| | 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
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2018/08/15 03:23pm 
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