Recreational drugs : No Physical examination Abdomen: . Right upper quadrant discomfort with deep palpation ; slightly worse with deep breath . Abdomen non-distended . Normative bowel sounds throughout . No hepatosplenomegaly . No abdominal bruits The remainder of the examination is normal. ————— Case 13 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 location and radiation of pain . Asked about the intensity of pain . Asked about the quality of pain . Asked about the onset and duration of pain . Asked about the precipitating factors . Asked about the course of pain over time . Asked about any aggravating or relieving factors . Asked about nausea and vomiting . Asked about fever and chills . Asked about cough and breathing problems . Asked about any chest pain . Asked about jaundice . Asked about history of black stools Past medical /family/social history . Asked about similar episodes in the past . Asked about past medial issues (acid peptic disease , gallstone , heart problems) . Asked about previous hospitalizations and surgeries (especially gallbladder removal or appendectomy) . Asked about family history of healthy issue (especially gallstone) . Asked about current medications . Asked about occupation . Asked boy tobacco and alcohol use . Asked about diet Examination . Washed heads before examination . Examined without gown , not through gown . Auscultated abdomen(before palpation) . Palpated abdomen (Superficial and deep) . Checked for rebound tenderness . Percussed for liver span . Elicited murphy sign . Auscultated heart and lungs Counseling . Explained physical findings and possible diagnosis . Explained further workup . Discussed change in lifestyle , including quitting smoking , cutting down alcohol , healthier diet 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 Differential diagnosis . Acute cholecystitis . Biliary colic . Perforation of peptic ulcer . Pancreatitis . Acute hepatitis Diagnostic study/studies . CBC with differential count . EKG . Chest x-ray . Ultrasound abdomen . Serum amylase and lipase . LFTs (albumin , AST,ALT, alkaline phosphatase , total and direct bilirubin) ————— Case 13 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). . 45-yo female with 2 hours of worsening RUQ abdominal pain radiating to the right scapula. . 5 months of similar episodes (3-4/month) that resolved with antacids . Stabbing pain starting 30 minutes after food with nausea and nonbiilious and non bloody vomitus. . Pain worse with deep breathing and not improved with antacids. ROS : No jaundice , cough , shortness of breath , itching , chest pain , or diarrhea PMHx : None PSHx : Cesarian delivery 20 years ago Meds : OTC antacids PRN Allergies : None FHx : Parents and siblings are healthy SHx : 1 PPD smoker for 25 years , 2 or 3 beers /day for 15 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, 38.3’C (101.0F) ; blood pressure , 130/80 mmHg ; pulse , 100/min ; and respirations , 20/min . HEENT : PERRLA, EOMI, no jaundice . Abdomen : RUQ discomfort with deep palpation ; non-distended , normative bowel sounds throughout ; no hepatosplenomegaly or 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 : Acute cholecystitis History finding(s) . RUQ abdomen pain . 5 month of similar episodes . Pain radiating to right shoulder . Pain worsened with deep breathing Physical examination finding(s) . Fever . RUQ tenderness . Positive Murphy sign Diagnosis #2 : Acute pancreatitis History finding(s) . RUQ pain . Nausea and vomiting . Alcohol use Physical examination finding(s) . RUQ tenderness . Fever Diagnosis #3 : Peptic ulcer History finding(s) . Nausea and vomiting . RUQ pain . Alcohol /tobacco use Physical examination finding(s) . Fever . RUQ tenderness Diagnostic studies . Ultrasound of RUQ of abdomen . Serum amylase and lipase . Liver function tests . CBC with differential -- 作者： JuanFe -- 發表時間： 2018/08/15 03:31pm 14 Case 14 scenario (prenatal visit) Doorway information about patient The patient is a 24-year-old woman who comes to the office for an initial prenatal visit Vital signs . Temperature : 37.1’C(98.8F) . Blood pressure : 120/75 mmHg . Pulse : 78/min . Respirations : 20/min ————— Case 14 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 25-year-old woman here for your first prenatal visit . This is your first pregnancy (no prior miscarriage or abortion) . Last menstrual period 12 weeks ago . Positive home pregnancy test 6 weeks ago . Have not felt any fetal movements yet . Menarche at age 13 ; periods usually regular every 28-30 days with bleeding 4-5 days each month . No morning sickness , vomiting , abdominal pain , vaginal bleeding , fever , rash , breathing problems , sleep disturbances , or swelling in the feet Past medical history . No prior medical problems . No surgeries or hospitalizations . Medications : None . Medication allergies : None . Up to date on all standard adult immunizations . Immediate family members are all healthy . Occupation : Homemaker . Married , lived with husband . Tobacco 1 pack a day for 5 years . Alcohol : 1-3 beers a week for 3 years . Recreational drugs : None Physical examination HEENT . PERRLA, EOMI . Oropharynx clear Lungs : . Clear to auscultation bilaterally Heart : . Regular rate and rhythm without murmurs, gallops , or rubs Abdomen : . Non-tender , Non-distended . Normative bowel sounds throughout . No hepatopslenomegaly . No bruits Extremities . No cyanosis or edema ————— Case 14 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 LMP . Asked about how you first suspected and confirmed pregnancy . Asked about obstetrical / reproductive history (pregnancy and abortions) . Asked about gynecologic history (menarche, regular periods , contraception) . Asked about any pregnancy -related problems (vomiting , fever , abdominal pain, vaginal bleeding) . Asked about diet , appetite , and weight gain . Asked about genitourinary symptoms (eg , discharge, lesions, dysuria) . Asked about sleep Past medical /family/social history . Asked about past medical issues (especially heart conditions , autoimmune disorders , hypertension , diabetes , sexually transmitted infections ,ad n renal disease) . Asked about previous blood transfusions . Asked bit current medications . Asked about medication allergies . Asked about exposure to cats . Asked about rubella immunization in the past . Asked about family health (congenital or birth problems in the family) . Asked about tobacco , alcohol , and drug use . Asked about occupation Examination . Washed heads before examination . Examined without gown , not through gown . Examined eyes (for pallor) . Examined oral cavity (for general hygiene) . Examined legs (for edema and varicose viens) . Auscultated heart and lungs . Examined and auscultated abdomen (if <28 weeks of fundal grip ; if > 28 weeks do Leopold maneuvers) Counseling . Explained physical findings . Discussed appropriate prenatal tests . Advised you to stop usage of tobacco and alcohol . Advised safe sexual practices . Explained the need for prenatal vitamins , iron supplementation , and nutritious diet . Explained the importance of regular antenatal visits 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 Diagnostic study/studies . RH(D) blood type , antibody screen . CBC (hemoglobin /hematocrit , MCV) . HIV , VDRL/RPR, HBsAg . Rubella and varicella titers . Pelvic examination (with Pap test, if indicated) . Chlamydia PCR . Urinalysis and culture ————— Case 14 clinical summary Clinical Skills Evaluation Case 14 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). . 24-yo woman , G1P0A0 and LMP 12 weeks ago , who presents for her first prenatal visit. . No fetal movements yet. ROS : No mooning sickness , vomiting , abdominal pain , vaginal bleeding , fever , rash , breathing problems , sleep disturbances , or swelling in the feet PMHx : None PSHx : None Meds : None Allergies : None FHx : parents and siblings are healthy SHx : 1 PPD smoker for 5 years , 1-3 beers/ week fro 3 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 , 37.1 ‘C (98.8F) ; blood pressure , 120/75 mmHg ; pulse , 78 /min; and respirations , 20/min . HEENT : PERRLA < EOMI , no jaundice , oropharynx clear . Lungs : Clear to auscultation bilaterally . Heart : RRR without murmurs, gallops , or rubs . Abdomen : Non-tender , non-distended , normative bowel sounds throughout ; no hepatosplenomegaly ; no bruits . Extremities : No cyanosis or edema 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 : Normal pregnancy History finding(s) . LMP 12 weeks ago . Home pregnancy test positive 6 weeks ago Physical examination finding(s) . non-distended abdomen . No edema Diagnostic studies . Rh(D)type , antibody screen . CBC . HIV, VDRL/RPR , HBsAg . Rubella and varicella titers . Pelvic examination . Chlamydia PCR . Urinalysis and culture -- 作者： JuanFe -- 發表時間： 2018/08/15 03:32pm 15 Case 15 scenario (shortness of breath) Doorway information about patient The patient is a 60-year-old man who comes to the emergency department due to acute shortness of breath. Vital signs . Temperature: 36.7’C(98F) . Blood pressure : 110/70 mmHg . Pulse : 90 /min . Respirations : 26/min Basic differential diagnosis . Pulmonary embolism . Congestive heart failure . Chronic obstructive pulmonary disease exacerbation . Pneumonia . Spontaneous pneumothorax . Asthma exacerbation . Anxiety/panic attack ————— Case 15 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 60-year-old man with acute shortness of breath. History of present illness . Onset 2 days ago . Mild shortness of breath with strenuous work that has slowly worsened over the past year. but is now suddenly worse . Not of breath with walking 1 block . Occasional dry cough . No fever , chills , or unusual fatigue . No syncope or palpations . No swelling in the legs . Difficulty at night . Worsen when lying down and better when sitting up Do not volunteer this information unless asked : You sleep on 2 pillows because you get short of breath when lying flat , also , you woke up in the middle of the night weigh shortness of breath and could not go back to sleep for 20 minutes. Past medical history . Spinal fusion surgeries 2 weeks ago for spinal stenosis that required 1 week in the hospital postoperatively . Hypertension diagnosed 20 years ago . Medications ; hydrochlorothiazide 25mg daily . Medication allergies : None . Father died of a heart attack at age 55; mother is alive and has hypertension ; no siblings . Occupation : Computer software analyst . Married , live with wife . Tobacco ; 1 pack of cigarettes a day for 40 years . Alcohol : 1-2 glasses of wine a day for 35 years . Recreational drugs : None Physical examination HEENT : . PERRLA , EOMI Neck : . Supple without lymphadenopathy . No JVD . No thyromegaly Lungs : . Clear to auscultation and percussion Heart : . Regular rate and rhythm . No murmurs , gallops , or rubs Extremities : . No edema , cyanosis , or clubbing . Pedal pulse 2+ bilaterally . No calf tenderness to palpation ————— Case 15 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 symptoms . Asked about the course over time . Asked about associated symptoms : - Chest pain - Orthopnea and paroxysmal nocturnal dyspnea - Wheezing - Coughing - Fever and chills - Palpitations - Syncope - Leg pain and swelling . Asked about recent travel or prolonged immobilization (recent surgery) Past medical /family/social history . Asked about similar episode in the past . Asked about past medical issue (especially high blood pressure ,heart problems , asthma , and chronic obstructive pulmonary disease) . Asked about surgeries and hospitalizations . Asked about current medications . Asked about medication allergies . Asked about occupation . Asked about tobacco , alcohol , and drug use . Asked about family history of blood clots and heart problems Examination . Washed heads before examination . Examined without gown , not through gown . Examined neck for jugular venous pressure . Examined heart : inspection , palpation , auscultation . Examined lungs : inspection , palpation , auscultation , percussion . Examined the extremities for pulses and edema . Checked calf muscle tenderness Counseling . Explained physical findings and possible diagnosis . Explained further workup . Discussed quitting smoking 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 Differential diagnosis . Pulmonary embolism . Pneumonia . Congestive heart failure . Chronic obstructive pulmonary disease Diagnostic study/studies . CBC with differential count . Chest x-ray . ECG . Ventilation / perfusion (V/Q) scan or  chest CT scan . Echocardiogram ————— Case 15 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 2 days of worsening shortness of breath. . 1 years of gradually worsening shortness of breaths that acutely worsened 2 days ago. . New 2 -pillow orthopnea , PND. . Spinal fusion surgery 2 weeks ago. . Occasional dry cough. ROS: No chest pain , wheezing , fatigue , palpations , leg swelling , syncope , fever , or chills PMHx : HTN PSHx : Spinal fusion surgery Meds : Hydrochlorothiazide 25 mg daily Allergies : None FHx: Father died of MI at age 55 , mother has HTN SHx : 1 PPD smoker for 40 years , 1 or 2 glasses of wine /day for 35 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 , 110/70 mmHg; pulse , 90/min; and respiration , 26/min . HEENT : PERRLA , EMOI , no jaundice . Neck ; Supple without lymphadenopathy , no JVD , no thyromegaly . Lungs ; clear to auscultation . Heart : RRR without murmurs, gallops , or rubs . Extremities ; No edema , pulse 2+ bilaterally , no cyanosis or clubbing , no lower extremities tenderness on palpation 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 :Pulmonary embolism History finding(s) . Acute worsening of dyspnea . Tecent spinal fusion surgery Physical examination finding(s) . None Diagnosis #2 : Congestive heart failure History finding(s) . 1 year of gradually worsening dyspnea . Dyspnea worse with exertion . Orthopnea and PND Physical examination finding(s) . None Diagnosis #3 : COPD History finding(s) . History of smoking . 1 year of gradually worsening dyspnea . Cough Physical examination finding(s) . None Diagnostic studies . Chest x-ray . CT anagram of chest . CBC with differential . Basic metabolic panel . ECG , echocardiogram -- 作者： JuanFe -- 發表時間： 2018/08/15 03:33pm 16 Case 16 scenario (increase urination) Doorway information about patient The patient is a 40-year-old woman who comes to the office due to increased urination Vital signs . Temperature : 36.7’C (98F) . Blood pressure : 110/70 mmHg . Pulse : 86/min . Respirations : 16/min Basic differential diagnosis Increased urine volume . Diabetes mellitus . Diabetes insipidus (central, nephrogenic) . Psychogenic : polydipsia . Diuretic use . hypercalcemia increased urinary frequency . Urinary tract infection . Overactive bladder . Excess caffeine intake . Vaginitis , urethritis ————— Case 16 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 40-year-old women complaining of increased urinary frequency History of present illness . Onset 2  months ago . Urination 8-10 times during the day and 2-3 times a night . increased urinary volume . Increased feelings of thirst for last month . Associated symptoms: - Fatigue - 4.5-kg (10-lb) weight loss (despite increased appetite) - No dysuria or urgency - No fever or chills Past medical/family/soical history . Bipolar disorder diagnosis 20 years ago . Minor head injury after falling off bicycle 3 months ago ; seen in emergency department and discharged without intervention . No surgeries or hospitalizations . Medications : lithium 60 mg twice daily . Medication allergies : None . Married , live with husband . 2 pregnancies with normal vaginal delivery ; both children are healthy . Both parents have type 2 diabetes mellitus l no siblings . Tobacco : No . Alcohol : No . Recreational drugs : No Physical examination HEENT : . PERRLA , EOMI . Visual fields intact Heart : . Regular rate and rhythm . No murmurs , gallops , or rubs Abdomen : . Soft and non-tender with normal bowel sounds . No suprapubic or CVA tenderness Neurologic : . Muscle strength 5/5 throughout . Sensation in tact in all 4 extremities . reflexes 2+ in all 4 extremities ————— Case 16 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 problem . Asked about the frequency of urination . Asked about nocturia . Asked about nocturne . Asked about urine volume . Asked about burning on urination . Asked about urgency and hesitancy of urination . Asked boy increased thirst and fluid intake . Asked about appetite  and changes in weight . Asked about the trauma to the head Past medical /family/social history . Asked about similar problems in the past . Asked about past medical issues , hospitalizations ,and surgeries . Asked about psychiatric problems (history of bipolar disorder , schizophrenia) . Asked about current medications . Asked about family health(especially diabetes) . Asked about tobacco , alcohol , and drug use . Asked about occupation Examination . Washed heads before examination . Examined without gown , not through gown . Examined mucous membranes . Examined heart and lungs . Tested muscle power in both upper and lower limbs . Tested sensation in the lower extremities . Tested reflexes in the lower extremities . Tested visual fields and examined funds . Tested for suprapubic and costovertebral angle tenderness 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 Differential diagnosis . Diabetes mellitus . Central diabetes insipidus . Nephrogenic diabetes insidious (lithium side effect) . Psychogenic polydipsia . Hypercalcemia Diagnostic study/studies . Fasting blood sugar . Urinalysis . Serum electrolytes (Na,K, Cl , CO2 , BUN , Cr , and calcium) . Urine and serum osmolality ————— Case 16 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). . 