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-=-=-=-=-=> [這篇文章最後由JuanFe在 2018/11/03 01:04pm 第 1 次編輯] 1 Case 1 Scenario (abdominal pain) Doorway information The patient is a 30-year-old woman who comes to the clinic due to abdomen pain Vital signs . Temperature : 38.5’C (101.3 F) . Blood pressure : 120/75 mmHg . Pulse : 98 /min . Respiration : 22/ min Basic differential diagnosis Gastrointestinal . Appendicitis . Acute cholecystitis . Pancreatitis . Inflammatory bowel disease . Irritable bowel syndrome . Diverticulitis . Bowel obstruction . Acute gastroenteritis Urinary . Urinary tract infection / pyelonephritis . Renal colic Reproductive . Pelvic inflammatory disease . Pelvic abscess . Endometriosis . Ovarian cyst / torsion . Ectopic pregnancy . Spontaneous abortion Miscellaneous . Shingles . Aortic dissection ————— Case 1 sim. pt . instructions If the doctor ask you about anything other then these , just say “no” , or provide an answer that a normal patient might give. You are a 30-year-old women who comes to the clinic with abdomen pain. History of present illness . The pain started 12 hours ago . Started slowly , progressively increasing . “Sharp” pain ; 6-7/10 in severity . Felt all mover lower abdomen , but worst right below the umbilicus . Began after eating a large meal . Moving around makes it worse . No alleviating factors . Fever since yesterday, with occasional chills today . Intermittent nausea and vomiting . Passing urine more frequently and having burning on urination . No bowel problems Review of the systems . Last menstrual period was 3 weeks ago . No discharge or abnormal bleeding form vagina . Appetite and weight have not changed recently Past medical /family /social history . One urinary tract infection in the past ; was serious and required hospitalization . Current medications is an oral contraceptive pill only . No allergies . Immediate family members are all healthy . Occupation : Receptionist (接待員) . Sexually active with multiple men . Tobacco : no . Alcohol : 2-3 drinks on weekend . Recreational drugs: no Ask this question : “Doctor , is this appendicitis ?” ————— Case 1 checklist Following the encounter , check which of the following items were performed by examinee. History of present illness / review of system . Asked about the location of pain . Asked about the intensity of pain . Asked about the quality of pain . Asked about the onset and duration of pain . Asked about the course pf pain over time . Asked about any radiation of pain . Asked about any aggravating or relieving factors . Asked about associated symptoms , especially : 1 Vomiting 2 Fever 3 Urinary problems 4 Bowel problems 5 Vaginal bleeding / discharge . Asked about last menstrual period . Asked about appetite and changes in weight Past medical/ family / social history . Asked about similar episodes in the past . Asked about past medical issue , hospitalization , and surgeries . Asked about current medications . Asked about medication allergies . Asked about family health . Asked about tobacco, alcohol, and drug use . Asked about sexual and reproductive history . Asked about occupation Examination . Examinee washed hands before examination . Examined without gown , not through gown . Auscultated abdomen . Palpated abdomen(superficial and deep) . Checked for rebound tenderness . Checked for costovertibral angle tenderness . Performed posts sign and obstructor sign Counseling . Explained physical findings and possible diagnosis . Explained further workup . Discussed safe sexual practices and sue of condom . Asked to perform rectal and vaginal examination Communication skills and professional conduct . Knocked before entering the room . Introduced self and greeted you warmly . Used your name to address you . Paid attention to what you said and maintained good eye contact . Asked open-ended questions . Asked non leading questions . Asked one question at a time . Listened to what you said without interrupting . Used plain english rather than technical jargon . Used appropriate transition sentences . Used appropriate draping techniques . Expressed empathy and made appropriated reassurances . Asked whether you had any concerns/ questions Differential diagnosis . Pelvic inflammatory disease . Pelvic abscess . Urinary tract infection . Appendicitis . Ovarian torsion / rupture of cyst Diagnostic study/ studies . Rectal and vaginal examination . CBC with differential count . Urinalysis . Pregnancy test . Abdomen x-ray . Abdomen ultrasound ————— Case 1 clinical summary Clinical skill evaluation Case 1 patient note The following represents a typical note or this patient encounter . the details may vary depending on the information given by the simulated patient. History : Described the history you just obtained from this patient, Include only information (pertinent positive and negatives ) relevant this patient’s problem(s) . 30-yo remake with 12 hours of abdominal pain . Ate a heavy meal at a barbecue restaurant a day ago. . Developed acute-onset periumbilical abdomen 12 hours later; described as a sharp , lasting a few minutes at a time , radiating diffusely in the abdomen , made worse with movement , and relieved with rest. . Dysuria , increased urinary frequency , fever to 38.5’C (101.3F) , chills , nausea ,and an episode of non bloody and non bilious vomiting. ROS : No chest pain , shortness of breath , diarrhea , constipation PMHx: Previous UTI with possible pyelonephritis PSHx: None Meds: None Allergies : None FHx: noncontributory SHx: HAs had 2 sexual partners with unprotected intercourse in the past month Physical examination : Describe any positive and negative findings relevant to this patient’s problem(s) . Be careful to include only those parts of the examination performed in this encounter . Vital signsL Temperature , 38.5C (101.3F) ; blood pressure , 120/75 mmHg, pulse 98/min; and respiration’s , 22/min . Abdomen :Tenderness in the periumbilical , RLQ and LLQ regions . No abdomen dissension or guarding . Normative bowel sounds . Negative Murphy sign, Rovsing sign , posts sign , and obturator sign . No CVA tenderness . Lungs : Clear to auscultation . Heart : Normal heart sounds with no murmurs Data interpretation : Based on what you have learned form the history and physical examination, list up to 3 diagnoses that might explain this patient;s complaint(s) , List your diagnoses form most to least likely . For some cases , fewer than 3 diagnoses will be appropriate . Then , enter the positive or negative findings form the history and the physical examination (if present) that support each diagnosis. Lastly , list initial diagnostic studies (if any) you would order for each listed diagnosis (e,g, restricted physical examination maneuvers ,laboratory tests , imaging , ECG ,etc.). Diagnosis #1 : Appendicitis History findings . Diffuse , abdomen pain . Fever , chills . Nausea ,vomiting Physical Exam finding(s) . Diffuse abdomen tenderness . Fever Diagnosis #2 : UTI History findings . Dysuria . Increased urinary frequency . Fever Physical Exam findings . Fever Diagnosis #3 : Pelvic inflammatory disease History findings . Multiple sexual partners with unprotected intercourse . Nausea, vomiting Physical Exam findings . Diffuse abdominal tenderness . Fever Diagnostic Studies . Pregnancy test . Urinalysis with culture . CT scan of abdomen -=-=-=-=-=>
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