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-=-=-=-=-=> 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) ————— 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 ————— 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 ————— 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 -=-=-=-=-=>
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