| | [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
| | |
|
|
|
頂端 
加到"我的最愛"
主題管理：
總固頂 
取消總固頂 
Message
查看
搜尋
通訊錄
複製
引用
回覆
2018/07/07 05:16am 
IP: 已設定保密