| | [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
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2018/07/07 05:19am 
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