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JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1118 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É22¤À57¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 16 ¼Ó]   15 Case 15 scenario (shortness of breath) Doorway information about patient The patient is a 60-year-old man who comes to the emergency department due to acute shortness of breath. Vital signs . Temperature: 36.7¡¦C(98F) . Blood pressure : 110/70 mmHg . Pulse : 90 /min . Respirations : 26/min Basic differential diagnosis . Pulmonary embolism . Congestive heart failure . Chronic obstructive pulmonary disease exacerbation . Pneumonia . Spontaneous pneumothorax . Asthma exacerbation . Anxiety/panic attack ¡X¡X¡X¡X¡X Case 15 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 60-year-old man with acute shortness of breath. History of present illness . Onset 2 days ago . Mild shortness of breath with strenuous work that has slowly worsened over the past year. but is now suddenly worse . Not of breath with walking 1 block . Occasional dry cough . No fever , chills , or unusual fatigue . No syncope or palpations . No swelling in the legs . Difficulty at night . Worsen when lying down and better when sitting up Do not volunteer this information unless asked : You sleep on 2 pillows because you get short of breath when lying flat , also , you woke up in the middle of the night weigh shortness of breath and could not go back to sleep for 20 minutes. Past medical history . Spinal fusion surgeries 2 weeks ago for spinal stenosis that required 1 week in the hospital postoperatively . Hypertension diagnosed 20 years ago . Medications ; hydrochlorothiazide 25mg daily . Medication allergies : None . Father died of a heart attack at age 55; mother is alive and has hypertension ; no siblings . Occupation : Computer software analyst . Married , live with wife . Tobacco ; 1 pack of cigarettes a day for 40 years . Alcohol : 1-2 glasses of wine a day for 35 years . Recreational drugs : None Physical examination HEENT : . PERRLA , EOMI Neck : . Supple without lymphadenopathy . No JVD . No thyromegaly Lungs : . Clear to auscultation and percussion Heart : . Regular rate and rhythm . No murmurs , gallops , or rubs Extremities : . No edema , cyanosis , or clubbing . Pedal pulse 2+ bilaterally . No calf tenderness to palpation ¡X¡X¡X¡X¡X Case 15 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 symptoms . Asked about the course over time . Asked about associated symptoms : - Chest pain - Orthopnea and paroxysmal nocturnal dyspnea - Wheezing - Coughing - Fever and chills - Palpitations - Syncope - Leg pain and swelling . Asked about recent travel or prolonged immobilization (recent surgery) Past medical /family/social history . Asked about similar episode in the past . Asked about past medical issue (especially high blood pressure ,heart problems , asthma , and chronic obstructive pulmonary disease) . Asked about surgeries and hospitalizations . Asked about current medications . Asked about medication allergies . Asked about occupation . Asked about tobacco , alcohol , and drug use . Asked about family history of blood clots and heart problems Examination . Washed heads before examination . Examined without gown , not through gown . Examined neck for jugular venous pressure . Examined heart : inspection , palpation , auscultation . Examined lungs : inspection , palpation , auscultation , percussion . Examined the extremities for pulses and edema . Checked calf muscle tenderness Counseling . Explained physical findings and possible diagnosis . Explained further workup . Discussed quitting smoking 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 . Pulmonary embolism . Pneumonia . Congestive heart failure . Chronic obstructive pulmonary disease Diagnostic study/studies . CBC with differential count . Chest x-ray . ECG . Ventilation / perfusion (V/Q) scan or  chest CT scan . Echocardiogram ¡X¡X¡X¡X¡X Case 15 clinical summary Clinical Skills Evaluation Case  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). . 60-yo man with 2 days of worsening shortness of breath. . 1 years of gradually worsening shortness of breaths that acutely worsened 2 days ago. . New 2 -pillow orthopnea , PND. . Spinal fusion surgery 2 weeks ago. . Occasional dry cough. ROS: No chest pain , wheezing , fatigue , palpations , leg swelling , syncope , fever , or chills PMHx : HTN PSHx : Spinal fusion surgery Meds : Hydrochlorothiazide 25 mg daily Allergies : None FHx: Father died of MI at age 55 , mother has HTN SHx : 1 PPD smoker for 40 years , 1 or 2 glasses of wine /day for 35 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 , 36.7¡¦C(98.1F) ; blood pressure , 110/70 mmHg; pulse , 90/min; and respiration , 26/min . HEENT : PERRLA , EMOI , no jaundice . Neck ; Supple without lymphadenopathy , no JVD , no thyromegaly . Lungs ; clear to auscultation . Heart : RRR without murmurs, gallops , or rubs . Extremities ; No edema , pulse 2+ bilaterally , no cyanosis or clubbing , no lower extremities tenderness on palpation 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 :Pulmonary embolism History finding(s) . Acute worsening of dyspnea . Tecent spinal fusion surgery Physical examination finding(s) . None Diagnosis #2 : Congestive heart failure History finding(s) . 1 year of gradually worsening dyspnea . Dyspnea worse with exertion . Orthopnea and PND Physical examination finding(s) . None Diagnosis #3 : COPD History finding(s) . History of smoking . 1 year of gradually worsening dyspnea . Cough Physical examination finding(s) . None Diagnostic studies . Chest x-ray . CT anagram of chest . CBC with differential . Basic metabolic panel . ECG , echocardiogram 2018/08/15 03:32pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 7910 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1118 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É22¤À57¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 17 ¼Ó]   16 Case 16 scenario (increase urination) Doorway information about patient The patient is a 40-year-old woman who comes to the office due to increased urination Vital signs . Temperature : 36.7¡¦C (98F) . Blood pressure : 110/70 mmHg . Pulse : 86/min . Respirations : 16/min Basic differential diagnosis Increased urine volume . Diabetes mellitus . Diabetes insipidus (central, nephrogenic) . Psychogenic : polydipsia . Diuretic use . hypercalcemia increased urinary frequency . Urinary tract infection . Overactive bladder . Excess caffeine intake . Vaginitis , urethritis ¡X¡X¡X¡X¡X Case 16 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 40-year-old women complaining of increased urinary frequency History of present illness . Onset 2  months ago . Urination 8-10 times during the day and 2-3 times a night . increased urinary volume . Increased feelings of thirst for last month . Associated symptoms: - Fatigue - 4.5-kg (10-lb) weight loss (despite increased appetite) - No dysuria or urgency - No fever or chills Past medical/family/soical history . Bipolar disorder diagnosis 20 years ago . Minor head injury after falling off bicycle 3 months ago ; seen in emergency department and discharged without intervention . No surgeries or hospitalizations . Medications : lithium 60 mg twice daily . Medication allergies : None . Married , live with husband . 2 pregnancies with normal vaginal delivery ; both children are healthy . Both parents have type 2 diabetes mellitus l no siblings . Tobacco : No . Alcohol : No . Recreational drugs : No Physical examination HEENT : . PERRLA , EOMI . Visual fields intact Heart : . Regular rate and rhythm . No murmurs , gallops , or rubs Abdomen : . Soft and non-tender with normal bowel sounds . No suprapubic or CVA tenderness Neurologic : . Muscle strength 5/5 throughout . Sensation in tact in all 4 extremities . reflexes 2+ in all 4 extremities ¡X¡X¡X¡X¡X Case 16 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 problem . Asked about the frequency of urination . Asked about nocturia . Asked about nocturne . Asked about urine volume . Asked about burning on urination . Asked about urgency and hesitancy of urination . Asked boy increased thirst and fluid intake . Asked about appetite  and changes in weight . Asked about the trauma to the head Past medical /family/social history . Asked about similar problems in the past . Asked about past medical issues , hospitalizations ,and surgeries . Asked about psychiatric problems (history of bipolar disorder , schizophrenia) . Asked about current medications . Asked about family health(especially diabetes) . Asked about tobacco , alcohol , and drug use . Asked about occupation Examination . Washed heads before examination . Examined without gown , not through gown . Examined mucous membranes . Examined heart and lungs . Tested muscle power in both upper and lower limbs . Tested sensation in the lower extremities . Tested reflexes in the lower extremities . Tested visual fields and examined funds . Tested for suprapubic and costovertebral angle tenderness 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 . Diabetes mellitus . Central diabetes insipidus . Nephrogenic diabetes insidious (lithium side effect) . Psychogenic polydipsia . Hypercalcemia Diagnostic study/studies . Fasting blood sugar . Urinalysis . Serum electrolytes (Na,K, Cl , CO2 , BUN , Cr , and calcium) . Urine and serum osmolality ¡X¡X¡X¡X¡X Case 16 clinical summary Clinical Skills Evaluation Case  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). . 