40-yo woman with 2 months of polyuria , polydipsia, nocturia , and polyphagia . 2-3 month of 4.5-kg(10-lb) weight loss with fatigue . No dysuria or urinary urgency ROS : No fever or chills PMHx : bipolar disorder diagnosed 20 years ago ; minor head trauma 3 months ago , seen in emergency department and discharged without intervention PSHx : None Meds : Lithium 600 mg 2 times daily Allergies : None FHx : Father and mother have diabetes SHx : No history of tobacco or alcohol 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 , 36.7’C(98.1F) ; blood pressure , 110/70mmHg; pulse , 86/min; and respirations , 16/min . HEENT : PERRLA , EOMI, intact visual fields . Abdomen : Non-tender without suprapubic tenderness, np CVA tenderness . Neurologic L muscle strength 5/5 throughout sensation grossly intact bilateral lower extremities , DTR 2 + in bilateral lower 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 : Diabetes mellitus History finding(s) . Polyuria . Polydipsia and polyphagia . Family history of diabetes in father and mother . Weight loss Physical examination finding(s) . None Diagnosis #2 : Diabetes insipidus History finding(s) . History of bipolar disorder . Lithium use . Polyuria Physical examination finding(s) . None Diagnosis #3 : Psychogenic polydipsia History finding(s) . history of bipolar disorder . Polyuria . Polydipsia Physical examination finding(s) . None Diagnostic studies . Fasting blood glucose . Hemoglobin A1c . Urinalysis . Serum electrolytes , lithium level . Urine and serum osmolality -- 作者： JuanFe -- 發表時間： 2018/08/15 03:34pm 17 Case 17 scenario (jaundice) Doorway information about patient The patient is a 35-year-old woman who comes to the office due to jaundice Vital signs . Temperature : 38.5’C (101.3F) . Blood pressure : 120/75 mmHg . pulse : 98/min . Respirations : 22/min Basic differential diagnosis . Infectious hepatitis . Hemolytic jaundice . Alcoholic hepatitis . Drug-induced hepatitis . Primary biliary cirrhosis . Wilson disease . Hemochromatosis . Malignancy ————— Case 17 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 who comes to the clinic due to jaundice History of present illness . Onset of jaundice 2 days ago . Fever beginning 5 days ago . Dark urine and pale stools ,then yellowing of the eyes . Associated symptoms : - Mild abdomen discomfort - 2-3 episodes non bilious , non bloody vomiting - No sore throat , headache , neck stiffness , itching , diarrhea , or constipation . Recent return form a trip to india (ate local food and drank bottled water) . No vaccination for hepatitis in the past Past medical history . Motor vehicle accident 2 years ago requiring hospitalization and blood transfusion . No surgires . No medications . No medication allergies . Immediate family members 9parents and 3 siblings ) are all healthy . Occupation: homemaker . Married , live with husband . 2 pregnancies with uncomplicated delivers . Tobacco : no . Alcohol  : 2-3 beers a day for 15 years . recreational drugs : No Physical examination HEENT . PERRLA, EOMI . Scleral icterus present . Oropharynx clear Neck : . No lymphadenopathy Abdomen : . Non-tender , non-distended . No hepatosplenomegaly . Normative bowel sounds ————— Case 17 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 and duration of jaundice . Asked about the color of stool and urine . Asked about itching /pruritis . Asked about abdominal pain . Asked about fever and chills . Asked about appetite and changes in weight . Asked about sore throat . Asked about any bleeding tendencies . Asked about enlarged glands . Asked about travel history Past medical /family/social history . Asked about similar episodes before . Asked about past medical issue (especially hepatitis ,liver disease , blood transfusion , high blood pressure , diabetes ) , hospitalizations , and surgeries . Asked about current medications . Asked about family health . Asked bout tobacco , alcohol , and drug use . Asked bout sexual and reproductive history . Asked bout occupation Examination . Washed heads before examination . Examined without gown , not through gown . Auscultation abdomen . Palpated abdomen (superficial abandon deep) , including liver and spleen . Checked rebound tenderness . Examined for enlarged nodes Counseling . Explained physical findings and possible diagnosis . Explained further workup . Explained the importance of lifestyle modifications (especially reducing alcohol intake) 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 Differential diagnosis . infectious hepatitis . Alcohol hepatitis . Drug-induced hepatitis . Primary biliary cirrhosis . Malignancy Diagnostic study/studies . CBC with differential . Liver function tests (AST,ALT, alkaline phosphatase , bilirubin) . Coagulation studies (PT,PTT) . Viral hepatitis serologies ( HBs antigen , HBc antibody , hepatitis A antibody , hepatitis C antibody) . Urine for bile salts . Anti-mitochondrial antibodies . Liver ultrasound ————— Case 17 clinical summary Clinical Skills Evaluation Case 17 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 2 days of jaundice associated with fever . Returned 3 weeks ago form trip to india . Dark urine endplate stools . Mild diffuse abdominal discomfort , nausea ,vomiting. ROS : No sore throat , headache , stiff neck , dysuria , weight loss , itching , diarrhea , or constipation PMHx: Car accident 2 years ago  requiring hospitalization and blood transfusion PSHx: None Meds: None Allergies : None FHx: Father , mother and siblings are healthy SHx: No history of tobacco use , 2-3 beers / day for the past 15 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 sign: temperature , 38.5’C (101.3F) ; blood pressure , 120/75 mmHg; pulse , 98/min; respirations , 22/min . HEENT : PERRLA , EOMI , icterus present , oropharynx clear . Neck : No lymphadenopathy . Abdomen : Non-tender and non-distended , no hepatosplenomegaly , normative 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 : infectious hepatitis History finding(s) . Travel to India . Jaundice . Nausea , vomiting , abdomen discomfort . Dark urine , pale stools Physical examination finding(s) . Fever . Jaundice Diagnosis #2 : Alcoholic hepatitis History finding(s) . Alcohol use . Nausea , vomiting , abdominal discomfort Physical examination finding(s) . Fever . Jaundice Diagnostic studies . Hepatitis serologies : A,B, and C . CBC with differential . Liver function tests . Urinalysis -- 作者： JuanFe -- 發表時間： 2018/08/15 03:35pm 18 Case 18 scenario (chest pain) Doorway information about patient The Patient is a 35-yea-old woman who comes to the emergency department due to chest pain Vital signs . Temperature ; 36.8’C (98.3F) . Blood pressure : 120/75 mmHg . Pulse : 98/min . Respirations : 12 /min Basic differential diagnosis . Pneumonia . Gastroesphageal reflux disease . Pain disorder/ hyperventilation syndrome . hyperthyroidism . Angina . Costochondritis ————— Case 18 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 with chest pain History of present illness . Onset of this episode 1 days ago . Squeezing sensation over the entire chest . 4-5/10 severity . No aggravating or relieving factors ( no relief form antacids) . Intermittent chest discomfort for the last year; episodes usually last 20 minutes ; initially about once a month but now every week; usually triggered buy going out in public . Associated symptoms: - Fasting breathing - Sweating - Headache - Palpations . Hospitalized over might 6 months ago for the same problem; all tests came back normal Review of systems . No nausea , vomiting , diarrhea , or abdominal pain . No dysuria . Headache . Palpitations Past medical history . Hospitalized following a motor vehicle accident 32 years ago (required blood transfusion) . No surgeries . Medications : None . Medication allergies : None . After os healthy ; mother has “hypochondriasis” ; sister has hyperthyroidism . Occupation : Secretary at a law firm . Single, live a lone . Tobacco : 1 pack a day for 15 years . Alcohol : None . Recreational drugs ; None Physical examination Neck : . No lymphadenopathy . No thyromegaly Lungs : . Clear to auscultation bilaterally Heart : . Regular rate and rhythm . No murmurs, gallops , or rubs Ask this question : “Do you think that this is a heart attack ? I feel like I am going to die “ ————— Case 18 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 location of pain . Asked about the intensity of pain . Asked about the quality of pain . Asked about the duration and frequency of pain . Asked about the course of the painter time . Asked about any radiation of pain . Asked about any aggravating or relieving factors . Asked about any precipitating factors . Asked about associated symptoms - Nausea and vomiting - Sweating - hyperventilation or trouble breathing - Cough - Palpitations or rapid heart beat - Fear of dying or sense of tremor - Syncope or dizziness - Headache - changes in appetite or weight Past medical /family/social history . Asked about similar episodes in the past . Asked about past medical issues (especially high blood pressure , heart problems , diabetes , thyroid problems) . Asked about previous hospitalizations and surgeries . Asked about current medications . Asked about medication allergies . Asked about family health . Asked about tobacco , alcohol , and drug use . Asked about sexual and reproductive history . Asked bout occupation and stress in life Examination . Washed heads before examination . Examined without gown , not through gown . Examined neck and thyroid . Listened to heart and lungs . Check reflexes Counseling . Explained physical findings and possible diagnosis . Discussed result of chest x-ray . Explained further workup . Discussed quitting smoking 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 Differential diagnosis . Panic disorder . Hyperthyroidism . Hyperventilation syndrome , Angina Diagnostic study/studies . CBC with differential . Electrolytes and blood glucose . ECG . TSH ————— Case 18 clinical summary Clinical Skills Evaluation Case 18 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 1 year of worsening episodes of chest pain . Diffuse chest tightness associated with headache , palpations , diaphoresis , hyperventilation ,a dn sense of impending doom . Previous hospitalization with normal testing . Episodes occur more often when out in public and are not relieved with antacids. ROS : No nausea , vomiting , dysuria , constipation , flushing , sleep disturbance , or abdominal pain PMHx: None PSHx: None Meds: None Allergies : None FHx : Fater os healthy , mother has hypochondriasis , and sister has hyperthyroidism SHx : 1 PPD smoker for 15 years , no use of alcohol or illicit drugs 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 , 36.8’C (98.3F); blood pressure , 120/75mmHg; pulse , 98/min; and respirations, 12/min . Neck : No lymphadenopathy por thyromegaly . Lungs ; Clear to auscultation bilaterally . heart : RRR without murmurs, gallops, or rubs 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 chest pain . Worse when in public . Normal investigation in the past Physical examination finding(s) . Normal vital signs . Normla cardiac examination Diagnosis #2 : Hyperthyroidism History finding(s) . Family history . Palpitations Physical examination finding(s) .None Diagnosis #3 : Cardiac arrthemia History finding(s) . Episodic palpations . Chest pain and diaphoresis Physical examination finding(s) . None Diagnostic studies . ECG . TSH . Chest x-ray shows only mild hyperinflation -- 作者： JuanFe -- 發表時間： 2018/08/15 03:36pm 19 Case 19 scenario (abdominal pain RLQ) Doorway information about patient The patient is a 45-year-old man who comes to the emergency department due to right lower abdominal pain Vital signs . Temperature : 37.1’C (89.7F) . Blood pressure : 130/80 mmHg . Pulse : 100/min . Respirations : 20/min Basic differential diagnosis . Appendicitis . Mickel diverticulitis . Perforation viscus . Intestinal obstruction . Yersinia enterocolitica . Pancreatitis . Urolithiasis . Acute cholecystitis . Herpis zoster (shingle) ————— Case 19 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 45-year-old man who comes to the emergency department with abdominal pain History of present illness . The pain stated suddenly 2 hours ago . Pain started behind the belly button , than radiated to the right lower abdomen . Pain is sharp. 8-9/10 severity , and has increased over time . The symptoms started after a large meal and are worse with movement ; nothing relives the pain . Associated symptoms -  Nausea - 2 episodes of non bilious , non bloody vomiting . Last bowel movement was 20 hours ago , and you are passing gas normally Review of systems . No fever or chill . No dysuria . No diarrhea or constipation . No back pain Past medical/family/social history . Peptic ulcer disease ; treated 10 years ago with omeprazole . No current medications . No surgeries . Immediate family members are all healthy . Occupation : Bus driver . Single ,live alone . Tobacco : 1 pack a day for 20 years . Alcohol : 3 beer a day for past 15 years . Recreational drugs : No Physical examination Abdomen : . Right lower quadrant tenderness to superficial and deep palpation . Rebound tenderness noted . Normative bowel sounds throughout . No hepatosplenomegaly . No CVA tenderness . Posts and obturator signs : Negative ————— Case 19 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 location and radiation of pain . Asked about the intensity of pain . Asked about the quality of pain . Asked about the origin and duration of pain . Asked about the course of pain over time . Asked about any aggravating or relieving factors . Asked about any vomiting . Asked about fever . Asked bout urinary problems . Asked about bowel problems , constipation , and last bowel movement . Asked about appetite and change in weight 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 ,medical allergies . Asked about family health . Asked about tobacco , alcohol ,and recreational drug use . Asked about sexual history . Asked occupation Examination . Washed heads before examination . Examined without gown , not through gown . Auscultated abdomen(before palpation) . Palpated abdomen(superficial and deep) . Checked rebound tenderness . Check for costovertebral angle tenderness . Percussed for liver span . Performed psoas sign and obturator sign Counseling . Explained physical findings and possible diagnosis . Explained further workup . Discussed lifestyle modifications , including quitting smoking and reducing alcohol 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 Differential diagnosis . Appendicitis . Meckel diverticulitis . Perforated peptic ulcer . Intestinal obstruction . Pancreatitis . Urolithiasis Diagnostic study/studies . CBC with differential . Serum chemistries(glucose, electrolytes , liver enzymes , creatinine) . Serum lipas . Abdomen x-ray . Abdomen ultrasound . Lipase, amylase . Upper GI endoscopy ————— Case 19 clinical summary Clinical Skills Evaluation Case 19 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 2 hors of worsening poplin form mid-epigastric region to RLQ . Pain worse with movement but not relieved buy anything . Nausea and vomiting (non-bloody , non-bilious) . Last bowel movement 20 hours ago with passage flatus. ROS : No fever , chills , diarrhea , constipation , or back pain PMHx : Peptic ulcer disease PSHx: None Meds : None Allergies : None FHx : Father ,mother , and siblings are healthy SHx : 1 PPD smoker for past 20 years , 3 beers .day for past 15 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, 37.1’C(98.8F) ; blood pressure , 130/80mmHg ; pulse ,100/min ; and respirations , 20/min . Abdomen ; RLQ tenderness to superficial and deep palpation , rebound tenderness present , normative bowel sounds throughout , no hepatosplenomegaly, no CVA tenderness ,negative psoas and obstructor signs 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 : Appendicitis History finding(s) . Sudden onset RLQ pain . Nausea and vomiting Physical examination finding(s) . RLQ tenderness . Rebound tenderness in abdomen Diagnosis #2 : Perforated peptic ulcer History finding(s) . History of peptic ulcer . Abdomen pain . Alcohol use Physical examination finding(s) . Rebound tenderness in abdomen Diagnosis #3 : Intestinal obstruction History finding(s) . Abdomen pain . Last bowel movement 20 hors ago Physical examination finding(s) . Rebound tenderness in abdomen Diagnostic studies . CBC with differential . Abdominal x-ray . CT of the abdomen -- 作者： JuanFe -- 發表時間： 2018/08/15 03:37pm 20 Case 20 scenario (leg pain bilateral) Doorway information about patient The patient is a 50-year-old man who comes to the office due to bilateral leg pain Vital signs . Temperature : 36.7”C(98F) . Blood pressure : 140/80 mmHg . Pulse : 78/min . Respirations : 20 /min Basic differential diagnosis Bilateral pain . Atherosclerotic vascular disease . Lumber spinal stenosis . Diabetic polyneuropathy . Radiculopathy due to spinal disease . Medications , such as statin . Trauma . Thromboangiitis obliterans Unilateral pain . Cellulitis / myofasciitis . Deep vein thrombosis . Rupture of baker cyst . Osteomyelitis . Radiculopathy /sciatica . Pathological fracture of the bone ————— Case 20 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 50 year-old-man with bilateral leg pain History of present illness . Onset 2 months ago . Pain stated gradually and has become progressively worse . Throbbing pain with 5-6 /10 severity . Located in the calf muscles , no radiation . Worse with walking , running , and prolonged standing . Better while sitting and at rest . No history of trauma Review of systems . No fever . No back pain . No weakness , numbness , or tingling in the leg . No sexual or bladder symptoms Past medical / Family / social history . Diabetes for the past 3 years , controlled by diet . High cholesterol . No surgires . Medications : Simvastain 40 mg  daily at bedtime . Allergies : No . Father died at age 65 of a stroke ; mother and 2 sibling are healthy . Occupation: Postal worker . Married , live with wife . Tobacco : 2 pack a day for past 30 years . Alcohol : Occasional beer . Recreational drugs : No Physical examination Abdomen: . No bruits Extremities . Pulse 2+ and symmetrical in bilateral lower extremities Musculoskeletal . Negative Homans sign . ,No calf tenderness to palpation bilaterally Neurologic . Motor strength 5/5 in both lower extremities . Grossly intact sensation . Deep tendon reflexes 2+ symmetrically ————— Case 20 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 location and radiation of the pain . Asked about the onset of pain . Asked about whether it is continuous or intermittent pain . Asked about the intensity of pain . Asked about the quality of pain . Asked about the course of pain over time . Asked about any aggravating or relieving factors . Asked about rest pain . Asked about swelling of the legs . Asked about sensory changes ( such as numbness ) and paresthesia . Asked boy any weakness of the legs . Asked about any history of back pain . Asked about fever . Asked about trauma to the legs . Asked about other joint pain . Asked about recent surgeries or prolonged immobilization . Asked about impotence Past medical /family/social history . Asked about similar episodes in the past . Asked about past medical issues (especially high blood pressure , diabetes , high cholesterol, disc prolapse) . Asked about current medications . Asked about family health (especially history of blood clots) . Asked about tobacco , alcohol , and recreational drug use . asked bout occupation Examination . Washed heads before examination . Examined without gown , not through gown . Examined calf tenderness . Elicited Homans sign . Checked pulses in both legs and  arms . Listened for bruits at the distal aorta , iliac , or femoral arteries . Checked sensation in both legs . Checked reflexes in bother legs . Checked for vibration sense in both legs Counseling . Explained physical findings and possible diagnosis . Explained further workup . Discussed lifestyle modifications, including quitting smoking 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 . 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 Differential diagnosis . Thromboangiitis obliterans . Atherosclerotic vascular disease . Drug induced (statins) . Diabetic polyneuropathy Diagnostic study/studies . Creatinine kinase . Blood sugar and hemoglobin A1c . Lipid profile . Arterial doppler study coif the lower extremities . Duplex venous ultrasound of power limbs . CBC with differential . Spine MRI ————— Case 20 clinical summary Clinical Skills Evaluation Case 20 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). . 50-yo man with 2 months of worsening bilateral leg pain . Trolling pain mainly over the calf muscle made worse with walking , running, and prolonged standing. . Symptom improvement with rest and sitting ROS : No pain at rest , fever , trauma , swelling , back pain, weakness , sexual difficulties , numbness , or tingling in legs PMHx : Diabetes for 3 years under diet control , hypercholesterolemia PSHx : None Meds: Simvasatin 40 mg daily at bedtime Allergies : None FHx : Father died at age 65 of stroke ; mother and 2 siblings are healthy SHx : 2 PPD smoker for past 30 years , occasional alcohol 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 , 36.7’C (98.1F); Blood pressure , 140/80 mmHg; pulse , 78/min; and respirations ,20/min . Abdomen : No bruits . Extremities : Pulse 2+ and symmetrical in bilateral lower extremities . Musculoskeletal : Negative Homans sign , no calf tenderness to palpation bilaterally . Neurologic : bilateral lower extremities with 5/5 motor strength , intact vibratory sensation and proprioception, and DTR 2+ 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 : Drug-induced (statin) myopathy History finding(s) . Proximal muscle pain . History of statin use Physical examination finding(s) . Normal motor strength in legs . No sensory deficits in legs Diagnosis #2 : Atherosclerotic peripheral vascular disease History finding(s) . History of diabetes and high cholesterol . History of smoking . Family history of stroke Physical examination finding(s) . None Diagnosis #3 : Diabetic polyneuropathy History finding(s) . Diet-controlled diabetes . History of high cholesterol Physical examination finding(s) . None Diagnostic studies . Creatinine kinase . Fasting blood sugar and hemoglobin A1c . Lower-extremity arterial Doppler -- 作者： JuanFe -- 發表時間： 2018/08/15 03:38pm 21 Case 21 scenario (vomiting) Doorway information about patient The patient is a 56-year-old woman who comes to the emergency department due to vomiting Vital signs . Temperature : 36.7’C (98F) . Blood pressure : 90/60 mmHg . Pulse : 98/min . Respirations : 20/min Clinical Images The paint has vomited into a pan of water at the bedside , as shown in the image : frank-blood or coffee-ground vomiting Basic differential diagnosis . Peptic ulcer disease . Gastric erosion . Esophageal varices . Mallory-Weiss tears . Esophagitis . Duodenitis . Malignancy (esophageal and gastric) ————— Case 21 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 56-year-old woman who is vomiting up blood History of present illness . Felt lightheaded while climbing stairs at home and passed out (2 hours ago) . Sharp mid-epigastric pain starting 1 day ago (4-5/10 severity , no radiation) . Nausea that is worse today . Threw up a teaspoon of blood twice at home ; threw up more blood in the emergency department . Back stools for 1 week Review of systems . No changes in appetite or weight . No fever or chills . No shortness of breath . No otters dizziness or chest pain Past medical history / family / social history . GERD for past 2 years relieved with antacids as needed . Chronic back pain . No surgeries . Medications : Ibuprofen as needed . No allergies . Father died of heart attack at age 60; mother and 2 siblings are healthy . Single ,live with roommate . Tobacco : 1 pack a day for past 25 years . Alcohol : 4-5 beers a day for past 20 years . Recreational drugs : No Do not volunteer this information unless asked about problems with drinking: You were admitted to an alcohol; treatment facility 1 years ago and left after 1 week Physical examination HEENT : . Oropharynx clear CV : . Regular rate and rhythm . No murmurs Abdomen : . Non-tender , non-distended . Normative bowel sounds . No hepatosplenomegaly ————— Case 21 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 vomiting . Asked about the frequency of vomiting . Asked about any blood in the vomit (frank-blood or coffee-ground vomiting) and quantity of blood . Asked about any abdomen pain associated with the vomiting . Asked about prior history abdomen pain ( or heartburn ) especially in relation to food . Asked specifically about melena (black stools) . Asked about recent change in appetite and weight loss Past medical /family/social history . Asked about similar episodes in the past . Asked about other medical issues (peptic ulcer disease , reflux disease , liver problems),hospitalizations , and surgeries . Asked about current medications . Asked about medication allergies . Asked about family health (including bleeding problems) . Asked about tobacco , alcohol , and recreational drug use (including detailed discussion of alcohol abuse and treatment) . Asked about occupation Examination . Washed heads before examination . Examined without gown , not through gown . Performed orthostatic vital signs . Examined oropharynx . Auscultated abdomen (prior to palpation) . Palpated abdomen (superficial and deep) . Checked for rigidity and rebound . Percussed for liver span . Performed neurologic examination . Performed cardiovascular examination Counseling . Explained physical findings and possible diagnosis . Explained further workup (blood test,endoscopy) . Explained the importance of lifestyle modifications , including quitting smoking and alcohol 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 Differential diagnosis . Variceal hemorrhage . Peptic ulcer decease . Gastric erosions . Esophagitis . Duodenitis Diagnostic study/studies . CBC with differential count . PT/PTT/INR . BUN, serum creatinine , electrolytes . Upper GI endoscopy . Liver function test (albumin, AST,ALT, alkaline phosphatase , total and direct bilirubin) . ECG ————— Case 21 clinical summary Clinical Skills Evaluation Case 21 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). . 56-yo woman with syncope while climbing stairs . Followed by recurrent hematemesis over the last 2 hours . History of GERD  relieved with as-needed antacids. . 1 day of mid-epigastric abdomen pain without radiation , associated with nausea . 1 week of melena ROS : No changes in appetite , weight loss , fever , chills , shortness of breath , or chest pain PMHx: GERD , chronic back pain , alcohol abuse PSHx: None Meds : ibuprofen , as needed Allergies : None FHx: Father died at age 60 of heart attack ; motor and 2 siblings are healthy SHx: 1 PPD smoker for past 20 years , 4-5 beers /day for past 20 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 , 90/60 mmHg; pulse , 98/min ; and respirations , 20/min . HEENT : Oropharynx clear . Heart : RRR with no M,G,R. Abdomen : non-tender , non-distended , normative bowel sounds , no hepatosplenomegaly 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 esophageal varices History finding(s) . History of ibuprofen and excessive alcohol use . Mid-epigastric pain . Hematemesis and melena Physical examination finding(s) . None Diagnosis #2 : Bleeding peptic ulcer History finding(s) . History of GERD and excessive alcohol use . Mid-epigastric pain and hematemesis . Melena Physical examination finding(s) . None Diagnosis #3 : Gastritis History finding(s) . History of ibuprofen and excessive alcohol use . Mid-epigastric pain . Melena Physical examination finding(s) . None Diagnostic studies . Orthostatic BP and HR measurement . CBC with differential . Basic metabolic panel . Liver function test . PT/PTT/INR . Upper GI endoscopy -- 作者： JuanFe -- 發表時間： 2018/09/13 07:49am 22 Case 22 scenario (chest pain) Doorway information about patient The patient is a 55-year-old man who comes to the emergency department due to chest pain Vital signs . Temperature : 37.1 C (98.7F) . Blood pressure : 130/80 mmHg . Pulse : 78 /min . Respirations : 20/min Clinical images ECG is shown in the image : S-T segment lowered Basic differential diagnosis . Miocardio infarction . Unstable angina . Pulmonary embolism . Costochrondritis . Pleuritis . Pericarditis . Aortic dissection . Gastroesophageal reflux . Esophageal; perforation ————— Case 22 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 55-year-old man who comes to the emergency department with chest pain. History of present illness . The pain came on suddenly and has progressively worsened . Pain located in substernal area with no radiation . “Tight , squeezing “ sensation with 8-9/10 severity . Pain is worse when walking and moving around . Associated symptoms: - Nausea - 1episode of vomiting - Sweating - Mild shortness of breath Review of systems . No fever , cough , headache . abdominal pain , diarrhea , constipation , recent trauma, appetite changes   weight loss , or urinary problems Past medical history . High blood pressure for 20 years . Diabetes for 5 years . Cholesterol tested a year ago was 280 ( you are trying to control your cholesterol who diet but not eat a lot of fast food) . No surgires . Medications : lisinopril , metformin . No allergies . Father died at age 60 of heat attack ; mother tis living and ad stroke at age 65 ; brother had a heart attack at age 58 . Occupation : lawyer . Married , live with wife . Tobacco : 1 pack a day for the past 30 years . Alcohol : 1 glass of wine a day for past 20 years . Recreational drugs : No Physical examination Physical examination Neck : . supple without JVD or lymphadenopathy . No thyromgaly Lungs : . Clear to auscultation bilaterally . No reproducible chest pain with palpation Heart : . Regular rate and rhythm . No murmurs , gallops , or rubs Review of system You have non of the following: . Fever . Cough . Headache . Abdominal pain . Diarrhea . Constipation . Recent trauma . Appetite changes . Weight loss . Urinary problems ————— Case 22 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 location and radiation of pain . Asked about the intensity of pain . Asked about the quality of pain . Asked about the origin and duration of pain . Asked about the course of pain over time . Asked about any aggravating or relieving factors . Asked about associated symptoms , especially : - Nausea and vomiting - Sweating - Fever - Coughing - Shortness of breath - Palpitations - Syncope and dizziness Past medical /family/social history . Asked about similar episodes in the past . Asked about past ,medical issue (especially high blood pressure , heart problems , diabetes , heart burn/reflux), hospitalizations , and surgeries . Asked about current medications and medication allergies . Asked about family health . Asked about tobacco , alcohol , and recreational drug use . Asked about occupation and stress in life . Asked about cholesterol level (if known) Examination . Washed heads before examination . Examined without gown , not through gown . Examined carotid artery and jugular viens . Examined heart (inspection , palpation , auscultation) . Auscultated the lungs . Examined peripheral pulse and edema . Examined abdomen Counseling . Explained the physical findings and possible diagnosis . Discussed ECG result . Explained further workup . Discussed lifestyle modifications ( especially quitting smoking and moderate alcohol intake). 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 Differential diagnosis . Myocardial infarction . Unstable angina . Pulmonary embolism . Aortic dissection . Gastroesphageal reflux Diagnostic study/studies . Complete blood count . Cardiac markers (eg, troponin) . Electrolytes . blood urea nitrogen, creating , glucose . Chest x-ray . Echocardiogram ————— Case 22 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). . 55-yo man with 2 hours of chest pain described as substernal tightness and pressure and increased  with movement and walking ; pain of 8-9 lb on a scale of 10 , no radiation. . Associated nausea , vomiting , sweating , and shortness of breath ROS : No fever , cough , headache , abdominal pain , diarrhea , constipation , recent trauma, appetite change , weight loss , or urinary problems PMHx : HTN , diabetes , hight cholesterol PSHx : None Meds : lisinpril, metformin Allergies : None FHx: Fateghr died at age 60 of heat attack , motor had a stroke at age 65 , and mother had a heart attack at age 58 SHx: 1 PPF smoker for past 30 years , 1 glass of wine/day for past 20 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 ,. 