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-=-=-=-=-=> [這篇文章最後由JuanFe在 2018/10/15 04:11pm 第 3 次編輯] 2 case 2 Scenario (rash) Doorway information about patient The patient is a 27-year-old woman who comes to the office due to a rash. Vital signs . Temperature : 36.8’C(98.3F) . Blood pressure : 120/75 mmHg . Pulse : 78/min . Respirations: 16/min Basic differential diagnosis . Infections - Bacterial (eg, cellulitis) - Viral (eg,herpes zoster/shingles) - Fungal (eg,tine corporis) - Parasitic (eg, scabies) . Psoriasis . Acne vulgaris . Rosacea . Immune / autoimmune (eg, systemic lupus erythematous , erythema multiforme) . Stasis dermatitis . Bullous disorders (eg , bullous pemphigoid , dermatitis herpetiformis) ————— Case2 sim. pt. instructions If the doctor asks you about anything other than these , just say “ no” or provide an answer that a normal patient might give. You are a 27-year-old woman who comes to the office with a rash History of present illness . the rash began 1 week ago . Started after working in the garden . Located on the face and neck . Flat, with no bumps or blisters . No associated itching , burning , pain . Felt feverish but did not check temperature . Rash getting larger but not spreading to other areas of the body . Worse after going out on the sun, no alleviating factors . No recent travel or sick contacts . Also noticed joint pain and stiffness for about an hour in the morning , starting 4 days ago Review of the system . Last menstrual period was 2 weeks ago ; regular menses Past medical /family/social history . Intermittent joint pains in the past that resolve spontaneously ; never was evaluated by a doctor . no medications except aspirin 7 days ago for a headache . No surgeries . No pregnancies . Father is 55 and healthy ; mother is 54 and has “rheumatism” ; sister is28 and has hypothyroidism . Single . Works as a computer operator in a chemical manufacturing facility . 1 sexual partner in the last month ; regular condom use . Tobacco: No . Alcohol: no . Recreational drugs : No Physical examination . Skin: Multiple , well-circumscribed lesions on face and neck without vesicles ; no tenderness to touch ————— Case2 sim. pt checklist Following the encounter , check which of the following items were performed by the examinee History of present illness/review of system . Asked about the location of rash . Asked about whether the rash was initially flat or raised /blistered . Asked whether the rash has changed over time or involved new areas . Asked about any aggravating or relieving factors . Asked about any causative factors . Asked about associated symptoms , especially - Itching or burning - Pain - Breathing problems or chest pain . Asked about redness of eyes . Asked about any joint pains . Asked about fever . Asked whether any close contacts have similar rash . Asked about rennet travel . Asked about any animal contact . Asked about insect bites or outdoor activities in the recent past Past medical / family / social history . Asked about similar epodes of rash in the past . Asked about past medical issue , hospitalizations ,a dn surgeries . Asked about current medications . Asked about medication allergies . Asked about family health . Asked bout tobacco, alcohol , and drug use . Asked about sexual and reproductive history . Asked about occupation Examination . Examinee washed heads before examination . Examined without gown , not though gown . Looked inside mouth for oral ulcers . Examined hand joints . Auscultate heart and lungs . Examined face and neck for rash Counseling . Explained physical findings and possible diagnosis . Explained further workup Communication skills and professional conduct . Knocked before entering the room . Introduced self and greeted you warmly . Used your name to address you . Paid attention to what you said and maintained good eye contact . Asked open-ended questions . Asked non leading questions . Asked one question at a time . Listened to what you said without interrupting . Used plain English rather than technical jargon ————— Clinical Skills evaluation The following represents a typical note for this patient encounter . the details may vary depending on the information given by the simulated patient. History : Describe the history you just obtained form this patient. Include only information (pertinent positive and negatives ) relevant to this patient’s problem(s) . 27-yo female with 1 week of rash, . Gardened for 3 hours a week ago and developed a rash on her face and neck a few hours later . . Rash has increased in size but dose not involve other areas of the body. . Morning joint pains and subjective fever. ROS: no chest pain , shortness of breath , diarrhea , constipation , sick contacts , or recent travel PMHx : Episodes of joint pain and stiffness in the past , with spontaneous resolution PSHx : None Meds : None Allergies : Noen FHx : Mother has possible rheumatoid arthritis. SHx: HAs 1 sexual partner and uses condoms Physical examination : Describe any positive and negative findings relevant to this patient’s [problem(s) . Be careful yo include only those parts of the examination performed i this encounter. . Vital signs : Temperature : 36.8’C (98.3F) , blood pressure : 120/75mmHg , Pulse : 78/min, respirations : 22/min . Face / neck : Multiple , well-circumscribes , erythematous macule without tenderness on palpation . Skin : No clines , vesicles , or cysts in rash area . . Joints : Normal range of motion in all joints without tenderness , edema , or erythema . HEENT : no pallor , jaundice or eye lesion . Lungs : CTA (C-lear T-o A-uscultate) bilaterally . Heart ; RRR without M/G/R Data interpretation: Based in what you have learned form the history and physical examination , lists up to 3 diagnosis that might explain this patient’s complaint(s) , List your diagnosis form most to least likely . For some cases , fewer than 3 diagnosis will be appropriate . then , enter the positive or negative diagnosis .Lastly , list initial diagnostic studies (if any) you would order for each listed diagnosis (eg , restricted physical exam maneuvers ,laboratory tests , imaging , ECG , eft.) . Diagnosis #1 : SLE History finding(s) . Cutaneous photosensitive rash . Fever . Joint pain Physical Examination finding(s) . Discoid lupus rash Diagnosis #2 : Rheumatoid arthritis History findings . Joint pain and morning stiffness . Fever . Family history Physical Exam findings . None Diagnosis #3 : Photodermatitis History finding(s) . History of sun exposure followed by rash Physical Exam finding(s) . Photosensitive rash on face and neck . No progression of rash to other areas Diagnosis Studies . ANA and anti-ds DNA . Rheumatoid factor and ESR . Skin biopsy -=-=-=-=-=>
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