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-=-=-=-=-=> [這篇文章最後由JuanFe在 2019/05/23 08:10pm 第 1 次編輯] 39 Case 39 scenario Doorway information about patient ( epigastric pain ) The patient is a 53-year-old man who comes to the emergency department due to epigastric pain Vital signs . Temperature : 36.1’C . Blood pressure : 120/70 mmHg . Pulse : 84 /min . Respirations : 16/min Abdominal x-ray is as shown in the exhibit [UploadFile=practice20case20_1558613418.jpg] [UploadFile=practice20case20_1558613429.jpg] Basic differential diagnosis . Peptic ulcer . Gastritis . Esophagitis(GERD) . Carcinoma of esophagus , stomach , or pancreas . Acute or chronic pancreatitis . Cholecystitis . Hepatitis . Acute coronary event ————— Case 39 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 53-year-old man who abdominal pain History of present illness . Intermittent abdominal pain for the past 2 years . Located in midepigastric area and sometimes radiates to back . Sharp quality ; 7/10 severity at worst . Worse with meals and sometimes relieved with antacids; the pain also occurs in the middle of the night . Associated symptoms : - Decreased appetite with 6.8-kg(15-lb) weight loss in the last 6 months - Abdominal bloating and feeling of fullness - Occasional black stools . Asked the doctor : ” Can you please stop this pain ? Is it durable?” Review of systems . No fever or chills . No jaundice . No shortness of breath . No nausea , vomiting , diarrhea , or constipation Past medical / family / social history . Osteoarthritis of the knee for past 10 years . Surgeries : None . Medications : Ibuprofen 600 mg 3 times a day as needed , over-the-counter antacids as needed . No drug allergies . Father is healthy , mother died of pancreatic cancer at age 60, broth is healthy . Occupation ; stockbroker . Married , live with wife and 2 children . Tobacco : No Physical examination Neck : . Supple without thyromegaly or lymphadenopathy Abdomen : . Soft , non-tender, non-disveended . Normative bowel sounds throughout . No hepatosplenomegaly . No bruits ————— Case 39 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 pain . Asked about the course over time . Asked about the location and radiation of pain . Asked about the quality and intensity of pain . Asked about any aggravating or relieving factors (especially with relation of food) . Asked bout associated symptoms , especially : - Nausea - Vomiting - Heartburn - Black stools or red blood in stools - Jaundice - Changes in appetite or weight . Asked about dietary and bowel habits . Asked about postprandial fullness or early satisfy Past medical /family/social history . Asked about similar episodes in the past . Asked about previous medical issues , hospitalizations ,and surgeries . Asked about current medications . Asked bout medication allergies . Asked bout family health . Asked bout tobacco , alcohol , and recreational drug use . Asked about occupation Examination . Washed heads before examination . Examined without gown , not through gown . Examined heart and lungs . Examined abdomen (auscultation , superficial and deep palpation) . Palpated axilla and above clavicle for lymph nodes 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 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 . Gastritis (NSAID gastropathy) . Peptic ulcer . GERD . Gastric or pancreatic carcinoma . Chronic pancreatitis Diagnostic study/studies . CBC with differential count . Upper GI endoscopy . Serum amylase and lipase . Liver function tests (albumin , bilirubin, AST , ALT , alkaline phosphatase) . Fecal occult blood test . Abdomen ultrasound or CT scan ————— Case 39 clinical summary Clinical Skills Evaluation Case 39 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). . 53-yo man with 2 years of episodic midepigastric pain worse with food and sometimes relieved with antacids . Pain also occurring at night and sometimes radiating to the back . Pain is 7/10 severity . Decreased appetite , feeling of a full stomach . abdominal bloating , occasional back stools , and a 6.7-kg(15-lb) weight loss in the past 6 months. ROS : No jaundice , fever ,chills, vomiting , shortness of breath , diarrhea , or constipation PMHx : Osteoarthritis of the knee for past 10 years PSHx : None Meds : Over-the -counter antacids as needed , ibuprofen 600mg 3 times a day as needed Allergies : None FHx : Father healthy , mother died at age 60 of pancreatic cancer SHx : No tobacco use ; 2 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 , 36.1C (97F) ; blood pressure , 120/70 mmHg; pulse , 84/min; and respirations ,16/min . Neck : Supple without thyromegaly or lymphadenopathy . Heart : RRR with no murmurs . Lungs : Clear to auscultation and percussion . Abdomen : Non0tender , non-distended , normative bowel sounds throughout , no hepatosplenomegaly , no 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 : Peptic ulcer disease History finding(s) . Midepigastric pain . Relief with antacids . History of NSAID use Physical examination finding(s) . None Diagnosis #2 : Chronic pancreatitis History finding(s) . Chronic midepigastric pain . Pina radiating to back . History of alcohol use Physical examination finding(s) . None Diagnosis #3 : Gastric cancer History finding(s) . Midepigastric pain increased with food . Nocturnal pain . Weight loss Physical examination finding(s) . None Diagnostic studies . Abdominal X-ray (is normal) . CBC with differential . Serum amylase and lipase . Upper GI endoscopy . Liver function tests -=-=-=-=-=>
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