37.1”C (98.8F) : blood pressure , 130/80 mmHg; pulse , 78/min; and respirations , 20/min . Neck ; Supple without JVD or lymphadenopathy , no thyromegaly . Lungs ; Clear to auscultation bilaterally , no reproducible chest pain to palpation . Heart : RRR without murmurs , gallops , or rubs 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 : Acute contrary syndrome History finding(s) . Substernal chest pain . History of multiple cardiac risk factors . Nausea , vomiting , diaphoreses Physical examination finding(s) . No reproducible chest pain to palpation Diagnosis #2 : Aortic dissection History finding(s) . History of hypertension . substernal pain . Sudden-onset symptoms Physical examination finding(s) . No reproducible chest pain to palpation Diagnosis #3 : Pulmonary embolism History finding(s) . Sudden -onset chest pain . Shortness of breath Physical examination finding(s) . No reproducible chest pain to palpation Diagnostic studies . ECG shows ST depressions in V2-V5 . Chest x-ray . Cardiac enzymes . Echocardiogram -- 作者： JuanFe -- 發表時間： 2018/09/13 07:50am 23 Case 23 scenario ( frequent falls ) Doorway information about patient The patient is a 70-year-old man who comes to the office due to frequent falls. Vital signs . Temperature : 37.1’C (98.7F) . Blood pressure : 130/80 mmHg . Pulse : 78/min . Respirations : 20/min Basic differential diagnosis Neurologic . Cerebellar disease (alcohol, tumor , stroke) . Parkinson disease . Brain tumor . Seizure . Depressed vision Metabolic . Diabetic neuropathy . Hypoglycemia . Thyroid disease Cardiovascular . Valvular disease Miscellaneous . Medication side effect . Vitamin B12 deficiency . Vertigo ————— Case 23 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 70-year-old man who comes to the clinic due to frequent falls. History of present illness . Several falls over he last 2 months . Initially once a week , now twice a week . Decreased balance while standing . No major injury/fracture but you are concerned that you may develop one . Also have tremor that makes it difficult to hold things ; worse when reaching for an object . Headache in the morning . Friend said you speech is different Review of systems . No weakness , numbness , or tingling in arms or legs . No dizziness/vertigo . No fever . No chest pain . No nausea , vomiting , diarrhea , constipation , or abdominal pain . No urinary symptoms . No sin or hear changes Past medical history . Diabetes for last 10 years (under good control) . No surgires . Medications : Metformin 500mg twice a day . No allergies . Father and mother both died of”old age”; no siblings . Retired machinist . Widower (wife passed away 5 years ago), live alone . Tobacco : No . Alcohol : 2 beers a day for 40 years . Recreational drugs : No Physical examination HEENT: . Visual acuity and visual fields normal Neck : . Supple without IVD or lymphadenopathy . No thyromegaly . No bruits Lungs : . Clear to auscultation bilaterally Heart : . Regular rate and rhythm . No murmurs , gallops , or rubs Neurologic : . Motor 5/5 bilaterally . Sensory grossly intact bilaterally . Resting tremor . Mild dysmetria (finger to nose ) present . Mild dysdiadochokinesia (alternating movements) . DTR2+ bilaterally ————— Case 23 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 and frequent of falls . Asked about any injury associated with falls . Asked about loss of consciousness . Asked about any difficult in initiating , controlling , stopping movements . Asked about progression of the problem . Asked about associated symptoms: - Tremors - Headache - Nausea /vomiting, bowel problem - Fever - Palpations and syncope - Thyroid symptoms(eg, temperature intolerance , skin or hear changes) - Changes in appetite or weight - Problems with speech or memory - Problems wit attention or calculation - urinary problem . Asked abort living conditions and support systems 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 about tobacco, alcohol , and recreational drug use . Asked about occupation Examination . Washed heads before examination . Examined without gown , not through gown . Checked orthostatic vital signs . Examined eyes . Examined heart and lungs . Performed mini-mental status exam . Examined touch , pain , and temperature sensations in legs add hands . Tested muscle power in limbs . Tested for muscle tone/rigidity . Asked you to get up and walk and turn around and sit again (“ Get up and go “ test) . Performed finger nose test . Performed alternating movements test . Performed Romberg test . Checked reflexes Counseling . Explained the 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 Differential diagnosis . Cerebellar disease . Parkinson disease . Diabetic neuropathy . Brain tumor . Thyroid disease . Vitamin B12 deficiency Diagnostic study/studies . CBC with differential . CT or MRI of brain . Serum electrolytes, glucose, creatinine . Hemoglobin A1c . ECG . TSH ————— Case 23 clinical summary Clinical Skills Evaluation Case 23 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). . 70-yo man with 2 months of frequent fall . Balanced problems while standing up ; no syncope . Tremor in hands worse when reaching for objects. . Change in speech , occasional morning headache. . No sensory symptoms (numbness , tingling) in legs. . No dizziness or vertigo ROS : No fever , nausea , hair loss, chest pin , abdominal , pain , recent trauma, diarrhea , constipation , or urinary problems PMHx : Diabetes PSHx : None Meds : Metformin 500 mg BID Allergies : None FHx : Father and mother both fiddled of old age SHx : No smoking , 2 beers daily for past 40 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 , 37.1’C (98.8F) ; blood pressure , 130/80 mmHg ; pulse , 78/min ; and respirations , 20 /min . HEENT : PERRLA , EOMI , normla visual acuity . Neck : Supple without JVD or lymphadenopathy , no thyromegaly , no bruits . Lungs : Clear to auscultation bilaterally . Heart : RRR without murmurs, gallops , and rubs . Neurologic ; Motor 5/5 bilaterally , sensory grossly intact bilaterally , resting tremor , mild dysmetria (finger to nose) , mild dysdiadochokinesia (alternating movements) , DTR 2+ bilaterally 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 : Cerebellar disease due to alcohol use History finding(s) . History of chronic alcohol use . Difficulty with balance Physical examination finding(s) . Dysmetria . Disdiadochokineasia Diagnosis #2 : Parkinson disease History finding(s) . Tremor . Balance problems Physical examination finding(s) . Resting tremor Diagnosis #3 : Brain tumor History finding(s) . Speech difficulties, headache . Balance problems . 2 months of symptoms Physical examination finding(s) . None Diagnostic studies . Orthostatic vitals . Brain imaging (CT scan or MRI) . Basic metabolic panel . Thyroid function tests; vitamin B 12 levels . Complete blood count -- 作者： JuanFe -- 發表時間： 2018/09/13 07:51am 24 Case 24 scenario ( cough and chest pain ) Doorway information about patient The patient is a 35-year-old man who comes to the office due to cough and chest pain. Vital signs . Temperature L 38.7’C (101.7F) . Blood pressure : 130/80 mmHg . Pulse ; 94/min . Respirations : 24/min Basic differential diagnosis . Pneumonia . Pleuretic pain . Pleural effusion . Pulmonary edema . Tuberculosis . Pulmonary embolism . Lung cancer . Infective endocarditis . GERD ————— Case 24 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 man who comes to the clinic due to a cough History of present illness . Onset 2 days ago . Started with “ feeling tired and sick” . Productive cough with yellow sputum and blood streaks . Sharp pain 5-6/10 severity at left chest ; worse with moving and any deep breath and better with exhalation . Associated symptoms : - Fever - Chills - Sweating - Mild shortness of breath . Exposure to “ pneumonia “ form a colleague at work Ask the doctor : “ Do I have pneumonia too?” Review of systems . No changes in appetite . No weight loss . No abdominal pain . No recent trauma . No diarrhea or constipation . No urinary symptoms Past medical / family / social history . Hospitalized once for chest pain 5 years ago with negative testing . No surgieres . No medications . Allergies : Penicillin (rash) . Father and mother are both healthy ; no siblings . Occupations ; Investment advisor . Tobacco : 1 pack a day for 15 years . Alcohol : often go out with friends on weekends and drink average of 2 shot of liquor . Recreational drugs : No Physical examination HEENT : . Oropharynx clear Neck : . Supple without JVD and lymphadenopathy . No thyromegaly . No bruits . No accessory muscle use Lungs : . Clear to auscultation bilaterally . Fremitus symmetrical bilaterally . Resonant to percussion bilaterally . No bronchophony or egophony Heart : . Regular rate and rhythm . No murmurs ,  gallops,  or rubs Abdomen : . Non-Tender, non-distended . No hepatosplenomegaly . Normative bowel sounds ————— Case 24 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 location and radiation of pain . Asked about the intensity of pain . Asked about the quality of pain . Asked about the onset and duration of pain . Asked about the course of pain one time . Asked about any aggravating or relieving factors . Asked about associated symptoms , especially : - Vomiting - Fever - Coughing( and details of expectoration) - Shortness of breath - Hemoptysis - Change in appetite Past medical /family/social history . Asked about similar episodes in the past . Asked about past medical issues ( especially lung problems) , 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 sexual history . Asked about occupation Examination . Washed heads before examination . Examined without gown , not through gown’ . Inspected neck , accessory muscles of respiration , and jugular views . Examined heart : inspection , palpation , auscultation . Examined lungs including: - Inspection of lung inflation - Anterior and posterior auscultation - Percussion - Tests for consolidation (tactile fremitus ,, egophony) . Palpated abdomen for splenomegaly and hepatomegaly Counseling . Explained the physical findings and possible diagnosis . Explained further workup . Discussed quitting smoking 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 Differential diagnosis . Pneumonia . Pleuritic pain . Pleural effusion . Pericarditis . Lung cancer Diagnostic study/studies . CBC with differential count . Sputum Gram stain, C/S . ECG . Chest x-ray . Blood culture ————— Case 24 clinical summary Clinical Skills Evaluation Case 24 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 man with 2 days go product cough of yellow , blood-tinged sputum . 2 dash pf sharp . left-sided chest pain worse with inspiration and improved with expiration. . Fever . chills , sweating , and mild shortness of breath . Sick contact in office ROS : No changes in appetite our weight , abdominal pain, recent trauma , diarrhea , constipation , or urinary problems PMHx : None PSHx : None Meds : None Allergies ; Penicillin (rash) FHx : Father and mother are healthy SHx : 1 PPD smoker for past 15 tears , 2 shots a week for past 10 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 , 38.7’C(101.7F) ; blood pressure , 130/80 mmHg ; pulse , 94/min ; and respirations , 24/min . HEENT ; Oropharynx clear . Neck : Supple without JVD or lymphadenopathy , no thyromegaly, no bruits , no accessory muscle use . Lungs ; clear to auscultation bilaterally , fremitus symmetrical bilaterally , resonant to percussion bilaterally , no brochophony or egophony . Heart : RRR without murmurs, gallops, our rubs . Abdomen : Non-tender , non-distended , no hepatopslenomegaly , normative 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 : Acute bronchitis History finding(s) . Smoking history . Fever . Cough productive of yellow , blood-tinged sputum Physical examination finding(s) . Fever Diagnosis #2 : Pneumonia History finding(s) . Fever and chills . Cough productive of yellow, blood-tinged sputum . Pleuritic chest pain . Sick contact at office Physical examination finding(s) . Fever . Respirations , 24/min Diagnosis #3 : Lung cancer History finding(s) . Smoking history . Cough productive of blood-tinged sputum Physical examination finding(s) . None Diagnostic studies . Chest x-ray . Sputum Gram stain and culture . CBC with differential -- 作者： JuanFe -- 發表時間： 2018/09/13 07:52am 25 Case 25 scenario ( lower abdominal pain ) Doorway information about patient The parents is 60-year-old man who comes to the emergency department due to lower abdominal pain Vital signs . Temperature : 38.3’C (101F) . Blood pressure : 130/84 mmHg . Pulse : 98/min . Respirations : 22/min Basic differential diagnosis . Diverticulitis . Renal colic . Appendicitis . Ischemic colitis . Infectious colitis . Abdominal aortic aneurysm . Intestinal obstruction ————— Case 25 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 60-year-old man who comes to the emergency department with lower abdominal pain History of present illness . The pain onset was 1 day ago after eating at a restaurant with family . Pain is located at lower abdomen with no radiation . 6/10 severity , progressively with no radiation . Episodic (10-15 minute episodes ) . crampy pain . No aggravated or alleviating factors . Associated symptoms - 1 episode non bilious , non bloody vomiting - You did not check temperature but feel “ a little feverish’ - 2-3 episodes of diarrhea with visible blood (no black stools) . No family members with symptoms . No recent travel or sick contact Do not volunteer this information unless asked : Review of systems . No chills . No urinary symptoms Past medical / family / social history . Hospitalized once 10 years ago for kidney stone that passed spontaneously . Hypertension . No surgeries . Medications : Hydrochlorothiazide 25 mg daily . No allergies . Father died at 65 of colon cancer ; mother died at 70 of breath cancer ; no siblings . Occupation : Financial planner . Married , live with wife . Tobacco : No . Alcohol : 1 beer a day for past 30 years . Recreational drugs : No Physical examination Heart : . Regular rate and rhythm . No murmurs , gallops , or rubs Abdomen : . LLQ tenderness to deep palpation , no rebound tenderness . Non-distended . No hepatosplenomegaly . Normative bowel sounds . No CVA tenderness ————— Case 25 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 location and radiation of pain . Asked about the intensity of pain . Asked about the quality of pain . Asked about the onset and duration of pain . Asked about the progression of pain . Asked about any aggravating or relieving factors . Asked about associated symptoms , especially : - Nausea and vomiting - Fever and chills - Changes in appetite and weight - Bowel problems (constipation and diarrhea) - Blood in the stool or black stood - Urinary symptoms . Asked bout recent travel and contaminated food ingestion . Asked about recent antibiotic use Past medical /family/social history . Asked about similar episodes in the past . Asked about past medical issues , hospitalizations ,ad surgeries (especially abdominal surgeries) . Asked about current medications . Asked about medication allergies . Asked about family health . Asked about tobacco , alcohol , and recreational drug use Examination . Washed heads before examination . Examined without gown , not through gown . Auscultated abdomen . Palpated abdomen . Checked rebound tenderness . Checked for costovertebral angel tenderness . Examined the heart Counseling . Explained physical findings and possible diagnosis . Explained further workup . Discussed need to perform 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 Differential diagnosis . Diverticulitis . Renal colic . Intestinal obstruction . Infectious colitis . Ischemic colitis Diagnostic study/studies . Rectal examination , genital examination . CBC with differential count . Electrolytes , glucose , BUN , creatinine . Urinalysis . ECG . Abdomen x-ray . CT scan of the abdomen and pelvis ————— Case 25 clinical summary Clinical Skills Evaluation Case 25 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 1 day of episodic , crapmy LLQ abdominal pain lasting 10-15 minutes each time ; no radiation. . Pian is 6/10 . Ate at a local restaurant with family , but no one else is sick . Nausea ,  1 episode of vomiting , 2-3 episodes of diarrhea with blood , subjective fever ROS :  no recent travel , sick contact , chills , or urinary problems PMHx : HTN , kidney stone in past PSHx : None Meds : Hydrochlorothiazide 25 mg daily Allergies ; None FHx : Father died at age 65 of colon cancer ; mother died at age 70 of breast cancer SHx : No smoking , 1 beer daily for past 30 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 , 38.3’C (100.9F) ; blood pressure , 130/84 mmHg; pulse , 98/min; and respirations , 22/min . Heart : RRR without murmurs , gallops , or rubs . Abdomen : LLQ tenderness to deep palpation , no rebound tenderness , non distended , no hepatosplenomegaly , normative bowel sounds , no CVA tenderness 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 : Acute diverticulitis History finding(s) . Abdominal pain . Fever . Diarrhea with blood Physical examination finding(s) . Fever . LLQ abdomen tender to palpation Diagnosis #2 : Infectious colitis History finding(s) . Fever . Ate at local restaurant before symptom onset . Diarrhea with blood Physical examination finding(s) . Fever . Abdomen tender to palpation Diagnosis #3 : Ischemic colitis History finding(s) . History of hypertension . Fever . Abdominal pain Physical examination finding(s) . Fever Diagnostic studies . Rectal examination with stool guaiac . Abdominal imaging (x-ray, CT scan) . CBC with differential . Urinalysis -- 作者： JuanFe -- 發表時間： 2018/09/13 07:52am 26 Case 26 scenario ( fatigue ) Doorway information about patient The patient is a 35-year-old man who comes to the office due to fatigue Vital signs . Temperature : 37’C (98.6F) . Blood pressure : 120/80 mmHg . Pulse : 82/min . Respirations : 16/min Basic differential diagnosis . Depression . Anemia . Thyroid disorder . Chronic fatigue syndrome ————— Case 26 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 man who comes to the office due to fatigue History of present illness . Onset 2 months ago . Previously well until victim of robbery . Tired during the day with constant anxiety and impaired concentration . Difficulty falling asleep at night with frequent nightmare . You have cut back on daily activities and feel emotionally distant and lonely . No other significant stress at work or home Do not volunteer this information unless asked : Review of systems . No shortness of breath . No palpations . No seating , fever , or chills . No weight loss . No change in appetite Past medical / family / social history . No significant illness , surgeries , or hospitalizations . No medications . No allergies . Immediate family members are all healthy . Live with girlfriend . Occupation : Florist . Tobacco : 1 pack a day for last 15 years . Alcohol : Social occasions only . Recreational drugs : No Physical examination HEENT . No pallor . Oropharynx clear Neck . Supple without lymphadenopathy . No thyromegaly Heart . Regular rate and rhythm . No murmurs, gallops, or