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JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1119 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É55¤À55¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [¼Ó ¥D]   [³o½g¤å³¹³Ì«á¥ÑJuanFe¦b 2018/09/13 08:08am ²Ä 7 ¦¸½s¿è] 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 2018/06/05 11:03pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 1087 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1119 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É55¤À55¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 2 ¼Ó]   [³o½g¤å³¹³Ì«á¥ÑJuanFe¦b 2018/11/03 01:04pm ²Ä 1 ¦¸½s¿è] 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 ¡X¡X¡X¡X¡X 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 ¡]±µ«Ý­û¡^ . Sexually active with multiple men . Tobacco : no . Alcohol : 2-3 drinks on weekend . Recreational drugs: no Ask this question : ¡§Doctor , is this appendicitis ?¡¨ ¡X¡X¡X¡X¡X 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 ¡X¡X¡X¡X¡X 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 2018/07/07 05:16am¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 7892 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1119 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É55¤À55¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 3 ¼Ó]   [³o½g¤å³¹³Ì«á¥ÑJuanFe¦b 2018/10/15 04:11pm ²Ä 3 ¦¸½s¿è] 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) ¡X¡X¡X¡X¡X 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 ¡X¡X¡X¡X¡X 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 ¡X¡X¡X¡X¡X 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 2018/07/07 05:19am¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 7173 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1119 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É55¤À55¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 4 ¼Ó]   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 ¡X¡X¡X¡X¡X 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?¡¨ ¡X¡X¡X¡X¡X 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 ¡X¡X¡X¡X¡X 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 2018/07/07 05:20am¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 8595 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1119 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É55¤À55¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 5 ¼Ó]   [³o½g¤å³¹³Ì«á¥ÑJuanFe¦b 2018/08/15 03:39pm ²Ä 1 ¦¸½s¿è] 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 ¡X¡X¡X¡X¡X 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. ¡X¡X¡X¡X¡X 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) ¡X¡X¡X¡X¡X 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 2018/07/31 03:21am¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 9310 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1119 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É55¤À55¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 6 ¼Ó]   [³o½g¤å³¹³Ì«á¥ÑJuanFe¦b 2018/08/15 04:00pm ²Ä 2 ¦¸½s¿è] 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 ¡X¡X¡X¡X¡X 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 ¡X¡X¡X¡X¡X 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) ¡X¡X¡X¡X¡X 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 2018/07/31 03:22am¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 7660 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1119 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É55¤À55¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 7 ¼Ó]   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 ¡X¡X¡X¡X¡X 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 ¡X¡X¡X¡X¡X 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 ¡X¡X¡X¡X¡X 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 2018/08/15 03:22pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 8614 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1119 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É55¤À55¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 8 ¼Ó]   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 ¡X¡X¡X¡X¡X 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 ¡X¡X¡X¡X¡X 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 ¡X¡X¡X¡X¡X 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 2018/08/15 03:23pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 8052 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1119 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É55¤À55¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 9 ¼Ó]   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 ¡X¡X¡X¡X¡X 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 ¡X¡X¡X¡X¡X 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 ¡X¡X¡X¡X¡X 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 2018/08/15 03:25pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 7224 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1119 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É55¤À55¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 10 ¼Ó]   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 ¡X¡X¡X¡X¡X 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+ ¡X¡X¡X¡X¡X 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 ¡X¡X¡X¡X¡X 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 2018/08/15 03:26pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 7971 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1119 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É55¤À55¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 11 ¼Ó]   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) ¡X¡X¡X¡X¡X 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 ¡X¡X¡X¡X¡X 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 ¡X¡X¡X¡X¡X 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 2018/08/15 03:27pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 8249 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1119 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É55¤À55¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 12 ¼Ó]   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) ¡X¡X¡X¡X¡X 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 ¡X¡X¡X¡X¡X 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 ¡X¡X¡X¡X¡X 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 2018/08/15 03:28pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 7584 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1119 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É55¤À55¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 13 ¼Ó]   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 ¡X¡X¡X¡X¡X 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 ¡X¡X¡X¡X¡X 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 ¡X¡X¡X¡X¡X 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 2018/08/15 03:30pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 6800 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1119 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É55¤À55¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 14 ¼Ó]   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) ¡X¡X¡X¡X¡X 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. ¡X¡X¡X¡X¡X 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) ¡X¡X¡X¡X¡X 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 2018/08/15 03:31pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 8162 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1119 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É55¤À55¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 15 ¼Ó]   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 ¡X¡X¡X¡X¡X 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 ¡X¡X¡X¡X¡X 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 ¡X¡X¡X¡X¡X 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 2018/08/15 03:31pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 7201 ¦ì¤¸²Õ]¡@

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