40-yo woman with 2 months of polyuria , polydipsia, nocturia , and polyphagia . 2-3 month of 4.5-kg(10-lb) weight loss with fatigue . No dysuria or urinary urgency ROS : No fever or chills PMHx : bipolar disorder diagnosed 20 years ago ; minor head trauma 3 months ago , seen in emergency department and discharged without intervention PSHx : None Meds : Lithium 600 mg 2 times daily Allergies : None FHx : Father and mother have diabetes SHx : No history of tobacco or alcohol use 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 , 36.7¡¦C(98.1F) ; blood pressure , 110/70mmHg; pulse , 86/min; and respirations , 16/min . HEENT : PERRLA , EOMI, intact visual fields . Abdomen : Non-tender without suprapubic tenderness, np CVA tenderness . Neurologic L muscle strength 5/5 throughout sensation grossly intact bilateral lower extremities , DTR 2 + in bilateral lower extremities 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 : Diabetes mellitus History finding(s) . Polyuria . Polydipsia and polyphagia . Family history of diabetes in father and mother . Weight loss Physical examination finding(s) . None Diagnosis #2 : Diabetes insipidus History finding(s) . History of bipolar disorder . Lithium use . Polyuria Physical examination finding(s) . None Diagnosis #3 : Psychogenic polydipsia History finding(s) . history of bipolar disorder . Polyuria . Polydipsia Physical examination finding(s) . None Diagnostic studies . Fasting blood glucose . Hemoglobin A1c . Urinalysis . Serum electrolytes , lithium level . Urine and serum osmolality 2018/08/15 03:33pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 7569 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1118 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É22¤À57¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 18 ¼Ó]   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 ¡X¡X¡X¡X¡X 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 ¡X¡X¡X¡X¡X 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 ¡X¡X¡X¡X¡X 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 2018/08/15 03:34pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 7196 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1118 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É22¤À57¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 19 ¼Ó]   18 Case 18 scenario (chest pain) Doorway information about patient The Patient is a 35-yea-old woman who comes to the emergency department due to chest pain Vital signs . Temperature ; 36.8¡¦C (98.3F) . Blood pressure : 120/75 mmHg . Pulse : 98/min . Respirations : 12 /min Basic differential diagnosis . Pneumonia . Gastroesphageal reflux disease . Pain disorder/ hyperventilation syndrome . hyperthyroidism . Angina . Costochondritis ¡X¡X¡X¡X¡X Case 18 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 with chest pain History of present illness . Onset of this episode 1 days ago . Squeezing sensation over the entire chest . 4-5/10 severity . No aggravating or relieving factors ( no relief form antacids) . Intermittent chest discomfort for the last year; episodes usually last 20 minutes ; initially about once a month but now every week; usually triggered buy going out in public . Associated symptoms: - Fasting breathing - Sweating - Headache - Palpations . Hospitalized over might 6 months ago for the same problem; all tests came back normal Review of systems . No nausea , vomiting , diarrhea , or abdominal pain . No dysuria . Headache . Palpitations Past medical history . Hospitalized following a motor vehicle accident 32 years ago (required blood transfusion) . No surgeries . Medications : None . Medication allergies : None . After os healthy ; mother has ¡§hypochondriasis¡¨ ; sister has hyperthyroidism . Occupation : Secretary at a law firm . Single, live a lone . Tobacco : 1 pack a day for 15 years . Alcohol : None . Recreational drugs ; None Physical examination Neck : . No lymphadenopathy . No thyromegaly Lungs : . Clear to auscultation bilaterally Heart : . Regular rate and rhythm . No murmurs, gallops , or rubs Ask this question : ¡§Do you think that this is a heart attack ? I feel like I am going to die ¡§ ¡X¡X¡X¡X¡X Case 18 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 of pain . Asked about the intensity of pain . Asked about the quality of pain . Asked about the duration and frequency of pain . Asked about the course of the painter time . Asked about any radiation of pain . Asked about any aggravating or relieving factors . Asked about any precipitating factors . Asked about associated symptoms - Nausea and vomiting - Sweating - hyperventilation or trouble breathing - Cough - Palpitations or rapid heart beat - Fear of dying or sense of tremor - Syncope or dizziness - Headache - changes in appetite or weight Past medical /family/social history . Asked about similar episodes in the past . Asked about past medical issues (especially high blood pressure , heart problems , diabetes , thyroid problems) . Asked about previous hospitalizations and surgeries . Asked about current medications . Asked about medication allergies . Asked about family health . Asked about tobacco , alcohol , and drug use . Asked about sexual and reproductive history . Asked bout occupation and stress in life Examination . Washed heads before examination . Examined without gown , not through gown . Examined neck and thyroid . Listened to heart and lungs . Check reflexes Counseling . Explained physical findings and possible diagnosis . Discussed result of chest x-ray . Explained further workup . Discussed quitting smoking 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 . Panic disorder . Hyperthyroidism . Hyperventilation syndrome , Angina Diagnostic study/studies . CBC with differential . Electrolytes and blood glucose . ECG . TSH ¡X¡X¡X¡X¡X Case 18 clinical summary Clinical Skills Evaluation Case 18 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 1 year of worsening episodes of chest pain . Diffuse chest tightness associated with headache , palpations , diaphoresis , hyperventilation ,a dn sense of impending doom . Previous hospitalization with normal testing . Episodes occur more often when out in public and are not relieved with antacids. ROS : No nausea , vomiting , dysuria , constipation , flushing , sleep disturbance , or abdominal pain PMHx: None PSHx: None Meds: None Allergies : None FHx : Fater os healthy , mother has hypochondriasis , and sister has hyperthyroidism SHx : 1 PPD smoker for 15 years , no use of alcohol or illicit drugs 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 , 36.8¡¦C (98.3F); blood pressure , 120/75mmHg; pulse , 98/min; and respirations, 12/min . Neck : No lymphadenopathy por thyromegaly . Lungs ; Clear to auscultation bilaterally . heart : RRR without murmurs, gallops, or rubs 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 : Panic disorder History finding(s) . Episodes of chest pain . Worse when in public . Normal investigation in the past Physical examination finding(s) . Normal vital signs . Normla cardiac examination Diagnosis #2 : Hyperthyroidism History finding(s) . Family history . Palpitations Physical examination finding(s) .None Diagnosis #3 : Cardiac arrthemia History finding(s) . Episodic palpations . Chest pain and diaphoresis Physical examination finding(s) . None Diagnostic studies . ECG . TSH . Chest x-ray shows only mild hyperinflation 2018/08/15 03:35pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 7508 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1118 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É22¤À57¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 20 ¼Ó]   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) ¡X¡X¡X¡X¡X 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 ¡X¡X¡X¡X¡X 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 ¡X¡X¡X¡X¡X 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 2018/08/15 03:36pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 7481 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1118 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É22¤À57¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 21 ¼Ó]   20 Case 20 scenario (leg pain bilateral) Doorway information about patient The patient is a 50-year-old man who comes to the office due to bilateral leg pain Vital signs . Temperature : 36.7¡¨C(98F) . Blood pressure : 140/80 mmHg . Pulse : 78/min . Respirations : 20 /min Basic differential diagnosis Bilateral pain . Atherosclerotic vascular disease . Lumber spinal stenosis . Diabetic polyneuropathy . Radiculopathy due to spinal disease . Medications , such as statin . Trauma . Thromboangiitis obliterans Unilateral pain . Cellulitis / myofasciitis . Deep vein thrombosis . Rupture of baker cyst . Osteomyelitis . Radiculopathy /sciatica . Pathological fracture of the bone ¡X¡X¡X¡X¡X Case 20 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 50 year-old-man with bilateral leg pain History of present illness . Onset 2 months ago . Pain stated gradually and has become progressively worse . Throbbing pain with 5-6 /10 severity . Located in the calf muscles , no radiation . Worse with walking , running , and prolonged standing . Better while sitting and at rest . No history of trauma Review of systems . No fever . No back pain . No weakness , numbness , or tingling