| | 19 Case 19 scenario (abdominal pain RLQ)
Doorway information about patient
The patient is a 45-year-old man who comes to the emergency department due to right lower abdominal pain
Vital signs
. Temperature : 37.1’C (89.7F)
. Blood pressure : 130/80 mmHg
. Pulse : 100/min
. Respirations : 20/min
Basic differential diagnosis
. Appendicitis
. Mickel diverticulitis
. Perforation viscus
. Intestinal obstruction
. Yersinia enterocolitica
. Pancreatitis
. Urolithiasis
. Acute cholecystitis
. Herpis zoster (shingle)
—————
Case 19 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 45-year-old man who comes to the emergency department with abdominal pain
History of present illness
. The pain stated suddenly 2 hours ago
. Pain started behind the belly button , than radiated to the right lower abdomen
. Pain is sharp. 8-9/10 severity , and has increased over time
. The symptoms started after a large meal and are worse with movement ; nothing relives the pain
. Associated symptoms
- Nausea
- 2 episodes of non bilious , non bloody vomiting
. Last bowel movement was 20 hours ago , and you are passing gas normally
Review of systems
. No fever or chill
. No dysuria
. No diarrhea or constipation
. No back pain
Past medical/family/social history
. Peptic ulcer disease ; treated 10 years ago with omeprazole
. No current medications
. No surgeries
. Immediate family members are all healthy
. Occupation : Bus driver
. Single ,live alone
. Tobacco : 1 pack a day for 20 years
. Alcohol : 3 beer a day for past 15 years
. Recreational drugs : No
Physical examination
Abdomen :
. Right lower quadrant tenderness to superficial and deep palpation
. Rebound tenderness noted
. Normative bowel sounds throughout
. No hepatosplenomegaly
. No CVA tenderness
. Posts and obturator signs : Negative
—————
Case 19 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 location and radiation of pain
. Asked about the intensity of pain
. Asked about the quality of pain
. Asked about the origin and duration of pain
. Asked about the course of pain over time
. Asked about any aggravating or relieving factors
. Asked about any vomiting
. Asked about fever
. Asked bout urinary problems
. Asked about bowel problems , constipation , and last bowel movement
. Asked about appetite and change in weight
Past medical /family/social history
. Asked about similar episodes in the past
. Asked about past medical issues, hospitalizations , and surgeries
. Asked about current medications
. Asked about ,medical allergies
. Asked about family health
. Asked about tobacco , alcohol ,and recreational drug use
. Asked about sexual history
. Asked occupation
Examination
. Washed heads before examination
. Examined without gown , not through gown
. Auscultated abdomen(before palpation)
. Palpated abdomen(superficial and deep)
. Checked rebound tenderness
. Check for costovertebral angle tenderness
. Percussed for liver span
. Performed psoas sign and obturator sign
Counseling
. Explained physical findings and possible diagnosis
. Explained further workup
. Discussed lifestyle modifications , including quitting smoking and reducing alcohol
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
. Appendicitis
. Meckel diverticulitis
. Perforated peptic ulcer
. Intestinal obstruction
. Pancreatitis
. Urolithiasis
Diagnostic study/studies
. CBC with differential
. Serum chemistries(glucose, electrolytes , liver enzymes , creatinine)
. Serum lipas
. Abdomen x-ray
. Abdomen ultrasound
. Lipase, amylase
. Upper GI endoscopy
—————
Case 19 clinical summary
Clinical Skills Evaluation
Case 19 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).
. 45-yo man with 2 hors of worsening poplin form mid-epigastric region to RLQ
. Pain worse with movement but not relieved buy anything
. Nausea and vomiting (non-bloody , non-bilious)
. Last bowel movement 20 hours ago with passage flatus.
ROS : No fever , chills , diarrhea , constipation , or back pain
PMHx : Peptic ulcer disease
PSHx: None
Meds : None
Allergies : None
FHx : Father ,mother , and siblings are healthy
SHx : 1 PPD smoker for past 20 years , 3 beers .day for 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 signs : Temperature, 37.1’C(98.8F) ; blood pressure , 130/80mmHg ; pulse ,100/min ; and respirations , 20/min
. Abdomen ; RLQ tenderness to superficial and deep palpation , rebound tenderness present , normative bowel sounds throughout , no hepatosplenomegaly, no CVA tenderness ,negative psoas and obstructor signs
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 : Appendicitis
History finding(s)
. Sudden onset RLQ pain
. Nausea and vomiting
Physical examination finding(s)
. RLQ tenderness
. Rebound tenderness in abdomen
Diagnosis #2 : Perforated peptic ulcer
History finding(s)
. History of peptic ulcer
. Abdomen pain
. Alcohol use
Physical examination finding(s)
. Rebound tenderness in abdomen
Diagnosis #3 : Intestinal obstruction
History finding(s)
. Abdomen pain
. Last bowel movement 20 hors ago
Physical examination finding(s)
. Rebound tenderness in abdomen
Diagnostic studies
. CBC with differential
. Abdominal x-ray
. CT of the abdomen
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2018/08/15 03:36pm 
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