rubs Lungs : . Clear to auscultation Abdomen : . No masses or tenderness Psychiatric . Alert and oriented to person , place , and time ————— Case 26 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 onset of symptoms . Asked about severity and change over time . Asked if you are having difficulty falling or staying asleep . Asked nightmares . Asked if you had any traumatic events recently . Asked about feeling of guilt . Asked about suicidal intentions . Asked if you have been feeling lonely . Asked about anxiety . Asked about associated symptoms , especially - Palpitations - Dizziness - Sweating - Tremors - Changes in appetite or weight - Shortness of breath - Swelling /limps in neck - Changes in bowel or bladder habits . Asked about stress at work or home 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 about occupation . Asked bout tobacco , alcohol , and recreational; drug use . Asked about sexual history Examination . Washed heads before examination . Examined without gown , not through gown . Examined oral mucous membranes for pallor . Palpated neck for masses or swelling . Checked memory , orientation , and judgement Counseling . Explained physical findings and possible diagnosis . Explained further workup . Offered to help and support while getting treated . Discussed the importance of quitting smoking and offered help 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 Differential diagnosis . Post-Traumatic stress disorder/anxiety disorder . Depression . Hypothyroidism . Occult medical disease Diagnostic study/studies . CBC with differential . TSH . Electrolytes , glucose , BUN , Creatinine . HIV test ————— Case 26 clinical summary Clinical Skills Evaluation Case 26 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 man with 2 months of fatigue after robbery . Insomnia increased daytime fatigue , nightmares every night , generalized anxiety throughout the day , and inability to concentrate at work . Feels emotionally alone and distant , no increased stress at work or home . No hallucinations or delusions. . Constipation for 3-4 months ROS : No shortness of breath , chest pain , palpations , sweating, fever , chills , weight loss, or change in appetite PMHx : None PSHx : None Meds : None Allergies : None FHx : Father , mother , and 3 siblings are healthy SHx : 1 PPD smoker for 15 years , occasional alcohol 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’C (98.6F) ; blood pressure , 120/80 mmHg;pulse , 82/min; and respirations , 16/min . HEENT : No pallor , oropharynx car . Neck : Supple without lymphadenopathy or thyromegaly . Heart : RRR without murmurs, gallops, or rubs . Lungs ; Clear to auscultation . Abdomen ; no masses or tenderness . Psychiatric : Alert and oriented to person , place,and time 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 : Post-traumatic stress disorder History finding(s) . Symptom onset after robbery 2 months ago . Insomnia . Difficulty concentrating , nightmares Physical examination finding(s) . None Diagnosis #2 : Depression History finding(s) . Fatigue . Insomnia . Feels alone and distant Physical examination finding(s) . None Diagnosis #3 : Hypothyroidism History finding(s) . Constipation for 3-4 months . Fatigue . Inability to concentrate at work and home Physical examination finding(s) . None Diagnostic studies . TSH . CBC with differential . Electrolytes, glucose, BUN , creatinine . HIV test -- 作者： JuanFe -- 發表時間： 2018/09/13 07:53am 27 Case 27 scenario ( loss of hearing ) Doorway information about patient The patient is a 65-year-old woman who comes to the office due to loss of hearing Vital signs . Temperature ; 36.7’C (98.1F) . Blood pressure : 130/86 mmhm . Pulse ; 80 /min . Respirations : 16/min Basic differential diagnosis conductive hearing loss . Cerumen impaction . Otitis media with effusion . Tympanic membrane perforation . Otosclerosis . Foreign body in ear canal . cholseteatoma . Tympanosclerosis . Tumor of the ear canal or middle ear Sensorineural hearing loss . Prescycusis (age-0related hearing loss) . Ototoxicity . Noise-induced hearing loss . Meniere disease . Diabetes . Acoustic neuroma ————— Case 27 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 65-year-old woman who comes to the clinic due to hearing loss History of present illness . 3 months of reduced hearing in the left . Hearing loss was initially mild but is progressively worsening . Has been difficult to hear people with high-pitched voice . No associated pain , ringing in the ear , or discharge from the ear . Admitted to the hospital 4 months ago for a kidney infection and treated with IV antibiotics (you do not recall the name of the drug) Review of systems . No dizziness . No facial muscle weakness . No weakness or numbness i other parts of the body Past medical / family / social history . Hypertension for the last 30 years . No surgires . Medications : Hydrochlorothiazide 50 mg daily . No drug allergies . Father and mother both died of ‘ old age” ; 2 siblings , both healthy . Occupations ; Supervisor at a steel factory (If the examinee specifically asks about the noise exposure , say “ there is a lot of noise every day at work.”) . Married , live with husband . Tobacco : No . Alcohol : Occasional beer or wine . Recreational drugs : No Physical examination HEENT : . PERRLA , EOMI . Oropharynx clear . Tympanic membrane clear bilaterally . Rinne test : Air conduction > bone conduction bilaterally . Weber test ; localizes to the right ear Neck: . Supple . No lymphadenopathy . Thyroid normal Neurologic: . Alert and oriental to person , place , and time . Cranial nerves 2-12 intact , except for decreased hearing in the left ear ————— Case 27 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 which ear is affected (right , left , bilateral) . Asked about the onset of symptoms . Asked about the course of symptoms over time . Asked about the subjective severity of hearing loss(mild , moderate , severe , profound) . Asked about the possible initiating events . Asked about associated symptoms , especially: - Earache - Tinnitus - Vertigo - Aural fullness - Drainage from the ear . Asked about any occupational exposure to noise . Asked about trauma to the ear . Asked about the social impact that it was had Past medical /family/social history . Asked about any similar episodes in the past . Asked about past medical issues (especially ear. nose. throat and neurologic disorders ) ,hospitalizations , and surgeries . Asked about current (and recent0 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 eye movements and pupillary reflexes . Examined facial sensation and motor function (eg , show teeth , puff out cheeks , stick out tongue) . Examined external ear and ear canal ( with otoscope) . Tested hearing , including Rinne and Weber tests 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 Differential diagnosis . Presbycusis . Occupational exposure . Ceremony impaction . Drug induced Diagnostic study/studies . Serum electrolytes and blood sugar . Audiometry . MRI of the brain ————— Case 27 clinical summary Clinical Skills Evaluation Case 27 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). . 65-yo woman with 3 moths of heigh-frequency hearing loss . Hospitalized for pyelonephritis 4 months ago and treated with unknown antibiotic. . Exposure to loud noises at work in steel factory. ROS : No discharge from ear , ringing in ear , dizziness , facial muscle weakness , weakness or numbness in other parts of the body , or earache PMHx : HTN PSHx : None Meds : Hydrochlorothiazide 50 mg daily Allergies : None FHx : Father and mother died of old age , healthy siblings SHx : No smoking , occasional alcohol 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 , 36.7’C (98.1F) ; blood pressure , 130/86 mmHg; pulse , 80/min; and respirations , 16/min . HEENT : PERRLA , EOMI , oropharynx clear , TMs clear bilaterally , Rinne test with AC>BC , Weber test localization to the right ear , oropharynx clear . Neck l Supple without lymphadenopathy or thyromegaly . Neurologic : Alert and oriented to person , place , and time ; cranial nerves II-XII intact except for decreased hearing in left ear 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 : Presbycusis (age-related hearing loss) History finding(s) . Decreased hearing for 2-3 months . High-Frequency hearing loss Physical examination finding(s) . Weber test localization to right ear Diagnosis #2 : Noise-induced hearing loss History finding(s) . Decreased hearing . Work at still factory with loud noise Physical examination finding(s) . Weber test localization to right ear Diagnosis #3 : Drug-induced hearing loss History finding(s) . History of recent antibiotic use Physical examination finding(s) . Weber test localization to right ear Diagnostic studies . Audiometric testing . Electrolytes and blood sugar . MRI of brain -- 作者： JuanFe -- 發表時間： 2018/09/13 07:53am Case 28 scenario ( knee pain ) Doorway information about patient The patient is a 53-year-old man who comes to the emergency department due to right knee pain and swelling. Vital signs . Temperature ; 38.3’C (101F) . Blood pressure : 130/60/mmHg . Pulse : 80/min . aspirations : 18/min Basic differential diagnosis . Osteoarthritis . Septic arthritis and bursitis . Pseudogout and gout . Reactive arthritis . Traumatic knee injury . Lyme disease . Monoarticular rheumatoid arthritis . Psoriatic arthritis ————— Case 28 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 with right knee pain History of present illness . 2 days of worsening right knee pain . Throbbing pain , 7/10 severity . No radiation of pain . no relief with ibuprofen . No recent trauma . Chronic bilateral knee pain starting a year ago that is worse with walking and thought to be due to being overweight . Stiffness in multiple joints every morning for 10-15 minute that resolves spontaneously . No other aggravating or relieving factors Do not volunteer this information unless asked : Review of systems . No fever or chills . No nausea , vomiting , diarrhea , or constipation . No rash . No recent travel or sick contacts . No inset bite . No urinary symptoms Past medical / family / social history . Hypertension for the past 10 years . No surgeries or hospitalizations . Medications ; Hydrochlorothiazide 25 mg daily ; ibuprofen 600 mg up to 3 times a day as needed . Medication allergies : None . Father as hypertension and mother has pseudo gout ; no siblings . Occupation : Librarian . Married , live with wife . Tobacco : none . Alcohol ; 1 or 2 beers on social occasions . Recreational drugs ; None Physical examination HEENT : . PERRLA , EOMI . No conjunctival abnormalities Heart : . Regular rate and rhythm . No murmurs , gallops , or rubs Musculoskeletal : . Right knee is tender to palpation with decreased range of motion but no redness or warmth . no other joint abnormalities Skin : . No rates or lesions ————— Case 28 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 bout the course of pain over time . Asked about the intensity of pain . Asked about the quality of pain . Asked about the location of pain . Asked about any radiation of pain . Asked about any aggravating or relieving factors . Asked about associated symptoms , especially : - Fever - Joint swelling - Joint redness - Rash . Asked about history of trauma to the joint . Asked about morning stiffness . Asked about history of travel (especially areas with endemic Lyme disease) . Asked about any rennet ticks bites . Asked about any pain and swelling in the other joints . Asked about nay recent history of febrile illness . Asked about any eye symptoms Past medical /family/social history . Asked about similar episodes in the past or other joint problems . Asked about past medical issue , surgeries , and hospitalizations . Asked about current medications . Asked about medication allergies . Asked about family health (especially joint disorders) . Asked bout tobacco , alcohol , and recreational drug use . Asked about occupation . Asked about living situation and sexual contacts Examination . Washed heads before examination . Examined without gown , not through gown . Checked knee for range of motion . Checked other joints for swelling and redness . Auscultated heart . Examined eyes . Examined skin for washed or painful nodules 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 Differential diagnosis . Osteoarthritis . Septic arthritis or bursitis . Pseudo gout , gout . Inflammatory (eg, rheumatoid ) arhritis Diagnostic study/studies . CBC with differential . Joint aspiration . X-ray of knee . Sedimentation rate or C-reactive protein , antinuclear antibody, rheumatoid factor or cyclic citrullinated peptide antibodies . MRI of joint . Lyme serology (if travel to endemic area) The following points should be addressed for traumatic knee pain: . Asked what you were doing at the time of injury . Asked about mechanism of injury . Asked bout any noise or popping sensations at the time of injury . Asked whether you can bear weight and whether the knee is unstable with walking . Asked about locking of joint . Performed Lachman maneuver or drawer test . Performed McMurray maneuver ————— Case 28 clinical summary Clinical Skills Evaluation Case 28 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 1 year of bilateral knee pain , now with 2 days of worsening right knee pain described as throbbing and constant . Pain is 7/10 , no relief with ibuprofen . 15-20 minute of morning stiffness in multiple joints each day that resolves spontaneously. . No H/O trauma ROS : No fever , chills , nausea , vomiting , diarrhea , constipation , rashes , travel history , sick contacts , insect bites , or urinary issue PMHx : HTN for 10 years PSHx : None Meds : Hydrochlorothiazide 25mg  daily , ibuprofen 600mg as needed Allergies : None FHx : Father has hypertension ; mother has pseudogout SHx : No smoking , occasional alcohol 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 , 130/60 mmHg; pulse , 80/min; and respirations , 18/min . HEENT : PERRLA , EOMI , no conjunctival hemorrhage . Heart : RRR without murmurs , gallops , or rubs . Musculoskeletal : Tender right knee , decreased ROM , no swelling or warmth , no other joint deformities . Skin ; No rashes or lesions 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 : Osteoarthritis flare History finding(s) . History of chronic knee pain . Acute worsening of right knee pain Physical examination finding(s) . Decreased ROM in right knee Diagnosis #2 : Septic joints History finding(s) . Acute-onset right knee pain Physical examination finding(s) . Fever . Decreased ROM in right knee Diagnosis #3 : Acute crystal arthritis (Gout or pseudogout ) History finding(s) . History of diuretic use . Acute-onset right knee pain . Family history of pseudogout Physical examination finding(s) . Fever . Decreased ROM in right knee Diagnostic studies . Right knee arthrocentesis . Right knee x-ray . ESR . CBC with differential -- 作者： JuanFe -- 發表時間： 2018/09/13 07:54am 29 Case 29 scenario ( blurred vision ) Doorway information about patient The patient is a 50-year-old man who comes to the office due to blurred vision Vital signs . Temperature : 36.7’C (98.1F) . Blood pressure : 160/90 mmHg . Pulse : 70/min . Respirations : 22/min Basic differential diagnosis . Diabetes mellitus . Cataract . Hypertensive retinopathy . Glaucoma . Macular degeneration . Brain lesion . Hyperviscosity syndorme (eg, polycythemia) . Illicit drugs . Temporal arthritis (usually starts unilaterally) . Trauma to or infections of the eye (if unilateral) ————— Case 29 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 50-year-old man who comes to the office due to blurry vision History of present illness . Onset 2 month ago . Objects are becoming increasingly blurry with no halos around them . No headache , eye pain , or eye discharge . Over-the -counter reading glasses have made only minimal improvement . Last physician visit was 10 years ago Do not volunteer this information unless asked : Review of systems . 10-lb weight loss . Increased appetite , thirst , and urination . No nausea or vomiting . No muscle weakness . No dizziness or loss pf consciousness . No numbness or tingling in the extremities Past medical / family / social history . No prior ,medical issue , surgeries , or hospitalizations . Medications : None . No medication allergies . Father has hypertension and motor has diabetes(you have no siblings) . Married;live with wife . Occupation ;Truck driver . Tobacco ; 1 pack a day for the last 30 years . Alcohol : Occasional beer . Recreational drugs : None Physical examination HEENT : . PERRLA , EOMI . Funds show no hemorrhage or AV nicking Neck : . Supple . No lymphadenopathy or thyromegaly . No bruits Heart : . Regular rate and rhythm without murmurs , gallops, or rubs Extremities : . Pulse 2+ in bilateral lower extremities Neurologic : . Motor strength 5/5 bilaterally . Sensation grossly intact bilaterally ————— Case 29 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 symptoms . Asked whether symptoms were in 1 or both eyes . Asked about the severity and course over time , Asked about the eye discharge . Asked about halos around the light . Asked about eye pain . Asked about any headache . Asked about nausea and vomiting . Asked bout any weakness or sensory changes in the areas and legs . Asked about excessive thirst and urination . Asked about changes in the appetite and weight Past medical /family/social history . Asked about similar episodes in the past . Asked about past medical issues (especially diabetes and hypertension) . Asked about current medications . Asked about medication allergies . Asked about family health . Asked bout tobacco , alcohol , and recreational drug use . Asked bout occupation Examination . Washed heads before examination . Examined without gown , not through gown . Examined eyes , including extra ocular movements , pupillary reflexes , and ophthalmoscope examination . Did a neurological examination with emphasis on sensory examination . Auscultated heart and carotid arteries . Examined peripheral pulses Counseling . Explained physical findings and possible diagnosis (especially diabetes) . Discussed dietary changes and weight reduction . Explained further evaluation 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 Differential diagnosis . Diabetic retinopathy and /or diabetes osmotic changes in the lens . Hypertensive retinopathy . Cataracts . Glaucoma . Macular degeneration Diagnostic study/studies . Fasting blood glucose and /or hemoglobin A1c . Urinalysis for microscopic proteinuria . Lipid profile . Carotid ultrasound ————— Case 29 clinical summary Clinical Skills Evaluation Case 29 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). . 