in the leg . No sexual or bladder symptoms Past medical / Family / social history . Diabetes for the past 3 years , controlled by diet . High cholesterol . No surgires . Medications : Simvastain 40 mg  daily at bedtime . Allergies : No . Father died at age 65 of a stroke ; mother and 2 sibling are healthy . Occupation: Postal worker . Married , live with wife . Tobacco : 2 pack a day for past 30 years . Alcohol : Occasional beer . Recreational drugs : No Physical examination Abdomen: . No bruits Extremities . Pulse 2+ and symmetrical in bilateral lower extremities Musculoskeletal . Negative Homans sign . ,No calf tenderness to palpation bilaterally Neurologic . Motor strength 5/5 in both lower extremities . Grossly intact sensation . Deep tendon reflexes 2+ symmetrically ¡X¡X¡X¡X¡X Case 20 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 the pain . Asked about the onset of pain . Asked about whether it is continuous or intermittent pain . Asked about the intensity of pain . Asked about the quality of pain . Asked about the course of pain over time . Asked about any aggravating or relieving factors . Asked about rest pain . Asked about swelling of the legs . Asked about sensory changes ( such as numbness ) and paresthesia . Asked boy any weakness of the legs . Asked about any history of back pain . Asked about fever . Asked about trauma to the legs . Asked about other joint pain . Asked about recent surgeries or prolonged immobilization . Asked about impotence Past medical /family/social history . Asked about similar episodes in the past . Asked about past medical issues (especially high blood pressure , diabetes , high cholesterol, disc prolapse) . Asked about current medications . Asked about family health (especially history of blood clots) . Asked about tobacco , alcohol , and recreational drug use . asked bout occupation Examination . Washed heads before examination . Examined without gown , not through gown . Examined calf tenderness . Elicited Homans sign . Checked pulses in both legs and  arms . Listened for bruits at the distal aorta , iliac , or femoral arteries . Checked sensation in both legs . Checked reflexes in bother legs . Checked for vibration sense in both legs Counseling . Explained physical findings and possible diagnosis . Explained further workup . Discussed lifestyle modifications, including quitting smoking 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 . 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 . Thromboangiitis obliterans . Atherosclerotic vascular disease . Drug induced (statins) . Diabetic polyneuropathy Diagnostic study/studies . Creatinine kinase . Blood sugar and hemoglobin A1c . Lipid profile . Arterial doppler study coif the lower extremities . Duplex venous ultrasound of power limbs . CBC with differential . Spine MRI ¡X¡X¡X¡X¡X Case 20 clinical summary Clinical Skills Evaluation Case 20 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). . 50-yo man with 2 months of worsening bilateral leg pain . Trolling pain mainly over the calf muscle made worse with walking , running, and prolonged standing. . Symptom improvement with rest and sitting ROS : No pain at rest , fever , trauma , swelling , back pain, weakness , sexual difficulties , numbness , or tingling in legs PMHx : Diabetes for 3 years under diet control , hypercholesterolemia PSHx : None Meds: Simvasatin 40 mg daily at bedtime Allergies : None FHx : Father died at age 65 of stroke ; mother and 2 siblings are healthy SHx : 2 PPD smoker for past 30 years , occasional alcohol use 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 , 36.7¡¦C (98.1F); Blood pressure , 140/80 mmHg; pulse , 78/min; and respirations ,20/min . Abdomen : No bruits . Extremities : Pulse 2+ and symmetrical in bilateral lower extremities . Musculoskeletal : Negative Homans sign , no calf tenderness to palpation bilaterally . Neurologic : bilateral lower extremities with 5/5 motor strength , intact vibratory sensation and proprioception, and DTR 2+ 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 : Drug-induced (statin) myopathy History finding(s) . Proximal muscle pain . History of statin use Physical examination finding(s) . Normal motor strength in legs . No sensory deficits in legs Diagnosis #2 : Atherosclerotic peripheral vascular disease History finding(s) . History of diabetes and high cholesterol . History of smoking . Family history of stroke Physical examination finding(s) . None Diagnosis #3 : Diabetic polyneuropathy History finding(s) . Diet-controlled diabetes . History of high cholesterol Physical examination finding(s) . None Diagnostic studies . Creatinine kinase . Fasting blood sugar and hemoglobin A1c . Lower-extremity arterial Doppler 2018/08/15 03:37pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 8262 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1118 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É22¤À57¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 22 ¼Ó]   21 Case 21 scenario (vomiting) Doorway information about patient The patient is a 56-year-old woman who comes to the emergency department due to vomiting Vital signs . Temperature : 36.7¡¦C (98F) . Blood pressure : 90/60 mmHg . Pulse : 98/min . Respirations : 20/min Clinical Images The paint has vomited into a pan of water at the bedside , as shown in the image : frank-blood or coffee-ground vomiting Basic differential diagnosis . Peptic ulcer disease . Gastric erosion . Esophageal varices . Mallory-Weiss tears . Esophagitis . Duodenitis . Malignancy (esophageal and gastric) ¡X¡X¡X¡X¡X Case 21 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 56-year-old woman who is vomiting up blood History of present illness . Felt lightheaded while climbing stairs at home and passed out (2 hours ago) . Sharp mid-epigastric pain starting 1 day ago (4-5/10 severity , no radiation) . Nausea that is worse today . Threw up a teaspoon of blood twice at home ; threw up more blood in the emergency department . Back stools for 1 week Review of systems . No changes in appetite or weight . No fever or chills . No shortness of breath . No otters dizziness or chest pain Past medical history / family / social history . GERD for past 2 years relieved with antacids as needed . Chronic back pain . No surgeries . Medications : Ibuprofen as needed . No allergies . Father died of heart attack at age 60; mother and 2 siblings are healthy . Single ,live with roommate . Tobacco : 1 pack a day for past 25 years . Alcohol : 4-5 beers a day for past 20 years . Recreational drugs : No Do not volunteer this information unless asked about problems with drinking: You were admitted to an alcohol; treatment facility 1 years ago and left after 1 week Physical examination HEENT : . Oropharynx clear CV : . Regular rate and rhythm . No murmurs Abdomen : . Non-tender , non-distended . Normative bowel sounds . No hepatosplenomegaly ¡X¡X¡X¡X¡X Case 21 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 vomiting . Asked about the frequency of vomiting . Asked about any blood in the vomit (frank-blood or coffee-ground vomiting) and quantity of blood . Asked about any abdomen pain associated with the vomiting . Asked about prior history abdomen pain ( or heartburn ) especially in relation to food . Asked specifically about melena (black stools) . Asked about recent change in appetite and weight loss Past medical /family/social history . Asked about similar episodes in the past . Asked about other medical issues (peptic ulcer disease , reflux disease , liver problems),hospitalizations , and surgeries . Asked about current medications . Asked about medication allergies . Asked about family health (including bleeding problems) . Asked about tobacco , alcohol , and recreational drug use (including detailed discussion of alcohol abuse and treatment) . Asked about occupation Examination . Washed heads before examination . Examined without gown , not through gown . Performed orthostatic vital signs . Examined oropharynx . Auscultated abdomen (prior to palpation) . Palpated abdomen (superficial and deep) . Checked for rigidity and rebound . Percussed for liver span . Performed neurologic examination . Performed cardiovascular examination Counseling . Explained physical findings and possible diagnosis . Explained further workup (blood test,endoscopy) . Explained the importance of lifestyle modifications , including quitting smoking and 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 . Variceal hemorrhage . Peptic ulcer decease . Gastric erosions . Esophagitis . Duodenitis Diagnostic study/studies . CBC with differential count . PT/PTT/INR . BUN, serum creatinine , electrolytes . Upper GI endoscopy . Liver function test (albumin, AST,ALT, alkaline phosphatase , total and direct bilirubin) . ECG ¡X¡X¡X¡X¡X Case 21 clinical summary Clinical Skills Evaluation Case 21 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). . 56-yo woman with syncope while climbing stairs . Followed by recurrent hematemesis over the last 2 hours . History of GERD  relieved with as-needed antacids. . 1 day of mid-epigastric abdomen pain without radiation , associated with nausea . 