| | 17 Case 17 scenario (jaundice)
Doorway information about patient
The patient is a 35-year-old woman who comes to the office due to jaundice
Vital signs
. Temperature : 38.5’C (101.3F)
. Blood pressure : 120/75 mmHg
. pulse : 98/min
. Respirations : 22/min
Basic differential diagnosis
. Infectious hepatitis
. Hemolytic jaundice
. Alcoholic hepatitis
. Drug-induced hepatitis
. Primary biliary cirrhosis
. Wilson disease
. Hemochromatosis
. Malignancy
—————
Case 17 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 comes to the clinic due to jaundice
History of present illness
. Onset of jaundice 2 days ago
. Fever beginning 5 days ago
. Dark urine and pale stools ,then yellowing of the eyes
. Associated symptoms :
- Mild abdomen discomfort
- 2-3 episodes non bilious , non bloody vomiting
- No sore throat , headache , neck stiffness , itching , diarrhea , or constipation
. Recent return form a trip to india (ate local food and drank bottled water)
. No vaccination for hepatitis in the past
Past medical history
. Motor vehicle accident 2 years ago requiring hospitalization and blood transfusion
. No surgires
. No medications
. No medication allergies
. Immediate family members 9parents and 3 siblings ) are all healthy
. Occupation: homemaker
. Married , live with husband
. 2 pregnancies with uncomplicated delivers
. Tobacco : no
. Alcohol : 2-3 beers a day for 15 years
. recreational drugs : No
Physical examination
HEENT
. PERRLA, EOMI
. Scleral icterus present
. Oropharynx clear
Neck :
. No lymphadenopathy
Abdomen :
. Non-tender , non-distended
. No hepatosplenomegaly
. Normative bowel sounds
—————
Case 17 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 and duration of jaundice
. Asked about the color of stool and urine
. Asked about itching /pruritis
. Asked about abdominal pain
. Asked about fever and chills
. Asked about appetite and changes in weight
. Asked about sore throat
. Asked about any bleeding tendencies
. Asked about enlarged glands
. Asked about travel history
Past medical /family/social history
. Asked about similar episodes before
. Asked about past medical issue (especially hepatitis ,liver disease , blood transfusion , high blood pressure , diabetes ) , hospitalizations , and surgeries
. Asked about current medications
. Asked about family health
. Asked bout tobacco , alcohol , and drug use
. Asked bout sexual and reproductive history
. Asked bout occupation
Examination
. Washed heads before examination
. Examined without gown , not through gown
. Auscultation abdomen
. Palpated abdomen (superficial abandon deep) , including liver and spleen
. Checked rebound tenderness
. Examined for enlarged nodes
Counseling
. Explained physical findings and possible diagnosis
. Explained further workup
. Explained the importance of lifestyle modifications (especially reducing alcohol intake)
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
. infectious hepatitis
. Alcohol hepatitis
. Drug-induced hepatitis
. Primary biliary cirrhosis
. Malignancy
Diagnostic study/studies
. CBC with differential
. Liver function tests (AST,ALT, alkaline phosphatase , bilirubin)
. Coagulation studies (PT,PTT)
. Viral hepatitis serologies ( HBs antigen , HBc antibody , hepatitis A antibody , hepatitis C antibody)
. Urine for bile salts
. Anti-mitochondrial antibodies
. Liver ultrasound
—————
Case 17 clinical summary
Clinical Skills Evaluation
Case 17 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 2 days of jaundice associated with fever
. Returned 3 weeks ago form trip to india
. Dark urine endplate stools
. Mild diffuse abdominal discomfort , nausea ,vomiting.
ROS : No sore throat , headache , stiff neck , dysuria , weight loss , itching , diarrhea , or constipation
PMHx: Car accident 2 years ago requiring hospitalization and blood transfusion
PSHx: None
Meds: None
Allergies : None
FHx: Father , mother and siblings are healthy
SHx: No history of tobacco use , 2-3 beers / day for the past 15 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 sign: temperature , 38.5’C (101.3F) ; blood pressure , 120/75 mmHg; pulse , 98/min; respirations , 22/min
. HEENT : PERRLA , EOMI , icterus present , oropharynx clear
. Neck : No lymphadenopathy
. Abdomen : Non-tender and non-distended , no hepatosplenomegaly , normative bowel sounds
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 : infectious hepatitis
History finding(s)
. Travel to India
. Jaundice
. Nausea , vomiting , abdomen discomfort
. Dark urine , pale stools
Physical examination finding(s)
. Fever
. Jaundice
Diagnosis #2 : Alcoholic hepatitis
History finding(s)
. Alcohol use
. Nausea , vomiting , abdominal discomfort
Physical examination finding(s)
. Fever
. Jaundice
Diagnostic studies
. Hepatitis serologies : A,B, and C
. CBC with differential
. Liver function tests
. Urinalysis
| | |
|
|
|
頂端 
加到"我的最愛"
主題管理：
總固頂 
取消總固頂 
Message
查看
搜尋
通訊錄
複製
引用
回覆
2018/08/15 03:34pm 
IP: 已設定保密