50-yo man with 2 months of blurry vision , polyuria , polydipsia , polyphagia , and 4.5-kg (10-lb ) weight loss . Has not seen a doctor in 10 years . Objects blurry without complete loss of vision or halos around it ROS : No nausea , vomiting , headache , arm/leg weakness , eye discharge , eye pain , dizziness , loss of consciousness, or numbness or tingling in the extremities PMHx : None PSHx : None Meds : none Allergies : None FHx : Father has hypertension , mother has diabetes SHx : 1 PPD smoker for past 30 years , occasional alcohol 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 , 36.7”C(98.1F) ; blood pressure , 160/90 mmHg; pulse , 70/min; and respirations , 16/min . HEENT : PERRLA , EOMI < funds without hemorrhages or AV nicking . Neck : Supple without lymphadenopathy , thyromegaly, or bruits . Extremities : Pulses 2+ in bilateral lower extremities . Neurologic : Motor 5/5 bilaterally , sensory grossly intact bilaterally 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 : Diabetic retinopoathy History finding(s) . Polyuria , polydipsia , polyphagia . Weight loss . Blurry vision Physical examination finding(s) . None Diagnosis #2 : Hypertension retinopathy History finding(s) . Blurry vision Physical examination finding(s) . BP 160/90 mmHg Diagnosis #3 : Glaucoma History finding(s) . Decreased vision Physical examination finding(s) . None Diagnostic studies . Fasting blood glucose and hemoglobin A1c . Eye examination to mesure pressure . Lipid profile . CBC with differential -- 作者： JuanFe -- 發表時間： 2018/09/13 07:55am 30 Case 30 scenario ( multiple bruises ) Doorway information about patient The patient is a 32-year-old woman who comes to the emergency department due to multiple bruises Vital signs . Temperature : 37.4’C(99.3F) . Blood pressure : 120/80 mmHg . Pulse : 90/min . Respiration : 16/min Basic differential diagnosis . Accident . Physical assault . Spousal abuse . Bleeding disorders . Collagen vascular disorders ————— Case 30 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 32-year-old woman who is brought to the emergency department by your husband due to bruises History of present illness . Bruises on the right are between the shoulder and elbow . When asked how you sustained the injury , say , “ My husband told me that I fell down the stairs” . If the examinee asks for further clarification, say that you have been hit by your husband . Husband hits you whenever he has a “ rage episode “ - usually once a week . He dose not hit your children , although they are afraid to go near him wen he has a rage episode . Husband is an alcoholic , and he almost always has a bottle of bourbon by his side . Both of your parents live in the same town as you do but they are not aware of the abuse . You feel that your husband loves you; you love your husband , but are always on edge when he is around and you do not feel safe . There have been 2 episodes when you thought height kill you (there is a shotgun in the house and you are afraid he might use it) . You feel that it would be very difficult for you to leave him . You have never reported the matter to any government of social agency and of not with to do so . You have a satisfying sexual relationship with him , and you are monogamous . If the examinee explains that you need not endure such a relationship in which you are always in mortal fear, say that you will think about reporting it to the social welfare agencies and ask for an emergency contact number for the emergency department Past medical / family / social history . No prior medical problems . No medications . No drug allergies . Mother and father are healthy . Married 7 years , live with spouse . 2 children , bout age 6 and girl age 5 . Tobacco: No . Alcohol : No . Recreational drugs : No Physical examination Multiple bruises at right upper arm in various stages f healing . Examination is otherwise normal. ————— Case 30 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 how the injuries occurred . Asked an open-ended question regarding the abuse . Asked this happens regularly . Asked how you feel about your husband . Asked how your husband feels about you . Asked if you feel safe at home . Asked if there are nay weapons at home . Asked about your sexual relationship with your husband . Asked if you had emergency plan to leave the house if the need were to arise . Asked bout any other injuries that you had . Asked if your daily is aware that you are being abused . Asked about your husband’s alcoholism . Asked about child abuse at home Past medical /family/social history . Asked about past medical issues , hospitalizations , and surgeries . Asked about current medications . Asked about allergies . Asked about tobacco , alcohol , and recreational drug use . Asked about sexual history . Asked about occupation . Asked about personal supports (eg, friends, family) Examination . Washed heads before examination . Examined without gown , not through gown . Examined shoulder and elbow on affected side . Check for the injuries Counseling . Explained physical findings . Explained further workup(eg,x-ray) . Discussed the need for an emergency action plan . Discussed finding additional support groups in the community . Gave you emergency contact number and offered ongoing 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 . If husband is present , discussed the need to ask additional questions privately . Did not pressure you to leave your husband , report abuse to authorities , or take additional actions you did not want to take . Listened to what you said without interrupting me . Used plain English rather than technical jargon . Used appropriate transition sentences . Used appropriate draping techniques . Expressed empathy and gave appropriate reassurances . Asked whether you have any concerns/questions Differential diagnosis . Spousal abuse Diagnostic study/studies . X-ray in involved area(s) ————— Case 30 clinical summary Clinical Skills Evaluation Case 30 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). . 32-yo woman with bruises on the right upper extremity . caused by multiple incidence of altercation/ abuse by her husband . Husband has frequent “ rage episodes : associated with alcohol abuse . Patient has not reported abuse to civil authorities of family member ROS : Negative PMHx : Noncontributory PSHx : None Meds : None Allergies : None FHx : Mother and father are healthy SHx : Married 7 years , lives with spouse and 2 children ; no tobacco , alcohol , or illicit 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 , 37.4’C (99.3F) ; blood pressure ,120/80 mmHg; pulse , 90/min; and respirations , 16/min . HEENT : PERRLA , EOMI , normal ENT examination , no head trauma . Neck : No visible injuries . Musculoskeletal ; Multiple bruises in various stages of hearing on right upper arm . Neurologic L CN II-XII grossly intact , UE and LE motor strength and reflexes normla and symmetric . Psychologic : Awake and alert , affected apprehensive but with appropriate range , clear speech 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 : Intimate partner abuse History finding(s) . Recurrent spouse assault . Spouse with history of alcohol abuse Physical examination finding(s) . Multiple bruises in various stages of healing Diagnostic studies . x-rays of shoulder, humerus , and elbow . CBC . PT/PTT/INR -- 作者： JuanFe -- 發表時間： 2018/09/13 07:56am 31 Case 31 scenario ( burning during urination ) Doorway information about patient The patient is a 20-year-old woman who comes to the office due to burning during urination Vital signs . Temperature : 38.3’C (100.9F) . Blood pressure : 110/80 mmHg . Pulse : 82/min . Respirations : 16/min Basic differential diagnosis . Cystitis . Pyelonephritis . Urethritis . Vulvovaginitis . Pelvic inflammatory disease ————— Case 31 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 20-year-old woman who has burning with urination History of present illness . 4 day of burning with urination . Fever to 38.3’C (101F) , chills , and rigors . Urinating 10-12 times a day , sometimes with increased urgency and little urine . Dull , intermittent pain in the lower pelvic area , greenish vaginal discharge , and occasional blood in the urine . Similar episode 1 year ago; diagnosed as chlamydia and treated with doxycycline . Last menstrual period was 2 weeks ago . New sexual partner for the past 2 months . You do not use condoms ad have no pain during intercourse Review of systems . No back pain . No nausea , vomiting , diarrhea , or constipation . No abnormal vaginal bleeding Past medical / family / social history . No otters significant past medical issue or surgeries . Medications ; Oral contraceptive pill . No drug allergies . Father and mother are healthy ; no siblings . Single , lives alone . Occupation: college student . Smoking : No . Alcohol : Occasional heavy drink at parties . Recreational drugs : no Physical examination Abdomen: . Mild suprapubic discomfort with deep palpation . Non-distended , normative bowel sounds . No CVA tenderness ————— Case 31 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 dysuria . Asked about the frequency and urgency . Asked about hematuria . Asked about suprapubic , abdominal , and back pain . Asked about fever and chills . Asked about nausea and vomiting . Asked about vaginal discharge and abdominal vaginal bleeding . Asked bout pain during intercourse . Asked about last menstrual period . Asked bout sexual practices and contraceptive methods 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 about tobacco , alcohol , and recreational drug use . Asked about sexual history . Asked about occupation Examination . Washed heads before examination . Examined without gown , not through gown . Auscultated abdomen . Palpated abdomen (superficial and deep), including suprapubic area . Palpated / percussed back for constoverbral angle tenderness Counseling . Explained physical findings and problems diagnosis . Explained further workup . Explained need for pelvic 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 Differential diagnosis . Cystitis . Pyelonephritis . Urethritis . Vulvovaginitis . Pelvic inflammatory disease Diagnostic study/studies . Pelvic examination . CBC with differential . Urinalysis . Culture of urine . Urine PCR assay for gonorrhea and chlamydia ————— Case 31 clinical summary Clinical Skills Evaluation Case 31 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). . 20-yo woman with 4 days of dysuria , increased urinary frequency and urgency , fever , chills , and an episode of hematuria . New sexual partner 2 months ago with no condom use . Treated for chlamydia cervicitis a year ago with similar symptoms . Intermittent suprapubic pain with green vaginal diachange ROS : No back pain , nausea , vaginal bleeding , pain with intercourse , vomiting , diarrhea , or constipation PMHx : None PSHx : None Meds : Birth control pills Allergies : None FHx : Father and mother are healthy SHx : No smoking , occasion alcohol 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 , 110/80 mmHg ; pulse , 82/min; and respirations , 16/min . Abdomen : Mild suprapubic discomfort on deep palpation , non-distended , normative bowel sounds , no CVA tenderness 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 : Cystitis History finding(s) . Increased urinary frequency and urgency . Fever , chills . Hematuria, dysuria Physical examination finding(s) . Suprapubic discomfort . Fever Diagnosis #2 : Pyelonephritis History finding(s) . Increased urinary frequency and urgency . Fever , chills . Hematuria, dysuria Physical examination finding(s) . Fever Diagnosis #3 : Cervicitis History finding(s) . Fever . Vaginal discharge . New sexual partner with no condom use . History of previous cervicitis Physical examination finding(s) . Fever Diagnostic studies . Pelvic examination . Nucleic acid amplification test for chlamydia and gonorrhea . Urinalysis . Urine culture . CBC with differential -- 作者： JuanFe -- 發表時間： 2018/09/13 07:57am 32 Case 32 scenario ( difficulty swallowing ) Doorway information about patient The patient is a 50-year-old man who comes to the office due to difficulty swallowing Vital signs . Temperature : 36.7’C (98.1F) . Blood pressure ; 130/90 mmHg . Pulse : 85/min . Respirations : 16/min Basic differential diagnosis . Oropharynx dysphagia - Neuromuscular (stroke , parkinsonism , multiple sclerosis) - Mechanical obstruction (Zener diverticulum , thyromegaly) - Skeletal muscle disorders ( myasthenia gravis , muscle dystrophies ,polymyositis) - Miscellaneous (medication ,radiation) . Esophageal dysphagia - Mechanical obstruction (esophageal carcinoma, benign strictures ,webs and rings [Schazki]) - Abnormal motility (achalasia , scleroderma) - Gastroesphageal reflux disease - Miscellaneous (diabetes , alcoholism) ————— Case 32 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 50-year-old man who comes to the clinic due to difficulty swallowing History of present illness . Onset 3 months ago . Initially had difficulty swallowing soils (food would get stuck in the middle of the chest before slowly going down) . Symptoms progressed slowly and now you have had difficulty swallowing liquids for the past 3 weeks . Food regurgitates into the chest 2-3 hours after eating . No problem chewing of transferring food out of the mouth into the throat . 10-lb (4.5kg) weight loss in the past 3 months ; decreased appetite for the past 3 weeks Review of systems . No weakness in the arm or legs . No shortness of breath or chest pain . No nausea , vomiting , diarrhea , or constipation Past medical / family / social history . Gastroseophageal reflux (symptoms 2-3times a week for the past 25 years ; relieved with antacids) . No surgires . No other medications . No drug allergies . Father, mother , and 2 siblings are healthy . Married , live with wife . Occupation : Stockbroker . Tobacco : 1 pack a day for last 30 years . Alcohol : Occasional wine Physical examination ————— Case 32 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 an open-ended question about describing the dysphagia . Asked about the onset and progression over time . Asked bout exact location where food gets stuck . Asked whether the dysphagia is for solid , liquid , or both . Asked which started first( sold or liquids) . Asked whether there is any associated pain . Asked about any aggravating or relieving factors . Asked about episodes of chocking or regurgitation/ aspiration . Asked about any nausea and vomiting . Asked about heartburn / gastroesophageal reflux . Asked about history of ingestion of corrosive materials . Asked about appetite and changes in weight Past medical /family/social history . Asked about similar episodes in the past . Asked about past medical issues . Asked bout medications . Asked about medication allergies . Asked about family health . Asked about occupation . Asked about tobacco , alcohol , and recreational drug use Examination . Washed heads before examination . Examined without gown , not through gown . Palpated neck for swelling . Examined mouth and throat . Gave you water and asked you to swallow . Palpated lymph nodes in neck , axilla , and about the clavicles . Auscultated abdomen . Palpated abdomen(superficial and deep) . Examined heart and lungs Counseling . Explained physical findings and possible diagnosis . Explained further workup . Discussed smoking cessation 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 Differential diagnosis . Carcinoma of the esophagus . Achalasia . Reflux esophagitis . Stricture Diagnostic study/studies . CBC . Esophagram . Esophagogastroduodenoscopy . Chest x-ray ————— Case 32 clinical summary Clinical Skills Evaluation Case 32 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). . 50-yo man with 3 months of dysphagia , initially with solids and now with liquids for the past 3 weeks. . No problem with chewing and transferring food to throat , but feels food getting struck in the middle of the chest . Decreased appetite and 4.