1 week of melena ROS : No changes in appetite , weight loss , fever , chills , shortness of breath , or chest pain PMHx: GERD , chronic back pain , alcohol abuse PSHx: None Meds : ibuprofen , as needed Allergies : None FHx: Father died at age 60 of heart attack ; motor and 2 siblings are healthy SHx: 1 PPD smoker for past 20 years , 4-5 beers /day for past 20 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 ,36.7¡¦C(98.1F); blood pressure , 90/60 mmHg; pulse , 98/min ; and respirations , 20/min . HEENT : Oropharynx clear . Heart : RRR with no M,G,R. Abdomen : non-tender , non-distended , normative bowel sounds , no hepatosplenomegaly 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 : Bleeding esophageal varices History finding(s) . History of ibuprofen and excessive alcohol use . Mid-epigastric pain . Hematemesis and melena Physical examination finding(s) . None Diagnosis #2 : Bleeding peptic ulcer History finding(s) . History of GERD and excessive alcohol use . Mid-epigastric pain and hematemesis . Melena Physical examination finding(s) . None Diagnosis #3 : Gastritis History finding(s) . History of ibuprofen and excessive alcohol use . Mid-epigastric pain . Melena Physical examination finding(s) . None Diagnostic studies . Orthostatic BP and HR measurement . CBC with differential . Basic metabolic panel . Liver function test . PT/PTT/INR . Upper GI endoscopy 2018/08/15 03:38pm¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 7952 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1118 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É22¤À57¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 23 ¼Ó]   22 Case 22 scenario (chest pain) Doorway information about patient The patient is a 55-year-old man who comes to the emergency department due to chest pain Vital signs . Temperature : 37.1 C (98.7F) . Blood pressure : 130/80 mmHg . Pulse : 78 /min . Respirations : 20/min Clinical images ECG is shown in the image : S-T segment lowered Basic differential diagnosis . Miocardio infarction . Unstable angina . Pulmonary embolism . Costochrondritis . Pleuritis . Pericarditis . Aortic dissection . Gastroesophageal reflux . Esophageal; perforation ¡X¡X¡X¡X¡X Case 22 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 55-year-old man who comes to the emergency department with chest pain. History of present illness . The pain came on suddenly and has progressively worsened . Pain located in substernal area with no radiation . ¡§Tight , squeezing ¡§ sensation with 8-9/10 severity . Pain is worse when walking and moving around . Associated symptoms: - Nausea - 1episode of vomiting - Sweating - Mild shortness of breath Review of systems . No fever , cough , headache . abdominal pain , diarrhea , constipation , recent trauma, appetite changes   weight loss , or urinary problems Past medical history . High blood pressure for 20 years . Diabetes for 5 years . Cholesterol tested a year ago was 280 ( you are trying to control your cholesterol who diet but not eat a lot of fast food) . No surgires . Medications : lisinopril , metformin . No allergies . Father died at age 60 of heat attack ; mother tis living and ad stroke at age 65 ; brother had a heart attack at age 58 . Occupation : lawyer . Married , live with wife . Tobacco : 1 pack a day for the past 30 years . Alcohol : 1 glass of wine a day for past 20 years . Recreational drugs : No Physical examination Physical examination Neck : . supple without JVD or lymphadenopathy . No thyromgaly Lungs : . Clear to auscultation bilaterally . No reproducible chest pain with palpation Heart : . Regular rate and rhythm . No murmurs , gallops , or rubs Review of system You have non of the following: . Fever . Cough . Headache . Abdominal pain . Diarrhea . Constipation . Recent trauma . Appetite changes . Weight loss . Urinary problems ¡X¡X¡X¡X¡X Case 22 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 associated symptoms , especially : - Nausea and vomiting - Sweating - Fever - Coughing - Shortness of breath - Palpitations - Syncope and dizziness Past medical /family/social history . Asked about similar episodes in the past . Asked about past ,medical issue (especially high blood pressure , heart problems , diabetes , heart burn/reflux), hospitalizations , and surgeries . Asked about current medications and medication allergies . Asked about family health . Asked about tobacco , alcohol , and recreational drug use . Asked about occupation and stress in life . Asked about cholesterol level (if known) Examination . Washed heads before examination . Examined without gown , not through gown . Examined carotid artery and jugular viens . Examined heart (inspection , palpation , auscultation) . Auscultated the lungs . Examined peripheral pulse and edema . Examined abdomen Counseling . Explained the physical findings and possible diagnosis . Discussed ECG result . Explained further workup . Discussed lifestyle modifications ( especially quitting smoking and moderate 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 . Myocardial infarction . Unstable angina . Pulmonary embolism . Aortic dissection . Gastroesphageal reflux Diagnostic study/studies . Complete blood count . Cardiac markers (eg, troponin) . Electrolytes . blood urea nitrogen, creating , glucose . Chest x-ray . Echocardiogram ¡X¡X¡X¡X¡X Case 22 clinical summary Clinical Skills Evaluation Case  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). . 55-yo man with 2 hours of chest pain described as substernal tightness and pressure and increased  with movement and walking ; pain of 8-9 lb on a scale of 10 , no radiation. . Associated nausea , vomiting , sweating , and shortness of breath ROS : No fever , cough , headache , abdominal pain , diarrhea , constipation , recent trauma, appetite change , weight loss , or urinary problems PMHx : HTN , diabetes , hight cholesterol PSHx : None Meds : lisinpril, metformin Allergies : None FHx: Fateghr died at age 60 of heat attack , motor had a stroke at age 65 , and mother had a heart attack at age 58 SHx: 1 PPF smoker for past 30 years , 1 glass of wine/day for past 20 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 , 130/80 mmHg; pulse , 78/min; and respirations , 20/min . Neck ; Supple without JVD or lymphadenopathy , no thyromegaly . Lungs ; Clear to auscultation bilaterally , no reproducible chest pain to palpation . Heart : RRR without murmurs , gallops , or rubs 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 : Acute contrary syndrome History finding(s) . Substernal chest pain . History of multiple cardiac risk factors . Nausea , vomiting , diaphoreses Physical examination finding(s) . No reproducible chest pain to palpation Diagnosis #2 : Aortic dissection History finding(s) . History of hypertension . substernal pain . Sudden-onset symptoms Physical examination finding(s) . No reproducible chest pain to palpation Diagnosis #3 : Pulmonary embolism History finding(s) . Sudden -onset chest pain . Shortness of breath Physical examination finding(s) . No reproducible chest pain to palpation Diagnostic studies . ECG shows ST depressions in V2-V5 . Chest x-ray . Cardiac enzymes . Echocardiogram 2018/09/13 07:49am¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 8259 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1118 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É22¤À57¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 24 ¼Ó]   23 Case 23 scenario ( frequent falls ) Doorway information about patient The patient is a 70-year-old man who comes to the office due to frequent falls. Vital signs . Temperature : 37.1¡¦C (98.7F) . Blood pressure : 130/80 mmHg . Pulse : 78/min . Respirations : 20/min Basic differential diagnosis Neurologic . Cerebellar disease (alcohol, tumor , stroke) . Parkinson disease . Brain tumor . Seizure . Depressed vision Metabolic . Diabetic neuropathy . Hypoglycemia . Thyroid disease Cardiovascular . Valvular disease Miscellaneous . Medication side effect . Vitamin B12 deficiency . Vertigo ¡X¡X¡X¡X¡X Case 23 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 70-year-old man who comes to the clinic due to frequent falls. History of present illness . Several falls over he last 2 months . Initially once a week , now twice a week . Decreased balance while standing . No major injury/fracture but you are concerned that you may develop one . Also have tremor that makes it difficult to hold things ; worse when reaching for an object . Headache in the morning . Friend said you speech is different Review of systems . No weakness , numbness , or tingling in arms or legs . No dizziness/vertigo . No fever . No chest pain . No nausea , vomiting , diarrhea , constipation , or abdominal pain . No urinary symptoms . No sin or hear changes Past medical history . Diabetes for last 10 years (under good control) . No surgires . Medications : Metformin 500mg twice a day . No allergies . Father and mother both died of¡¨old age¡¨; no siblings . Retired machinist . Widower (wife passed away 5 years ago), live alone . Tobacco : No . Alcohol : 2 beers a day for 40 years . Recreational drugs : No Physical examination HEENT: . Visual acuity and visual fields normal Neck : . Supple without IVD or lymphadenopathy . No thyromegaly . No bruits Lungs : . Clear to auscultation bilaterally Heart : . Regular rate and rhythm . No murmurs , gallops , or rubs Neurologic : . Motor 5/5 bilaterally . Sensory grossly intact bilaterally . Resting tremor . Mild dysmetria (finger to nose ) present . Mild dysdiadochokinesia (alternating movements) . DTR2+ bilaterally ¡X¡X¡X¡X¡X Case 23 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 frequent of falls . Asked about any injury associated with