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-=-=-=-=-=> 7 Case 7 & scenario (diarrhea) Doorway information about patient The patient is a 35-year-old man who comes to the office due to acute diarrhea. Vital signs . Temperature: 36.7’C(98.1F) . Blood pressure: 110/65 mmHg . Pulse : 100 /min . Respirations: 18/min Basi differential diagnosis . Viral gastroenteritis . Bacterial gastroenteritis & food-borne pathogens . Medication induced . Giardiasis . Clostridium difficle colitis . Inflammatory bowel disease . Irritable bowel disease . Malabsorption . HIV ————— Case 7 sim. pt. instructions If the doctor asks you about anything otters than these . just say “no” , or provide an answer that a normal patient might give. You are a 35-year-old man who has diarrhea. History of present illness . Onset 1 day ago , 6-8 hours after meal . Ate salad and shrimp at a local seafood restaurant . Loose , watery stop,s with no blood or mucus . 6 or 7 bowel movements in 24 hours . Associated symptoms: - Diffuse abdominal cramps - Nausea and vomiting - Difficulty keeping down solids or liquids - no fever or chills . Nothing seems to make it worse , and you have not tried any over-the-counter treatments . 2 friends who ate with you have similar symptoms . No recent travel Review of system . Sinus infection 2 weeks ago , treated with amoxicillin (last dose 2 days ago) . No chest pain or shortness of breath . No urinary symptoms . No back pain Past medical / family / social history . No significant past medical problems or surgeries . No other medications (otters than amoxicillin) . No medication allergies . Bother parents and siblings (2 brothers) are healthy . Single , live alone . Occupation : Software engineer . Smoking : No . Alcohol : no . Recreational drugs: No Physical examination Head and neck: . No erythema or exudates in the mouth / pharynx . Dry mucous membranes . No enlarged lymph nodes Skin: . No jaundice Chest/lungs: . Clear to auscultation bilaterally Heart : . regular rhythm without murmurs , gallops , or rubs Abdomen: . Non tender, non distended . Normative bowel sounds throughout . Tympanic to percussion . No hepatosplenomegaly ————— Case 7 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 to clarify characteristics of diarrhea - Increased frequency ? Increased volume ? Altered consistency ? . Asked about the frequency of diarrhea . Asked about associated symptoms (eg,vomiting , fever , abdominal pain, anorexia, prior constipation , myalgia , tenesmus) . Asked about any blood or mucus in stools . Asked about any recent travel . Asked whether any otters family members or other contacts are sick . Asked about exposure to suspicious foods (eg, unpasteurized /undercooked food , unusual foods , dairy products , seafood) Past medical / family/ social history . Asked about prior episodes of diarrhea and gastrointestinal illness . Asked about otters medical issue . Asked bout medications (especially antibiotics) and medication allergies . Asked about recent and previous hospitalizations . Asked boy any abdomen surgeries . Asked bout occupation . Asked boy tobacco , alcohol , and drug use . Asked about family history (especially gastrointestinal disease) Examination . Examinee washed heads . Examined without gown , not though gown . Auscultated abdomen . Palpated abdomen superficially . Palpated abdomen deeply . Examination of skin for any rashes . Examination of oral cavity . Respiratory examination . Cardiac auscultation Counseling . Explained the physical findings and possible diagnosis . Explained further workup . Discussed need for rectal examination . Discussed fluids and otters basic interventions 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 heat 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 . Summarized the history and explained physical findings . Asked whether you have any concerns / questions Differential diagnosis .Viral gastroenteritis . Bacterial gastroenteritis . Clostridium difficile diarrhea Diagnostic study/ studies . Rectal examination . Fecal occult blood test . CBC with differential count . Basic metabolic panel (electrolytes , BUN , creatinine, glucose) . Stool for C. difficile toxin . Stool for fecal leukocytes ————— Case 7 clinical summary Clinical Skills Evaluation Case 7 Patient Note The following represents a typical note for this patient encounter . the details amy vary depending on the information given by the simulated patient. history : Describe the history you jus obtained for this patient . Include only information (permanent positives and negatives) relevant to this patient’s problem(s) . 35-yo male with 1 day of diarrhea with 6-7 loose BM/day without blood or mucus. . Ate seafood and salad at restaurant 6-8 hours before symptom onset. . Recent sinus infection treated with amoxicillin , last dose 2 days ago. . Diffuse crampy abdominal pain , nausea , vomiting , decreased PO intake. , Two otters friends who ate at the restaurant have the same symptoms, ROS : No fever , chills , chest pain , shortness of breath , burning with urination , rennet travel , or back pain. PMHx : None PSHx : None Meds : None Allergies : None FHx : Noncontributory SHx : Denies tobacco and alcohol use 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. . Viral signs: Temperature , 36.7’C (98F) ; blood pressure , 110/65 mmHg : pulse , 100/min ; and respirations , 18/min. . Head / neck : Oropharynx with dry mucous membranes but no erythema or exudates , no enlarged lymph nodes , no jaundice . Chest /lungs : Clear to auscultation bilaterally . Heart : RRR without M/G/R . Abdomen : Contender , non distended , normoactive bowel sounds thought ; tympanic on percussion ; no hepatosplenomegaly Data interpretation : Based on what you have learned form the history and physical examination , List 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 findings forth 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 exam maneuvers , laboratory test, imaging , ECG , etc.). Diagnosis #1 : Viral gastroenteritis History finding(s) . Diarrhea without fever . No blood in stool . Other sick friends who also ate at same place Physical Exam finding(s) . No fever Diagnosis #2 : Bacterial gastroenteritis History finding(s) . Symptom onset 6-8 hours after eating at a restaurant . Nausea , vomiting Physical Exam finding(s) . None Diagnosis #3 : Clostridium difficile colitis History finding(s) . Symptoms starting 2 days after rennet amoxicillin use . No blood in stool Physical Exam finding(s) . None Diagnostic Studies . Stool for leukocytes . Stool for Clostridium difficile . Rectal examination with FOBT -=-=-=-=-=>
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