-kg (10-lb) weight loss . Food regurgitation 2-3 hours after eating ROS : No weakness in the arms or legs , shortness of  breath , nausea , vomiting , chest pain ,diarrhea , constipation , or urinary problems PMHx : GERD for 25 years ,relieved with OTC antacids PSHx : None Meds : OTC antacids Allergies : None FHx : Father , mother ,  and 2 sibling are healthy SHx ; 1 PPD smoker for 30 years , occasional alcohol 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 : 36.7’C(98.1F) ; blood pressure , 130/90 mmHg; pulse, 80/min; respirations , 16/min . HEENT : Oropharynx clear , difficulty swallowing water . Neck : supple with no lymphadenopathy . Lymph nodes: No axillary or supraclavicular adenopathy . Lungs : Clear to auscultation bilaterally . Heart : RRR with no murmurs , gallops, or rubs . Abdomen : Non-tender , non-distended , normative bowel sounds , no hepatopslenomeagly, no CVA tenderness 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 : Esophageal cancer History finding(s) . Dysphagia with solids and then liquids . Weight loss with decreased appetite . Smoking history Physical examination finding(s) . None Diagnosis #2 : Achalasia History finding(s) . Dysphagia with solids and liquids . Weight loss Physical examination finding(s) . None Diagnosis #3 : Reflux esophagitis / stricture History finding(s) . History of GERD . Food regurgitation 2-3 hours after eating . OTC antacid use Physical examination finding(s) . None Diagnostic studies . Chest-x-ray . Barium swallow . Upper GI endoscopy -- 作者： JuanFe -- 發表時間： 2018/09/13 07:57am 33 Case 33 scenario ( refill medication for HIV ) Doorway information about patient The patient is a 30-year0-old man who comes to the office to refill medications for HIV Vital signs . Temperature : 37.1’C (98.8F) . Blodpressure : 120/75 mmHg . Pulse : 78/min . Respirations : 16/min Basic differential diagnosis . HIV ————— Case 33 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 requesting a refill for your HIV medications History of present illness . Diagnosed with HIV 1 year ago . Your partner at the time terminated the relationship , and you were sad initially but have slowly recovered and currently have a positive outlook . You have been compliant with your medications for the past 6 months . Your CD4 count 3 months ago was 480 with an undetectable viral load Do not volunteer this information unless asked : Review of systems . Normal appetite with no recent change in weight . No fever , chills , or night sweats . No  weakness , numbness , or tingling in the extremities . No chest pain , cough , or shortness of breath . No abdominal pain , diarrhea , or constipation . No genital lesion , urethral discharge , or ruining with urination . No skin lesion or rashes Past medical / family / social history . HIV decided on screening 1 year ago . No prior medical problems . Medications : HARRT medications . Allergies : None . Surgeries : None . Immediate family members (after , mother , sister ) are all healthy . Occupation : Truck driver . Single ; male partners in the past but none in the last year . Tobacco : No . Alcohol : No . Recreational drugs : No Physical examination HEENT : . Oropharynx clear . Fund without papilledema or lesion Neck : . Supple without lymphadenopathy Lungs : . Clear to auscultation bilaterally Heart : . Regular rate and rhythm . No murmurs , gallops , or rubs Abdomen : . Non-tender , non-distended . Normative bowel sounds . No hepatosplenomegaly . No CVA tenderness Extremities : . No edema . No skin rashes ————— Case 33 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 current medication regimen and compliance . Asked about side effects of drugs . Asked about symptoms of possible HIV-related illness - Systemic symptoms (eg , fever , changes in weight ) - Breathing problems (eg, cough , shortness of breath) - Headaches - Eye problems (eg , pain , redness , blurred vision) - Oral ulcers or white patches - Pain of difficulty with swallowing - Skin lesion or rashes - Weakness and sensory symptoms - Abdominal /bowel problems (eg , pain , cause , vomiting , diarrhea) - Urogenital problems (dysuria, lesion) . Asked about  symptoms of depression Past medical /family/social history . Asked about past medical issues . Asked about concurrent medications . Asked about medical allergies . Asked about past hospitalizations and surgeries . Asked about family health . Asked about tobacco , alcohol , and recreational drug use . Asked about sexual history . Asked bout occupation Examination . Washed heads before examination . Examined without gown , not through gown . Examined eyes, ears, nose , and throat . Examined lymph nodes . Examined lungs and heart . Examined sensation in hands and legs . Examined abdomen Counseling . Explained physical findings and possible additional diagnosis(if any) . Explained further workup . Discussed safe sexual practices and use of condoms . Discussed potential complications and how to deal with them . Discussed recommended vaccinations 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 Differential diagnosis . HIV .(if the simulated patient is instructed to report additional symptoms or signs , consider also: Pneumocytis infection , Candida infection, cytomegalovirus retinitis , esophagitis) Diagnostic study/studies . CBC with differential count . Serum chemistry (including hepatic function markers) . CD4 cell count . Viral load (HIV , RNA , PCR) . Chest x-ray ————— Case 33 clinical summary Clinical Skills Evaluation Case 33 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 needing refill of HIV medications . Diagnosed a year ago . Initially felt sad but now has positive outlook . Compliant with medications . No weight loss , normal appetite ROS : No numbness or tingling in the extremities , weakness , chest pain , shortness of breath , abdominal pain . rashes , cough , diarrhea , constipation , genital lesions , fever, chills , or night sweats PMHx : HIV diagnosis a year ago ; 3 months ago , CD4 count was 480/mm3 with undectetable viral load PSHx : None Meds : HAART therapy Allergis : None FHx : Father , mother , and sister are healthy SHx : No tobacco or alcohol 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 , 37.1’C (98.8F) ; blood pressure , 120/75mmHg; pulse , 78/min; and respirations, 16/min . HEENT : Oropharynx clear , fund without papilledema or lesions . Necks ; Supple without lymphadenopathy . Lungs ; Clear to auscultation bilaterally . Heart : Regular rate and rhythm without murmurs , gallops, or rubs . Abdomen ; Non-tender, non-distended , normative bowel sounds , no hepatosplenomegaly, no CVA tenderness . Extremities ; No rash or edema 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 : Chronic HIV History finding(s) . HIV diagnosis a year ago . Recent stable CD4 count and viral load . Complaints with medications Physical examination finding(s) . Normal examination findings Diagnostic studies . CD4 count and viral load . CBC with differential . Liver function tests -- 作者： JuanFe -- 發表時間： 2018/09/13 07:58am 34 Case 34 scenario ( amenorrhea ) Doorway information about patient The patient is a 16-year-old girl who comes to the office due to amenorrhea Vital signs . Temperature : 36.7’C(98.1F) . Blood pressure ; 120/70 mmHg . Pulse : 76/min . Respirations : 16/min Basic differential diagnosis . Pregnancy . Primary amenorrhea - Chromosomal disorders - Abnormal mullerian development - Androgen insensitive . Secondary amenorrhea - Eating disorder - Hyperprolactinemia - Thyroid disfunction - Polycystic ovarian syndorme - Functional hypothalamic amenorrhea - Postpill amenorrhea - Hypothalamic / pituitary mass ————— Case 34 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 16-year-old girl who has not had a menstrual period for 2 months History of present illness . Menses began at age 13 and were regular with no missed periods until 2 months ago . The cycle usually last 28-30 days with moderate bleeding for 3-4 days (3-4 full soaked pads a day) . Increased stress at school for the past 4 months , and you are currently studying for mid-term examinations in 2 weeks . 10-lb (4.5kg) weight loss over the last 4 months despite normal appetite Do not volunteer this information unless asked : . No palpations . No diarrhea or constipation . No hair or skin changes . No breast tenderness or nipple discharge . No vaginal discharge or otters genitourinary symptoms During the interview , ask the examinee : “Do you think I’m pregnant ? I can’t be pregnant right now . My parents will not be happy .” Past medical / family / social history . No history of pregnancy (G0P0) . No surgeries . No medications . No drug allergies . Immediate family members ( father , mother , sister ) are healthy . Single , live with parents . Junior in high school ; during well in school and participate in multiple extracurricular activities . Sexually active with boyfriend for last 6 months ; do not always use a condom . Tobacco : No . Alcohol : No . Recreational drugs : No Physical examination HEENT : . PERRLA , EOMI . Oropharynx clear Neck : . Supple without lymphadenopathy or thyromegaly Abdomen : . Non-tender , non-distended . Normative bowel sounds . No hepatosplenomegaly Psychiatric : . Alert and oriented . Anxious affect ————— Case 34 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 and duration of amenorrhea (i.e., last menstrual period) . Asked about menarche and previous menses (frequency , duration , quantify of blood loss) . Asked bout associated symptoms: - Abdominal pain - Vaginal discharge - Change I’m appetite or weight - Cold or heat intolerance - Changes in skin or hair - Breast changes or nipple discharges - Headache . Asked about sexual activity (and use of contraception ) . Asked about life stressors Past medical /family/social history . Asked about similar episodes in the past . Asked about other medical problems . Asked about surgeries and gynecologic procedures (eg , dilation and curretage ) . Asked about current and recent medications . Asked about medication allergies . Asked about family  health . Asked about tobacco , alcohol , and recreational drug use Examination . Washed heads before examination . Examined without gown , not through gown . Examined eyes (including visual fields) . Examined neck ( including thyroid ) . Examined abdomen Counseling . Explained physical findings and possible diagnosis . Explained further workup . Discussed the need for pelvic and breadth examinations 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 Differential diagnosis . Pregnancy . Eating disorder . Thyroid dysfunction . hyperprolactinemia . Functional hypothalamic amenorrhea Diagnostic study/studies . Pelvic and breast examination . Pregnancy test . TSH . Serum prolactin level . Pelvic ultrasound . Brain MRI . LH and FSH levels ————— Case 34 clinical summary Clinical Skills Evaluation Case 34 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). . 16-yo girl with 2 month of amenorrhea . Menarche at age 13 with regular and no missed periods until 2 months ago. . Sexually active with boyfriend and dose not always use condoms. . Increased stress at school . Unintentional 4.52-kg (10-lb ) weight loss in past 4 months with good appetite. ROS : No palpation , diarrhea , constipation , hair loss  skin changes , breath tenderness , nipple discharge , vaginal discharge , or urinary problems PMHx : G0P0 PSH : None Meds : None Allergies : None FHx : Father , mother and sister are healthy SHx : No tobacco or alcohol 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 ,36.7’C (98.1F); blood pressure 120/70 mmHg; pulse : 76/min; and respiration , 16/min . HEENT : PERRLA , EOMI , oropharynx clear . Neck : Supple without lymphadenopathy or thyromegaly . Abdomen ; Non-tender, non-distended , normative bowel sounds ,. no hepatosplenomegaly 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 : Pregnancy History finding(s) . Amenorrhea . Sexually active, sometimes not using condoms Physical examination finding(s) . None Diagnosis #2 : Hyperthyroidism History finding(s) . Amenorrhea . Increased anxiety . Weight loss with good appetite Physical examination finding(s) . None Diagnosis #3 :Hyperprolactinemia History finding(s) . Amenorrhea Physical examination finding(s) . None Diagnostic studies . Pregnancy test . TSH and T4 . Pelvic and breath examination . Prolactin level -- 作者： JuanFe -- 發表時間： 2018/09/13 07:59am 35 Case 35 scenario ( right lumbar lower abdominal pain ) Doorway information about patient The patient is a 35-year-old woman who comes to the office due to acute right lumbar and lower abdominal pain Vital signs . Temperature : 38.3’C (100.9F) . Blood pressure : 110/70 mmHg . Pulse : 100/min . Respirations : 16/min Basic differential diagnosis . Renal colic . Ovarian torsion . Urinary tract infection /pyelonephritis . Pelvic inflammatory disease . Mittelschmerz . Appendicitis . Threatened abortion . Ectopic pregnancy . Dysmenorrhea . Endometriosis . Fibroids ————— Case 35 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 who has low back and abdominal pain History of present illness . 1 day of right low back pain that radiates to pelvis and lower abdomen . Sharp pain ; 7/10 severity . Progressively worsening and is not affected by positional charges . Preceded by burning with urination for 2-3 days . Associated with fever , chills , nausea (without vomiting) ,. and intermittent blood in urine . At the end of the interview say , “ aim in a lot of pain . please make it stop.” Review of systems . Last menstrual period 3 weeks ago . No vaginal discharge . No chest pain or shortness of breath . No diarrhea or consipation Past medical / family / social history . 2 pregnancies with uncomplicated vaginal delivery(G2P2) . Pelvic inflammatory disease 2 year ago . UTI twice 2 years ago treated with antibiotics . No surgeries or hospitalization . Medications : None . No drug allergies . Father , mother and sister are healthy . Occupation : Bank teller . Single , live with a children . Sexually active with boyfriend and do not usually use condoms . Tobacco : 1 pack a day for last 15 years . Alcohol L Occasional beer or wine . Recreational drugs : None Physical examination Abdomen : . Diffused abdominal discomfort during the examination but no focal tenderness . Non-distended . Normative bowel sounds . No hepatosplenomegaly . Mild CVA tenderness on the right . Negative psoas test ————— Case 35 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 if pain and course over time . Asked bout the location and radiation of pain . Asked bout the quality and intensity of pain . asked bout nay aggravating or relieving factors . Asked bout associated symptoms , especially : - Fever and chills - Nausea and vomiting - Constipation or diarrhea - Urinary symptoms (eg, burning , blood in urine, frequency) - Vaginal bleeding/ discharge . Asked about last menstrual period and menstrual cycle . Asked bout sexual practices and use of contraception Past medical /family/social history . Asked about similar episodes in the past . Asked about past medical issues (especially urinary tract infections , pelvic inflammatory disease , kidney stones) . Asked about hospitalizations and surgeries . Asked about current medications . Asked bout medication allergies . Asked about family health . Asked about occupation . Asked about tobacco , alcohol , and recreational drug use Examination . Washed heads before examination . Examined without gown , not through gown . Auscultated abdomen . Palpated abdomen (superficial and deep) . Tested for rebound tenderness and rigidity . Tested for constovertebral angle tenderness . Tested for signs of appendicitis (eg , psoas test) Counseling . Explained physical findings and possible diagnosis . Discussed the need for pelvic examination . 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 Differential diagnosis . Renal colic . UTI/ acute pyelonephritis . Pelvic inflammatory disease . Uterine fibrosis . Appendicitis Diagnostic study/studies . Pelvic examination . Pregnancy test . CBC with differential count . Urinary and culture . Abdomen ultrasound . Urine PCR for gonorrhea and chlamydia ————— Case 35 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). . 