falls . Asked about loss of consciousness . Asked about any difficult in initiating , controlling , stopping movements . Asked about progression of the problem . Asked about associated symptoms: - Tremors - Headache - Nausea /vomiting, bowel problem - Fever - Palpations and syncope - Thyroid symptoms(eg, temperature intolerance , skin or hear changes) - Changes in appetite or weight - Problems with speech or memory - Problems wit attention or calculation - urinary problem . Asked abort living conditions and support systems 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 medication allergies . Asked about family health . Asked about tobacco, alcohol , and recreational drug use . Asked about occupation Examination . Washed heads before examination . Examined without gown , not through gown . Checked orthostatic vital signs . Examined eyes . Examined heart and lungs . Performed mini-mental status exam . Examined touch , pain , and temperature sensations in legs add hands . Tested muscle power in limbs . Tested for muscle tone/rigidity . Asked you to get up and walk and turn around and sit again (¡§ Get up and go ¡§ test) . Performed finger nose test . Performed alternating movements test . Performed Romberg test . Checked reflexes Counseling . Explained the 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 . Cerebellar disease . Parkinson disease . Diabetic neuropathy . Brain tumor . Thyroid disease . Vitamin B12 deficiency Diagnostic study/studies . CBC with differential . CT or MRI of brain . Serum electrolytes, glucose, creatinine . Hemoglobin A1c . ECG . TSH ¡X¡X¡X¡X¡X Case 23 clinical summary Clinical Skills Evaluation Case 23 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). . 70-yo man with 2 months of frequent fall . Balanced problems while standing up ; no syncope . Tremor in hands worse when reaching for objects. . Change in speech , occasional morning headache. . No sensory symptoms (numbness , tingling) in legs. . No dizziness or vertigo ROS : No fever , nausea , hair loss, chest pin , abdominal , pain , recent trauma, diarrhea , constipation , or urinary problems PMHx : Diabetes PSHx : None Meds : Metformin 500 mg BID Allergies : None FHx : Father and mother both fiddled of old age SHx : No smoking , 2 beers daily for past 40 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 , 130/80 mmHg ; pulse , 78/min ; and respirations , 20 /min . HEENT : PERRLA , EOMI , normla visual acuity . Neck : Supple without JVD or lymphadenopathy , no thyromegaly , no bruits . Lungs : Clear to auscultation bilaterally . Heart : RRR without murmurs, gallops , and rubs . Neurologic ; Motor 5/5 bilaterally , sensory grossly intact bilaterally , resting tremor , mild dysmetria (finger to nose) , mild dysdiadochokinesia (alternating movements) , DTR 2+ bilaterally 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 : Cerebellar disease due to alcohol use History finding(s) . History of chronic alcohol use . Difficulty with balance Physical examination finding(s) . Dysmetria . Disdiadochokineasia Diagnosis #2 : Parkinson disease History finding(s) . Tremor . Balance problems Physical examination finding(s) . Resting tremor Diagnosis #3 : Brain tumor History finding(s) . Speech difficulties, headache . Balance problems . 2 months of symptoms Physical examination finding(s) . None Diagnostic studies . Orthostatic vitals . Brain imaging (CT scan or MRI) . Basic metabolic panel . Thyroid function tests; vitamin B 12 levels . Complete blood count 2018/09/13 07:50am¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 8510 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1118 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É22¤À57¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 25 ¼Ó]   24 Case 24 scenario ( cough and chest pain ) Doorway information about patient The patient is a 35-year-old man who comes to the office due to cough and chest pain. Vital signs . Temperature L 38.7¡¦C (101.7F) . Blood pressure : 130/80 mmHg . Pulse ; 94/min . Respirations : 24/min Basic differential diagnosis . Pneumonia . Pleuretic pain . Pleural effusion . Pulmonary edema . Tuberculosis . Pulmonary embolism . Lung cancer . Infective endocarditis . GERD ¡X¡X¡X¡X¡X Case 24 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 man who comes to the clinic due to a cough History of present illness . Onset 2 days ago . Started with ¡§ feeling tired and sick¡¨ . Productive cough with yellow sputum and blood streaks . Sharp pain 5-6/10 severity at left chest ; worse with moving and any deep breath and better with exhalation . Associated symptoms : - Fever - Chills - Sweating - Mild shortness of breath . Exposure to ¡§ pneumonia ¡§ form a colleague at work Ask the doctor : ¡§ Do I have pneumonia too?¡¨ Review of systems . No changes in appetite . No weight loss . No abdominal pain . No recent trauma . No diarrhea or constipation . No urinary symptoms Past medical / family / social history . Hospitalized once for chest pain 5 years ago with negative testing . No surgieres . No medications . Allergies : Penicillin (rash) . Father and mother are both healthy ; no siblings . Occupations ; Investment advisor . Tobacco : 1 pack a day for 15 years . Alcohol : often go out with friends on weekends and drink average of 2 shot of liquor . Recreational drugs : No Physical examination HEENT : . Oropharynx clear Neck : . Supple without JVD and lymphadenopathy . No thyromegaly . No bruits . No accessory muscle use Lungs : . Clear to auscultation bilaterally . Fremitus symmetrical bilaterally . Resonant to percussion bilaterally . No bronchophony or egophony Heart : . Regular rate and rhythm . No murmurs ,  gallops,  or rubs Abdomen : . Non-Tender, non-distended . No hepatosplenomegaly . Normative bowel sounds ¡X¡X¡X¡X¡X Case 24 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 onset and duration of pain . Asked about the course of pain one time . Asked about any aggravating or relieving factors . Asked about associated symptoms , especially : - Vomiting - Fever - Coughing( and details of expectoration) - Shortness of breath - Hemoptysis - Change in appetite Past medical /family/social history . Asked about similar episodes in the past . Asked about past medical issues ( especially lung problems) , hospitalizations , and surgeries . Asked about current medications . Asked about medication allergies . Asked about family health . Asked about tobacco , alcohol , and recreational drug use . Asked about sexual history . Asked about occupation Examination . Washed heads before examination . Examined without gown , not through gown¡¦ . Inspected neck , accessory muscles of respiration , and jugular views . Examined heart : inspection , palpation , auscultation . Examined lungs including: - Inspection of lung inflation - Anterior and posterior auscultation - Percussion - Tests for consolidation (tactile fremitus ,, egophony) . Palpated abdomen for splenomegaly and hepatomegaly Counseling . Explained the physical findings and possible diagnosis . Explained further workup . Discussed quitting smoking 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 . Pneumonia . Pleuritic pain . Pleural effusion . Pericarditis . Lung cancer Diagnostic study/studies . CBC with differential count . Sputum Gram stain, C/S . ECG . Chest x-ray . Blood culture ¡X¡X¡X¡X¡X Case 24 clinical summary Clinical Skills Evaluation Case 24 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 man with 2 days go product cough of yellow , blood-tinged sputum . 2 dash pf sharp . left-sided chest pain worse with inspiration and improved with expiration. . Fever . chills , sweating , and mild shortness of breath . Sick contact in office ROS : No changes in appetite our weight , abdominal pain, recent trauma , diarrhea , constipation , or urinary problems PMHx : None PSHx : None Meds : None Allergies ; Penicillin (rash) FHx : Father and mother are healthy SHx : 1 PPD smoker for past 15 tears , 2 shots a week for past 10 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 , 38.7¡¦C(101.7F) ; blood pressure , 130/80 mmHg ; pulse , 94/min ; and respirations , 24/min . HEENT ; Oropharynx clear . Neck : Supple without JVD or lymphadenopathy , no thyromegaly, no bruits , no accessory muscle use . Lungs ; clear to auscultation bilaterally , fremitus symmetrical bilaterally , resonant to percussion bilaterally , no brochophony or egophony . Heart : RRR without murmurs, gallops, our rubs . Abdomen : Non-tender , non-distended , no hepatopslenomegaly , 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 : Acute bronchitis History finding(s) . Smoking history . Fever . Cough productive of yellow , blood-tinged sputum Physical examination finding(s) . Fever Diagnosis #2 : Pneumonia History finding(s) . Fever and chills . Cough productive of yellow, blood-tinged sputum . Pleuritic chest pain . Sick contact at office Physical examination finding(s) . Fever . Respirations , 24/min Diagnosis #3 : Lung cancer History finding(s) . Smoking history . Cough productive of blood-tinged sputum Physical examination finding(s) . None Diagnostic studies . Chest x-ray . Sputum Gram stain and culture . CBC with differential 2018/09/13 07:51am¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 8032 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1118 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É22¤À57¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 26 ¼Ó]   25 Case 25 scenario ( lower abdominal pain ) Doorway information about patient The parents is 60-year-old man who comes to the emergency department due to lower abdominal pain Vital signs . Temperature : 38.3¡¦C (101F) . Blood pressure : 130/84 mmHg . Pulse : 98/min . Respirations : 22/min Basic differential diagnosis . Diverticulitis . Renal colic . Appendicitis . Ischemic colitis . Infectious colitis . Abdominal aortic aneurysm . Intestinal obstruction ¡X¡X¡X¡X¡X Case 25 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 60-year-old man who comes to the emergency department with lower abdominal pain History of present illness . The pain onset was 1 day ago after eating at a restaurant with family . Pain is located at lower abdomen with no radiation . 