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-=-=-=-=-=> 35 Case 35 scenario ( right lumbar lower abdominal pain ) Doorway information about patient The patient is a 35-year-old woman who comes to the office due to acute right lumbar and lower abdominal pain Vital signs . Temperature : 38.3’C (100.9F) . Blood pressure : 110/70 mmHg . Pulse : 100/min . Respirations : 16/min Basic differential diagnosis . Renal colic . Ovarian torsion . Urinary tract infection /pyelonephritis . Pelvic inflammatory disease . Mittelschmerz . Appendicitis . Threatened abortion . Ectopic pregnancy . Dysmenorrhea . Endometriosis . Fibroids ————— Case 35 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 35-year-old woman who has low back and abdominal pain History of present illness . 1 day of right low back pain that radiates to pelvis and lower abdomen . Sharp pain ; 7/10 severity . Progressively worsening and is not affected by positional charges . Preceded by burning with urination for 2-3 days . Associated with fever , chills , nausea (without vomiting) ,. and intermittent blood in urine . At the end of the interview say , “ aim in a lot of pain . please make it stop.” Review of systems . Last menstrual period 3 weeks ago . No vaginal discharge . No chest pain or shortness of breath . No diarrhea or consipation Past medical / family / social history . 2 pregnancies with uncomplicated vaginal delivery(G2P2) . Pelvic inflammatory disease 2 year ago . UTI twice 2 years ago treated with antibiotics . No surgeries or hospitalization . Medications : None . No drug allergies . Father , mother and sister are healthy . Occupation : Bank teller . Single , live with a children . Sexually active with boyfriend and do not usually use condoms . Tobacco : 1 pack a day for last 15 years . Alcohol L Occasional beer or wine . Recreational drugs : None Physical examination Abdomen : . Diffused abdominal discomfort during the examination but no focal tenderness . Non-distended . Normative bowel sounds . No hepatosplenomegaly . Mild CVA tenderness on the right . Negative psoas test ————— Case 35 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 if pain and course over time . Asked bout the location and radiation of pain . Asked bout the quality and intensity of pain . asked bout nay aggravating or relieving factors . Asked bout associated symptoms , especially : - Fever and chills - Nausea and vomiting - Constipation or diarrhea - Urinary symptoms (eg, burning , blood in urine, frequency) - Vaginal bleeding/ discharge . Asked about last menstrual period and menstrual cycle . Asked bout sexual practices and use of contraception Past medical /family/social history . Asked about similar episodes in the past . Asked about past medical issues (especially urinary tract infections , pelvic inflammatory disease , kidney stones) . Asked about hospitalizations and surgeries . Asked about current medications . Asked bout medication allergies . Asked about family health . Asked about occupation . Asked about tobacco , alcohol , and recreational drug use Examination . Washed heads before examination . Examined without gown , not through gown . Auscultated abdomen . Palpated abdomen (superficial and deep) . Tested for rebound tenderness and rigidity . Tested for constovertebral angle tenderness . Tested for signs of appendicitis (eg , psoas test) Counseling . Explained physical findings and possible diagnosis . Discussed the need for pelvic examination . 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 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 . Renal colic . UTI/ acute pyelonephritis . Pelvic inflammatory disease . Uterine fibrosis . Appendicitis Diagnostic study/studies . Pelvic examination . Pregnancy test . CBC with differential count . Urinary and culture . Abdomen ultrasound . Urine PCR for gonorrhea and chlamydia ————— Case 35 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). . 35-yo woman with 1 day of ship right flank pain radiating to the right pelvis and lower abdomen . Pain is 7 on scale of 10 . Progressive , worsening pain without relief and unaffected by position . Dysuria , fever , chills , nausea , and occasional hematuria ROS : No vaginal discharge , chest pain , shortness pf breath , diarrhea , or constipation PMHx : G2P2 , PID 2 years ago , UTI 2 years ago PSHx : None Meds : None Allergies ; None FHx : Father , mother , and sister are healthy SHx : 1 PPD smoker for 15 years , occasional alcohol use 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 (100.9’F) ; blood pressure , 110/70 mmHg; pulse 100/min; and respirations , 16/min . Abdomen : Diffuse abdominal discomfort without focal tenderness , non-distended , normative bowel sounds , no hepatosplenomegaly , mild CVA tenderness son the right , negative psoas test 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 : Nephrolithiasius with hydronephrosis History finding(s) . Frank pain radiating to lower abdomen . No comfort with any position change Physical examination finding(s) . Fever . CVA tenderness Diagnosis #2 : Pyelonephritis History finding(s) . Dysuria . Hematuria . Fever Physical examination finding(s) . CVA tenderness . Fever Diagnosis #3 : Pelvic inflammatory disease History finding(s) . Previous PID . Sexually active without condom use . Lower abdominal pain Physical examination finding(s) . None Diagnostic studies . Pregnancy test . Pelvic examination . CBC with differential . Urinalysis and urine culture -=-=-=-=-=>
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