35-yo woman with 1 day of ship right flank pain radiating to the right pelvis and lower abdomen . Pain is 7 on scale of 10 . Progressive , worsening pain without relief and unaffected by position . Dysuria , fever , chills , nausea , and occasional hematuria ROS : No vaginal discharge , chest pain , shortness pf breath , diarrhea , or constipation PMHx : G2P2 , PID 2 years ago , UTI 2 years ago PSHx : None Meds : None Allergies ; None FHx : Father , mother , and sister are healthy SHx : 1 PPD smoker for 15 years , occasional alcohol 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 (100.9’F) ; blood pressure , 110/70 mmHg; pulse 100/min; and respirations , 16/min . Abdomen : Diffuse abdominal discomfort without focal tenderness , non-distended , normative bowel sounds , no hepatosplenomegaly , mild CVA tenderness son the right , negative psoas test 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 : Nephrolithiasius with hydronephrosis History finding(s) . Frank pain radiating to lower abdomen . No comfort with any position change Physical examination finding(s) . Fever . CVA tenderness Diagnosis #2 : Pyelonephritis History finding(s) . Dysuria . Hematuria . Fever Physical examination finding(s) . CVA tenderness . Fever Diagnosis #3 : Pelvic inflammatory disease History finding(s) . Previous PID . Sexually active without condom use . Lower abdominal pain Physical examination finding(s) . None Diagnostic studies . Pregnancy test . Pelvic examination . CBC with differential . Urinalysis and urine culture -- 作者： JuanFe -- 發表時間： 2018/09/13 08:00am 36 Case 36 scenario ( insomnia ) Doorway information about patient The patient is a 70-year-old man wth insomnia Vital signs . Temperature ; 36.7’C(98.1F) . Blood pressure : 130/90 mmHg . Pulse ; 58/min . Respirations : 16/min Basic differential diagnosis . Depression . Post-Traumatic stress disorder . Anxiety disorder . Chronic pan syndormes . Adverse effect of medication . Age-related sleep change . Thyroid problems . Sleep apnea . Restless legs syndorme ————— Case 36 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 70-year-old man who has insomnia History of present illness . Admitted to the hospital 3 months ago with chest pain and diagnosed with coronary artery disease . Coronary angioplasty was performed and several new medications were initiated . you were very anxious throughout the hospitalization and were given lorazepam for anxiety . A few weeks after discharge , you began having difficulty falling asleep and are able to stay asleep for only 2-3 hours before getting up and pacing. . No unusual dreams or nightmares . You do not wake refreshed and feel tired in the morning and throughout the day . You do not drink alcohol or caffeine in the evening before you go to bed . Decreased appetite an a 2.27-kg (5-lb) weight loss since the hospitalization . Your son loves nearby and says that you have become more isolated and not interested in normal activities Review of systems . No chest pain . No shortness of breath or swelling in the ankles /feet . No tremors or change in strength or sensation . No changes in hair or skin . No nausea , vomiting , diarrhea , constipation , or abdominal pain . No palpitations or dizziness Past medical / family / social history . Coronary artery disease . no surgires . Medications ; Aspiri , clopidogrel , metoprolol, atovastatin , lisinpril , nitroglycerin, sublingual as needed (have not used) . No drug allergies . After died at age 75 of heart attack , motor died at age 68 of breath cancer , 1 sister (healthy) . Widowed for last 2 years , live alone . Retired accountant . Tobacco : 1 pack a day for last 50 years . Alcohol : Occasional beer . Recreational; drugs : No Physical examination General : . Awake and alert but appear fatigued . Grooming and hygiene normal . No distress HEENT : . Oropharynx clear Neck : . Supple without lymphadenopathy Lungs : . Clear to auscultation bilaterally Heart : . Regular rate and rhythm . no murmurs , gallops ,or rubs Abdomen : . Non-tender, non-distended . Normative bowel sounds . No hepatosplenomegaly Neurologic : . Oriented to person , place, and time . Motor 5/5 throughout . Reflexes 2+ throughout ————— Case 36 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 symptoms . Asked bout the average duration and quality of sleep . Asked if having difficulty falling asleep ,staying asleep , or both . Asked about bedtime habits . Asked if having nightmares . Asked if having anxiety or depressive symptoms . Asked if having any associated palpitations , sweating , or dizziness . Asked if having any pain . Asked about snoring / breathing problems . Asked about daytime sleepiness and morning headaches . Asked about appetite and changes in weight . Asked about constipation and diarrhea . Asked bout impact on personal relationship and daily activities Past medical /family/social history . Asked about similar episodes in the past . Asked about past medical issues , hospitalizations ,and surgeries . Asked about curent medications . Asked about medication allergies . Asked about family health . Asked bout current living situation and family support . Asked about occupation Examination . Washed heads before examination . Examined without gown , not through gown . Examined pharynx . Examined neck/thyroid . Performed neurologic examination including cranial nerves , motor strength , and reflexes . Examined heart and lungs Counseling . Explained physical findings and possible diagnosis . Explained further workup . Discussed sleep habits/ sleep hygiene . 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 Differential diagnosis . Anxiety disorder . Drug-induced insomnia . Depression . Sleep apnea Diagnostic study/studies . CBC . Basic metabolic panal (Na, K , BUN , Cr, CO2 , Cl) . TSH . Nocturnal polysomnography ————— Case 36 clinical summary Clinical Skills Evaluation Case 36 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). . 70yo man with 2 months of insomnia after hospitalization for CAD with angioplasty . Difficulty falling and staying asleep . Decreased appetite and 2.27-kg (5-lb ) weight loss. . Family thinks the patient feels isolated and has loss interest in activities ROS : Fatigue , no chest pain , shortness of breath , tremor , hair loss diarrhea , constipation, palpitations , dizziness , or recent trauma PMHx : CAD PSHx : None Meds : Aspirin , clopidogrel , metoprolol, lisinpril, atovastatin, nitroglycerin as needed Allergies : None FHx : Father died of MI ; mother died of breast cancer SHx: 1 PPD smoker for 50 years , occasional alcohol use . Vital signs : Temperature ,36.7’C(98.1F); blood pressure , 130/90 mmHg; pulse , 58/min; respirations , 16/min . HEENT : Oropharynx clear . Neck : Supple without lymphadenopathy . Heart : RRR without murmurs , gallops , or rubs . Abdomen ; Non-tender, non-distended, normative bowel sounds , no hepatosplenomegaly . Neurologic : Motor 5/5 bilaterally ; alert and oriented to person , place , and time ; DTR 2+ bilaterally 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. 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 : Anxiety disorder History finding(s) . Recent hospitalization . Difficulty falling and staying asleep . Previous anxiety requiring medications Physical examination finding(s) . None Diagnosis #2 : Depression History finding(s) . Decreased appetite and weight loss . Decreased interest in activities . Insomnia , fatigue Physical examination finding(s) . None Diagnosis #3 : Drug induced insomnia History finding(s) . Recently started metoprolol . Insomnia Physical examination finding(s) . Bradycardia Diagnostic studies . Basic metabolic panel . CBC with differential . TSH -- 作者： JuanFe -- 發表時間： 2018/09/13 08:01am 37 Case 37 scenario ( difficulty urination) Doorway information about patient . The patient is a 65-year-old man who comes to the office due to difficulty with urination Vital signs . Temperature : 37.2’C(99F) . Blood pressure ; 130/80 mmHg . Pulse ; 92/min . Respirations : 16/min Basic differential diagnosis . Benign prostate hyperplasia . Prostatitis . UTI / cystitis . Carcinoma of the prostate . Stone in the urinary tract (obstructive) . Carcinoma of the bladder . Neurologic dysfunction . Drug-induced bladder dysfunction ————— Case 37 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. History of present illness . Onset of symptoms 2 months ago . Difficulty initiating urine stream with decreased flow , straining with urination , sensation of incomplete emptying , and increased urinary frequency . Mild burning on urination and 1 episode of blood in the urine . Getting up 5-6 times a night to urinate . Asked doctor :” Do you think I have prostate cancer?” Review of systems . Decreased appetite with 4.5-kg (10-lb) weight loss over the last year . No fever or chills . No  abdominal pain , diarrhea , or constipation . No muscle weakness . No recent trauma Past medical / family / social history . Diabetes mellitus for the past 10 years . No surgeries or hospitalizations . Medications : Metformin 500mg twice daily . No drug allergies . Father died of prostate cancer at age 75 , mother died of “kidney problems” at age 78 , sister is healthy . Occupation : Accountant . Married , lived with wife . Tobacco : No . Alcohol : 2 beers /day for last 35 years . Recreational drugs : No Physical examination Abdomen : . Non-tender, non-distended . Normative bowel sounds . No hepatosplenomegaly . No CVA or suprapubic tenderness Neurologic : . Motor 5/5 throughout . DTR 2+bilaterally ————— Case 37 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 symptoms and course over time . Asked about difficulty initiating or maintaining urinary flow . Asked bout the strength of flow . Asked about intermittency (stopping and starting again while urinating), straining, and sensation of incomplete emptying . Asked about the frequency or urination . Asked about urgency . Asked about nocturia . Asked bout any burning sensations with urination . Asked if any blood in the urine . Asked about associated symptoms , especially : - Abdominal pain - Fever - Weakness in legs - Change in bowel movements - Change in appetite or weight - Back pain or trauma Past medical /family/social history . Asked about similar episode sin the past . Asked about past medical issues(especially urinary or sexually transmitted infections), Surgeries , and hospitalizations . 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 abdomen  (auscultation ,palpation) . Examined back , including palpation/ percussion for ocstovertebral angle tenderness . Tested lower extremity strength and reflexes Counseling . Explained physical findings and possible diagnosis . Explained further  workup . Explained the need for rectal / prostate 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 Differential diagnosis . Benign prostate hyperplasia . Urinary tract infection . Prostatitis . Prostatic carcinoma . Bladder carcinoma . Overflow incontinence Diagnostic study/studies . Rectal examination . urinalysis andurine culture . Serum BUN , Creatinine , glucose . Hemoglobin A1c . CBC with differential . Prostate-specific antigen ————— Case 37 clinical summary Clinical Skills Evaluation Case 37 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). . 95-yo man with 2 months of difficulty initiating urination , decreased urinary flow , nocturia , increase urinary frequency , and incomplete emptying of bladder . 1 episode of hematuria . Decreased appetite and 4.53kg(10-lb) weight loss over the past year. ROS : No increased urinary urgency , abdominal pain, flank pain , fever , chills , diarrhea , constipation, leg weakness , or trauma PMHx : Diarrhea for past 10 years PSHx : None Meds : Mptformin 500 mg twice a day Allergies : None FHx : Father died of prostate cancer ; motor died of kidney problems SHx : No tobacco use l 2 beers daily for 35 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 ,37.2;C(99F); blood pressure , 130/80 mmHg; pulse, 92/min; and respirations, 16/min . Abdomen : Non-tender, non-distended , normative bowel sounds , no hepatosplenomegaly, no CVA tenderness . Neurologic : Motor 5/5 bilaterally , DTR 2+ bilaterally 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 : Benign prostate hyperplasia History finding(s) . Difficulty with urination . Incomplete emptying of bladder . Nocturia, decreased urinary flow Physical examination finding(s) . None Diagnosis #2 : Prostate cancer History finding(s) . Family history of prostate cancer .Decreased urinary flow, nocturia . Weight loss Physical examination finding(s) . None Diagnosis #3 : Bladder cancer History finding(s) . Gross hematuria . Incomplete emptying of bladder . Weight loss Physical examination finding(s) . None Diagnostic studies . Rectal examination . Urinalysis with curse culture . PSA . Basic metabolic panel -- 作者： JuanFe -- 發表時間： 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. Vital signs . Temperature : 36.1’C(97F) . Blood pressure : 130/80 mmHg . Pulse ; 94/min . Respirations : 22/min Basic differential diagnosis . 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 ————— 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 Differential diagnosis . Panic disorder/ agoraphobia . Generalized anxiety disorder . Hyperthyroidism . Substance abuse Diagnostic study/studies . ECG . Electrolytes and glucose . TSH . Urine drug screen ————— 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 Physical examination finding(s) . None Diagnostic studies . ECG . TSH . Serum electrolytes and glucose -- 作者： JuanFe -- 發表時間： 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 Vital signs . Temperature : 36.1’C . Blood pressure : 120/70 mmHg . Pulse : 84 /min . Respirations : 16/min Abdominal x-ray is as shown in the exhibit [UploadFile=practice20case20_1558613418.jpg] [UploadFile=practice20case20_1558613429.jpg] Basic differential diagnosis . 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 Differential diagnosis . Gastritis (NSAID gastropathy) . Peptic ulcer . GERD . Gastric or pancreatic carcinoma . Chronic pancreatitis Diagnostic study/studies . 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 -- 作者： JuanFe -- 發表時間： 2018/09/13 08:04am 40 Case 40 scenario ( vomiting blood ) Doorway information about patient The patient is a 45-year-old ma who comes to the emergency department due to vomiting blood Vital signs . Temperature : 36.7’C(98F) . Blood pressure : 100/60 mmHg . Pulse : 90/min . Respirations : 18/min Basic differential diagnosis . Peptic ulcer . Esophageal and gastric varices . Mallory-Wises tear . Gastritis . Erosive esophagitis . Gastric malignancy . Vascular ectasia ————— Case 40 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 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 Differential diagnosis . Gastric ulcer . Duodenal ulcer . Gastritis . Erosive esophagitis . Gastric malignancy Diagnostic study/studies . 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 -- 作者： JuanFe -- 發表時間： 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 Vital signs . Temperature : 36.1’C (97F) . Blood pressure : 140/90 mmHg . Pulse ; 80 /min . Respirations : 16 /min Basic differential diagnosis . Vertigo (benign paroxysmal positional vertigo , labyrinthitis , Meziere disease , posterior circulation stroke ) . Lightheartedness (hypotension ,postural hypotension , arrhythmia , anemia, congestive heart failure) . Disequilibrium (anxiety , autonomic  dysfunction) . TIA or stroke . Medication affect . Hypoglycemia ————— Case 41 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 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 Differential diagnosis . Drug-induced postural hypotension . Benign paroxysmal positional vertigo . Autonomic dysfunction from disease . Hypoglycemia . Arrhythmia . Transient ischemic attack Diagnostic study/studies . 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). Diagnosis #1 : Benign paroxysmal positional vertigo History finding(s) . Intermittent / episodic dizziness . Symptoms provoked by position change Physical examination finding(s) . Subjectively positive Dix-Hallpike test Diagnosis #2 : Medication -induced postural hypotension History finding(s) . Symptoms trigged by position changes . Recent initiation of alpha blocker Physical examination finding(s) . None Diagnosis #3 : Transient ischemic attack History finding(s) . Chronic diabetes and hypertension . Unilateral lower extremity weakness that resolved spontaneously Physical examination finding(s) . None Diagnostic studies . ECG . Electrolytes and blood glucose . CT scan of brain -- 作者： JuanFe -- 發表時間： 2018/09/13 08:06am 42 Case 42 scenario ( new-onset seizure ) Doorway information about patient The patient is a 30-year-old man who comes to the emergency department due to new-onset seizure Vital signs . Temperature : 37.2’C (99F) . Blood pressure : 120/80 mmHg . Pulse ; 82/min, regular . Respirations : 18/min Basic differential diagnosis . 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 Differential diagnosis . Intracranial mass . Hypoglycemia . Alcohol withdraw . Meningitis / encephalitis Diagnostic study/studies . 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 -- 作者： JuanFe -- 發表時間： 2018/09/13 08:06am 43 Case 43 scenario ( rectal bleeding ) Doorway information about patient The patient is a 23-year-old man who comes to the emergency department due to rectal bleeding Vital signs . Temperature : 38.3’C(101F) . Blood pressure : 110/60 mmHg . Pulse : 90/min . Respirations : 18/min Basic differential diagnosis Young patients . Anal fistula /fissure . Hemorrhoid . Inflammatory bowel disease . Infectious colitis . Neoplasm . Vascular ectasis Elderly patients . Diverticulitis . Angiodysplasia . Malignancy / polyp . Ischemia colitis . Inflammatory bowel disease ————— Case 43 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 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 Differential diagnosis . Inflammatory . Anal fistula / fissure . Hemorrhoid . Proctitis . Infectious colitis . Neoplasm Diagnostic study/studies . Rectal examination . Facal occult blood test . CBC . Coagulation studies (PT/aPTT) . Anoscopy . Sigmoidoscopy / colonoscopy . Abdomen x-ray ————— Case 43 clinical summary Clinical Skills Evaluation Case 43 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). . 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 Physical examination finding(s) . None Diagnosis #2 : inflammatory bowel disease History finding(s) . Visible lower gastrointestinal bleeding . Vampy abdominal pain Physical examination finding(s) . Fever Diagnosis #3 : Rectal cancer History finding(s) . Visible lower gastrointestinal bleeding . First-degree family history of colon cancer Physical examination finding(s) . None Diagnostic studies . Rectal examination . CBC . Electrolytes and blood glucose . PT/ aPTT . Anoscopy . X-ray of abdomen