6/10 severity , progressively with no radiation . Episodic (10-15 minute episodes ) . crampy pain . No aggravated or alleviating factors . Associated symptoms - 1 episode non bilious , non bloody vomiting - You did not check temperature but feel ¡§ a little feverish¡¦ - 2-3 episodes of diarrhea with visible blood (no black stools) . No family members with symptoms . No recent travel or sick contact Do not volunteer this information unless asked : Review of systems . No chills . No urinary symptoms Past medical / family / social history . Hospitalized once 10 years ago for kidney stone that passed spontaneously . Hypertension . No surgeries . Medications : Hydrochlorothiazide 25 mg daily . No allergies . Father died at 65 of colon cancer ; mother died at 70 of breath cancer ; no siblings . Occupation : Financial planner . Married , live with wife . Tobacco : No . Alcohol : 1 beer a day for past 30 years . Recreational drugs : No Physical examination Heart : . Regular rate and rhythm . No murmurs , gallops , or rubs Abdomen : . LLQ tenderness to deep palpation , no rebound tenderness . Non-distended . No hepatosplenomegaly . Normative bowel sounds . No CVA tenderness ¡X¡X¡X¡X¡X Case 25 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 onset and duration of pain . Asked about the progression of pain . Asked about any aggravating or relieving factors . Asked about associated symptoms , especially : - Nausea and vomiting - Fever and chills - Changes in appetite and weight - Bowel problems (constipation and diarrhea) - Blood in the stool or black stood - Urinary symptoms . Asked bout recent travel and contaminated food ingestion . Asked about recent antibiotic use Past medical /family/social history . Asked about similar episodes in the past . Asked about past medical issues , hospitalizations ,ad surgeries (especially abdominal surgeries) . Asked about current medications . Asked about medication allergies . Asked about family health . Asked about tobacco , alcohol , and recreational drug use Examination . Washed heads before examination . Examined without gown , not through gown . Auscultated abdomen . Palpated abdomen . Checked rebound tenderness . Checked for costovertebral angel tenderness . Examined the heart Counseling . Explained physical findings and possible diagnosis . Explained further workup . Discussed need to perform 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 . Diverticulitis . Renal colic . Intestinal obstruction . Infectious colitis . Ischemic colitis Diagnostic study/studies . Rectal examination , genital examination . CBC with differential count . Electrolytes , glucose , BUN , creatinine . Urinalysis . ECG . Abdomen x-ray . CT scan of the abdomen and pelvis ¡X¡X¡X¡X¡X Case 25 clinical summary Clinical Skills Evaluation Case 25 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). . 60-yo man with 1 day of episodic , crapmy LLQ abdominal pain lasting 10-15 minutes each time ; no radiation. . Pian is 6/10 . Ate at a local restaurant with family , but no one else is sick . Nausea ,  1 episode of vomiting , 2-3 episodes of diarrhea with blood , subjective fever ROS :  no recent travel , sick contact , chills , or urinary problems PMHx : HTN , kidney stone in past PSHx : None Meds : Hydrochlorothiazide 25 mg daily Allergies ; None FHx : Father died at age 65 of colon cancer ; mother died at age 70 of breast cancer SHx : No smoking , 1 beer daily for past 30 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 , 38.3¡¦C (100.9F) ; blood pressure , 130/84 mmHg; pulse , 98/min; and respirations , 22/min . Heart : RRR without murmurs , gallops , or rubs . Abdomen : LLQ tenderness to deep palpation , no rebound tenderness , non distended , no hepatosplenomegaly , normative bowel sounds , no CVA tenderness 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 : Acute diverticulitis History finding(s) . Abdominal pain . Fever . Diarrhea with blood Physical examination finding(s) . Fever . LLQ abdomen tender to palpation Diagnosis #2 : Infectious colitis History finding(s) . Fever . Ate at local restaurant before symptom onset . Diarrhea with blood Physical examination finding(s) . Fever . Abdomen tender to palpation Diagnosis #3 : Ischemic colitis History finding(s) . History of hypertension . Fever . Abdominal pain Physical examination finding(s) . Fever Diagnostic studies . Rectal examination with stool guaiac . Abdominal imaging (x-ray, CT scan) . CBC with differential . Urinalysis 2018/09/13 07:52am¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 7770 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1118 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É22¤À57¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 27 ¼Ó]   26 Case 26 scenario ( fatigue ) Doorway information about patient The patient is a 35-year-old man who comes to the office due to fatigue Vital signs . Temperature : 37¡¦C (98.6F) . Blood pressure : 120/80 mmHg . Pulse : 82/min . Respirations : 16/min Basic differential diagnosis . Depression . Anemia . Thyroid disorder . Chronic fatigue syndrome ¡X¡X¡X¡X¡X Case 26 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 man who comes to the office due to fatigue History of present illness . Onset 2 months ago . Previously well until victim of robbery . Tired during the day with constant anxiety and impaired concentration . Difficulty falling asleep at night with frequent nightmare . You have cut back on daily activities and feel emotionally distant and lonely . No other significant stress at work or home Do not volunteer this information unless asked : Review of systems . No shortness of breath . No palpations . No seating , fever , or chills . No weight loss . No change in appetite Past medical / family / social history . No significant illness , surgeries , or hospitalizations . No medications . No allergies . Immediate family members are all healthy . Live with girlfriend . Occupation : Florist . Tobacco : 1 pack a day for last 15 years . Alcohol : Social occasions only . Recreational drugs : No Physical examination HEENT . No pallor . Oropharynx clear Neck . Supple without lymphadenopathy . No thyromegaly Heart . Regular rate and rhythm . No murmurs, gallops, or rubs Lungs : . Clear to auscultation Abdomen : . No masses or tenderness Psychiatric . Alert and oriented to person , place , and time ¡X¡X¡X¡X¡X Case 26 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 onset of symptoms . Asked about severity and change over time . Asked if you are having difficulty falling or staying asleep . Asked nightmares . Asked if you had any traumatic events recently . Asked about feeling of guilt . Asked about suicidal intentions . Asked if you have been feeling lonely . Asked about anxiety . Asked about associated symptoms , especially - Palpitations - Dizziness - Sweating - Tremors - Changes in appetite or weight - Shortness of breath - Swelling /limps in neck - Changes in bowel or bladder habits . Asked about stress at work or home 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 medication allergies . Asked about family health . Asked about occupation . Asked bout tobacco , alcohol , and recreational; drug use . Asked about sexual history Examination . Washed heads before examination . Examined without gown , not through gown . Examined oral mucous membranes for pallor . Palpated neck for masses or swelling . Checked memory , orientation , and judgement Counseling . Explained physical findings and possible diagnosis . Explained further workup . Offered to help and support while getting treated . Discussed the importance of quitting smoking and offered help 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 . Post-Traumatic stress disorder/anxiety disorder . Depression . Hypothyroidism . Occult medical disease Diagnostic study/studies . CBC with differential . TSH . Electrolytes , glucose , BUN , Creatinine . HIV test ¡X¡X¡X¡X¡X Case 26 clinical summary Clinical Skills Evaluation Case 26 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 man with 2 months of fatigue after robbery . Insomnia increased daytime fatigue , nightmares every night , generalized anxiety throughout the day , and inability to concentrate at work . Feels emotionally alone and distant , no increased stress at work or home . No hallucinations or delusions. . Constipation for 3-4 months ROS : No shortness of breath , chest pain , palpations , sweating, fever , chills , weight loss, or change in appetite PMHx : None PSHx : None Meds : None Allergies : None FHx : Father , mother , and 3 siblings are healthy SHx : 1 PPD smoker for 15 years , occasional alcohol use 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¡¦C (98.6F) ; blood pressure , 120/80 mmHg;pulse , 82/min; and respirations , 16/min . HEENT : No pallor , oropharynx car . Neck : Supple without lymphadenopathy or thyromegaly . Heart : RRR without murmurs, gallops, or rubs . Lungs ; Clear to auscultation . Abdomen ; no masses or tenderness . Psychiatric : Alert and oriented to person , place,and time 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 : Post-traumatic stress disorder History finding(s) . Symptom onset after robbery 2 months ago . Insomnia . Difficulty concentrating , nightmares Physical examination finding(s) . None Diagnosis #2 : Depression History finding(s) . Fatigue . Insomnia . Feels alone and distant Physical examination finding(s) . None Diagnosis #3 : Hypothyroidism History finding(s) . Constipation for 3-4 months . Fatigue . Inability to concentrate at work and home Physical examination finding(s) . None Diagnostic studies . TSH . CBC with differential . Electrolytes, glucose, BUN , creatinine . HIV test 2018/09/13 07:52am¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 7490 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1118 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É22¤À57¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 28 ¼Ó]   27 Case 27 scenario ( loss of hearing ) Doorway information about patient The patient is a 65-year-old woman who comes to the office due to loss of hearing Vital signs . Temperature ; 36.7¡¦C (98.1F) . Blood pressure : 130/86 mmhm . Pulse ; 80 /min . Respirations : 16/min Basic differential diagnosis conductive hearing loss . Cerumen impaction . Otitis media with effusion . Tympanic membrane perforation . Otosclerosis . Foreign body in ear canal . cholseteatoma . Tympanosclerosis . Tumor of the ear canal or middle ear Sensorineural hearing loss . Prescycusis (age-0related hearing loss) . Ototoxicity . Noise-induced hearing loss . Meniere disease . Diabetes . Acoustic neuroma ¡X¡X¡X¡X¡X Case 27 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 65-year-old woman who comes to the clinic due to hearing loss History of present illness . 3 months of reduced hearing in the left . Hearing loss was initially mild but is progressively worsening . Has been difficult to hear people with high-pitched voice . No associated pain , ringing in the ear , or discharge from the ear . Admitted to the hospital 4 months ago for a kidney infection and treated with IV antibiotics (you do not recall the name of the drug) Review of systems . No dizziness . No facial muscle weakness . No weakness or numbness i other parts of the body Past medical / family / social history . Hypertension for the last 30 years . No surgires . Medications : Hydrochlorothiazide 50 mg daily . No drug allergies . Father and mother both died of ¡¥ old age¡¨ ; 2 siblings , both healthy . Occupations ; Supervisor at a steel factory (If the examinee specifically asks about the noise exposure , say ¡§ there is a lot of noise every day at work.¡¨) . Married , live with husband . Tobacco : No . Alcohol : Occasional beer or wine . Recreational drugs : No Physical examination HEENT : . PERRLA , EOMI . Oropharynx clear . Tympanic membrane clear bilaterally . Rinne test : Air conduction > bone conduction bilaterally . Weber test ; localizes to the right ear Neck: . Supple . No lymphadenopathy . Thyroid normal Neurologic: . Alert and oriental to person , place , and time . Cranial nerves 2-12 intact , except for decreased hearing in the left ear ¡X¡X¡X¡X¡X Case 27 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 which ear is affected (right , left , bilateral) . Asked about the onset of symptoms . Asked about the course of symptoms over time . Asked about the subjective severity of hearing loss(mild , moderate , severe , profound) . Asked about the possible initiating events . Asked about associated symptoms , especially: - Earache - Tinnitus - Vertigo - Aural fullness - Drainage from the ear . Asked about any occupational exposure to noise . Asked about trauma to the ear . Asked about the social impact that it was had Past medical /family/social history . Asked about any similar episodes in the past . Asked about past medical issues (especially ear. nose. throat and neurologic disorders ) ,hospitalizations , and surgeries . Asked about current (and recent0 medications . Asked about medication allergies . Asked about family health . Asked about tobacco , alcohol , and recreational drug use . Asked about occupation Examination . Washed heads before examination . Examined without gown , not through gown . Examined eye movements and pupillary reflexes . Examined facial sensation and motor function (eg , show teeth , puff out cheeks , stick out tongue) . Examined external ear and ear canal ( with otoscope) . Tested hearing , including Rinne and Weber tests 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 . Presbycusis . Occupational exposure . Ceremony impaction . Drug induced Diagnostic study/studies . Serum electrolytes and blood sugar . Audiometry . MRI of the brain ¡X¡X¡X¡X¡X Case 27 clinical summary Clinical Skills Evaluation Case 27 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). . 65-yo woman with 3 moths of heigh-frequency hearing loss . Hospitalized for pyelonephritis 4 months ago and treated with unknown antibiotic. . Exposure to loud noises at work in steel factory. ROS : No discharge from ear , ringing in ear , dizziness , facial muscle weakness , weakness or numbness in other parts of the body , or earache PMHx : HTN PSHx : None Meds : Hydrochlorothiazide 50 mg daily Allergies : None FHx : Father and mother died of old age , healthy siblings SHx : No smoking , occasional alcohol use 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 , 36.7¡¦C (98.1F) ; blood pressure , 130/86 mmHg; pulse , 80/min; and respirations , 16/min . HEENT : PERRLA , EOMI , oropharynx clear , TMs clear bilaterally , Rinne test with AC>BC , Weber test localization to the right ear , oropharynx clear . Neck l Supple without lymphadenopathy or thyromegaly . Neurologic : Alert and oriented to person , place , and time ; cranial nerves II-XII intact except for decreased hearing in left ear 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 : Presbycusis (age-related hearing loss) History finding(s) . Decreased hearing for 2-3 months . High-Frequency hearing loss Physical examination finding(s) . Weber test localization to right ear Diagnosis #2 : Noise-induced hearing loss History finding(s) . Decreased hearing . Work at still factory with loud noise Physical examination finding(s) . Weber test localization to right ear Diagnosis #3 : Drug-induced hearing loss History finding(s) . History of recent antibiotic use Physical examination finding(s) . Weber test localization to right ear Diagnostic studies . Audiometric testing . Electrolytes and blood sugar . MRI of brain 2018/09/13 07:53am¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 8060 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1118 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É22¤À57¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 29 ¼Ó]   Case 28 scenario ( knee pain ) Doorway information about patient The patient is a 53-year-old man who comes to the emergency department due to right knee pain and swelling. Vital signs . Temperature ; 38.3¡¦C (101F) . Blood pressure : 130/60/mmHg . Pulse : 80/min . aspirations : 18/min Basic differential diagnosis . Osteoarthritis . Septic arthritis and bursitis . Pseudogout and gout . Reactive arthritis . Traumatic knee injury . Lyme disease . Monoarticular rheumatoid arthritis . Psoriatic arthritis ¡X¡X¡X¡X¡X Case 28 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 with right knee pain History of present illness . 2 days of worsening right knee pain . Throbbing pain , 7/10 severity . No radiation of pain . no relief with ibuprofen . No recent trauma . Chronic bilateral knee pain starting a year ago that is worse with walking and thought to be due to being overweight . Stiffness in multiple joints every morning for 10-15 minute that resolves spontaneously . No other aggravating or relieving factors Do not volunteer this information unless asked : Review of systems . No fever or chills . No nausea , vomiting , diarrhea , or constipation . No rash . No recent travel or sick contacts . No inset bite . No urinary symptoms Past medical / family / social history . Hypertension for the past 10 years . No surgeries or hospitalizations . Medications ; Hydrochlorothiazide 25 mg daily ; ibuprofen 600 mg up to 3 times a day as needed . Medication allergies : None . Father as hypertension and mother has pseudo gout ; no siblings . Occupation : Librarian . Married , live with wife . Tobacco : none . Alcohol ; 1 or 2 beers on social occasions . Recreational drugs ; None Physical examination HEENT : . PERRLA , EOMI . No conjunctival abnormalities Heart : . Regular rate and rhythm . No murmurs , gallops , or rubs Musculoskeletal : . Right knee is tender to palpation with decreased range of motion but no redness or warmth . no other joint abnormalities Skin : . No rates or lesions ¡X¡X¡X¡X¡X Case 28 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 bout the course of pain over time . Asked about the intensity of pain . Asked about the quality of pain . Asked about the location of pain . Asked about any radiation of pain . Asked about any aggravating or relieving factors . Asked about associated symptoms , especially : - Fever - Joint swelling - Joint redness - Rash . Asked about history of trauma to the joint . Asked about morning stiffness . Asked about history of travel (especially areas with endemic Lyme disease) . Asked about any rennet ticks bites . Asked about any pain and swelling in the other joints . Asked about nay recent history of febrile illness . Asked about any eye symptoms Past medical /family/social history . Asked about similar episodes in the past or other joint problems . Asked about past medical issue , surgeries , and hospitalizations . Asked about current medications . Asked about medication allergies . Asked about family health (especially joint disorders) . Asked bout tobacco , alcohol , and recreational drug use . Asked about occupation . Asked about living situation and sexual contacts Examination . Washed heads before examination . Examined without gown , not through gown . Checked knee for range of motion . Checked other joints for swelling and redness . Auscultated heart . Examined eyes . Examined skin for washed or painful nodules 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 . Osteoarthritis . Septic arthritis or bursitis . Pseudo gout , gout . Inflammatory (eg, rheumatoid ) arhritis Diagnostic study/studies . CBC with differential . Joint aspiration . X-ray of knee . Sedimentation rate or C-reactive protein , antinuclear antibody, rheumatoid factor or cyclic citrullinated peptide antibodies . MRI of joint . Lyme serology (if travel to endemic area) The following points should be addressed for traumatic knee pain: . Asked what you were doing at the time of injury . Asked about mechanism of injury . Asked bout any noise or popping sensations at the time of injury . Asked whether you can bear weight and whether the knee is unstable with walking . Asked about locking of joint . Performed Lachman maneuver or drawer test . Performed McMurray maneuver ¡X¡X¡X¡X¡X Case 28 clinical summary Clinical Skills Evaluation Case 28 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 1 year of bilateral knee pain , now with 2 days of worsening right knee pain described as throbbing and constant . Pain is 7/10 , no relief with ibuprofen . 15-20 minute of morning stiffness in multiple joints each day that resolves spontaneously. . No H/O trauma ROS : No fever , chills , nausea , vomiting , diarrhea , constipation , rashes , travel history , sick contacts , insect bites , or urinary issue PMHx : HTN for 10 years PSHx : None Meds : Hydrochlorothiazide 25mg  daily , ibuprofen 600mg as needed Allergies : None FHx : Father has hypertension ; mother has pseudogout SHx : No smoking , occasional alcohol use 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 , 38.3¡¦C(100.9F); blood pressure , 130/60 mmHg; pulse , 80/min; and respirations , 18/min . HEENT : PERRLA , EOMI , no conjunctival hemorrhage . Heart : RRR without murmurs , gallops , or rubs . Musculoskeletal : Tender right knee , decreased ROM , no swelling or warmth , no other joint deformities . Skin ; No rashes or lesions 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 : Osteoarthritis flare History finding(s) . History of chronic knee pain . Acute worsening of right knee pain Physical examination finding(s) . Decreased ROM in right knee Diagnosis #2 : Septic joints History finding(s) . Acute-onset right knee pain Physical examination finding(s) . Fever . Decreased ROM in right knee Diagnosis #3 : Acute crystal arthritis (Gout or pseudogout ) History finding(s) . History of diuretic use . Acute-onset right knee pain . Family history of pseudogout Physical examination finding(s) . Fever . Decreased ROM in right knee Diagnostic studies . Right knee arthrocentesis . Right knee x-ray . ESR . CBC with differential 2018/09/13 07:53am¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 8671 ¦ì¤¸²Õ]¡@

JuanFe    ¸ê®Æ: «Â±æ: 0 ¾y¤O: ¸gÅç: ¨Ó¦Û: ¦t©z¤¤¡@ µo¤å: 1118 ½g ºëµØ: 0 ½g ¦b½u: 47¤Ñ19®É22¤À57¬í µù¥U: 2013/06/17 Message ¬d¬Ý¡@·j´M¡@³q°T¿ý¡@½Æ»s¡@¤Þ¥Î¡@¦^ÂС@ [²Ä 30 ¼Ó]   29 Case 29 scenario ( blurred vision ) Doorway information about patient The patient is a 50-year-old man who comes to the office due to blurred vision Vital signs . Temperature : 36.7¡¦C (98.1F) . Blood pressure : 160/90 mmHg . Pulse : 70/min . Respirations : 22/min Basic differential diagnosis . Diabetes mellitus . Cataract . Hypertensive retinopathy . Glaucoma . Macular degeneration . Brain lesion . Hyperviscosity syndorme (eg, polycythemia) . Illicit drugs . Temporal arthritis (usually starts unilaterally) . Trauma to or infections of the eye (if unilateral) ¡X¡X¡X¡X¡X Case 29 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 50-year-old man who comes to the office due to blurry vision History of present illness . Onset 2 month ago . Objects are becoming increasingly blurry with no halos around them . No headache , eye pain , or eye discharge . Over-the -counter reading glasses have made only minimal improvement . Last physician visit was 10 years ago Do not volunteer this information unless asked : Review of systems . 10-lb weight loss . Increased appetite , thirst , and urination . No nausea or vomiting . No muscle weakness . No dizziness or loss pf consciousness . No numbness or tingling in the extremities Past medical / family / social history . No prior ,medical issue , surgeries , or hospitalizations . Medications : None . No medication allergies . Father has hypertension and motor has diabetes(you have no siblings) . Married;live with wife . Occupation ;Truck driver . Tobacco ; 1 pack a day for the last 30 years . Alcohol : Occasional beer . Recreational drugs : None Physical examination HEENT : . PERRLA , EOMI . Funds show no hemorrhage or AV nicking Neck : . Supple . No lymphadenopathy or thyromegaly . No bruits Heart : . Regular rate and rhythm without murmurs , gallops, or rubs Extremities : . Pulse 2+ in bilateral lower extremities Neurologic : . Motor strength 5/5 bilaterally . Sensation grossly intact bilaterally ¡X¡X¡X¡X¡X Case 29 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 symptoms . Asked whether symptoms were in 1 or both eyes . Asked about the severity and course over time , Asked about the eye discharge . Asked about halos around the light . Asked about eye pain . Asked about any headache . Asked about nausea and vomiting . Asked bout any weakness or sensory changes in the areas and legs . Asked about excessive thirst and urination . Asked about changes in the appetite and weight Past medical /family/social history . Asked about similar episodes in the past . Asked about past medical issues (especially diabetes and hypertension) . Asked about current medications . Asked about medication allergies . Asked about family health . Asked bout tobacco , alcohol , and recreational drug use . Asked bout occupation Examination . Washed heads before examination . Examined without gown , not through gown . Examined eyes , including extra ocular movements , pupillary reflexes , and ophthalmoscope examination . Did a neurological examination with emphasis on sensory examination . Auscultated heart and carotid arteries . Examined peripheral pulses Counseling . Explained physical findings and possible diagnosis (especially diabetes) . Discussed dietary changes and weight reduction . Explained further evaluation 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 . Diabetic retinopathy and /or diabetes osmotic changes in the lens . Hypertensive retinopathy . Cataracts . Glaucoma . Macular degeneration Diagnostic study/studies . Fasting blood glucose and /or hemoglobin A1c . Urinalysis for microscopic proteinuria . Lipid profile . Carotid ultrasound ¡X¡X¡X¡X¡X Case 29 clinical summary Clinical Skills Evaluation Case 29 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). . 50-yo man with 2 months of blurry vision , polyuria , polydipsia , polyphagia , and 4.5-kg (10-lb ) weight loss . Has not seen a doctor in 10 years . Objects blurry without complete loss of vision or halos around it ROS : No nausea , vomiting , headache , arm/leg weakness , eye discharge , eye pain , dizziness , loss of consciousness, or numbness or tingling in the extremities PMHx : None PSHx : None Meds : none Allergies : None FHx : Father has hypertension , mother has diabetes SHx : 1 PPD smoker for past 30 years , occasional alcohol use 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 , 36.7¡¨C(98.1F) ; blood pressure , 160/90 mmHg; pulse , 70/min; and respirations , 16/min . HEENT : PERRLA , EOMI < funds without hemorrhages or AV nicking . Neck : Supple without lymphadenopathy , thyromegaly, or bruits . Extremities : Pulses 2+ in bilateral lower extremities . Neurologic : Motor 5/5 bilaterally , sensory grossly intact bilaterally 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 : Diabetic retinopoathy History finding(s) . Polyuria , polydipsia , polyphagia . Weight loss . Blurry vision Physical examination finding(s) . None Diagnosis #2 : Hypertension retinopathy History finding(s) . Blurry vision Physical examination finding(s) . BP 160/90 mmHg Diagnosis #3 : Glaucoma History finding(s) . Decreased vision Physical examination finding(s) . None Diagnostic studies . Fasting blood glucose and hemoglobin A1c . Eye examination to mesure pressure . Lipid profile . CBC with differential 2018/09/13 07:54am¡@IP: ¤w³]©w«O±K [¥»¤å¦@ 7629 ¦ì¤¸²Õ]¡@

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