| | 10 Case 10 scenario (constipation)
Doorway information about patient
The paint is a 66-year-old man who comes to the clinic due to constipation
Vital signs
. Temperature ; 36.7’C (98F)
. Blood pressure : 120/70 mmHg
. Pulse : 70 /min
. Respirations : 16/min
Basic differential diagnosis
. Functional constipation
. Obstructive lesions (eg , bowel obstruction , carcinoma f colon)
. Metabolic disturbances (eg , hypothyroidism, diabetes mellitus , hypercalcemia)
. Neurologic dysfunction (eg , stroke , autonomic neuropathy , final cord trauma , multiple sclerosis, Parkinson disease)
. Medication-induced (eg , iron preparations , opiates , anticholinergics)
—————
Case 10 sim. pt. instructions
If the doctor asks you about anything other than ashes , just say “no,” or provide na answer that a normal patient might give.
You are a 66-year -old man with constipation.
history o present illness
. Onset 5 months ago
. Worse over the last 2 months
. Previously 1 film bowel movement a day , now every otters day
. Stool now become harder
. Straining , difficulty passing stool , sense of incomplete evacuation
. Occasional black stools; no red blood in stools
. eating fruits and vegetables regularly and have not changed diet recently
Review of systems
. Fatigue
. 10-lb weight loss over the last 2 months
. No fever , chills , night sweats
. No diarrhea , nausea , vomiting
. No urinary symptoms
Past medical / family / social history
. Arthritis of the right knee
. Hashimoto thyroiditis ; had normal blood work 1 year ago
. Never had colonoscopy but rectal examination was normal 2 years ago
. No surgeries
. Medications:
- Levothyroxine 100 mcg/day
- Hydrocodone/acetaminophen 5mg/650mg 1 pill 3 times /day 9started 2 months ago for knee pain
. No medication allergies
. After died of colon cancer at age 67 and mother is healthy
. Occupation; Supervisor at pharmaceutical company
. Tobacco : No
. Alcohol : 2-3 glasses of wine a week
. Recreational drug : No
Physical examination
HEENT :
. No pallor icterus
Neck :
. No enlarges lymph nodes
Chest /lungs :
. Clear to auscultation bilaterally
Heart :
. Regular rhythm without murmurs , gallops , or rubs
Abdomen :
. Non-tender, non-distended
. Hypoactive bowel sounds thought
. No hepatosplenomegaly
Neurologic :
. Muscle strength 5/5 throughout
. Reflexes 2+ symmetric
—————
Case 10 sim. pt. checklist
Following the encounter , check which for the following itms were performed by the examinee.
history of present illness / review of systems
. Asked an open-ended questions What do you mean by constipation)
. Asked about the onset of constipation
. Asked about the frequency of bowel movements
. Asked about amount and caliber of stool passed
. Asked about consistency of stool
. Asked about pain during defecation
. Asked about any blood in stools of black stools
. Asked about episodes of diarrhea
. Asked about nay nausea and vomiting
. Asked about abdominal pain or cramps
. Asked about urinary issue (polyuria, dribbling)
. Asked about intolerance to hot or cold temperatures
. Asked about loss of appetite and weight loss
. Asked about diet (especially fluids and dietary fiber)
Past medical / family /social history
. Asked about similar episodes in the past
. Asked about other medical issues
. Asked about previous hospitalizations and surgeries
. Asked about regular screening procedures (especially colon conner screening)
. Asked about current medications
. Asked about medication allergies
. Asked about family health (especially colon cancer)
. Asked about tobacco , alcohol , and recreational rug use
. Asked about occupation
Examination
. Washed hands before examination
. Examined without gown , not though gown
. Examined eyes for pallor
. Auscultated abdomen
. Palpated abdomen (superficial and deep)
. Checked muscle power and reflexes inlayer extremities
Counseling
. Explained the physical findings and possible diagnosis
. Explained further workup (include rectal examination)
Communication skills and professional conduct
. Knocked before entering the room
. introduced self and greeted you warmly
. Used your name to address you
. Paid attention to what you said and maintained good eye contact
. Asked opened questions
. Asked non-leading questions
. Asked one question at a time
. Listened to what you said without interrupting me
. Used plain English rather than technical jargon
. Used appropriate transition sentences
. Used appropriate draping techniques
. Summarized the history and explained physical findings
. Expressed empathy and gave appropriate reassurances
. Asked whether you have any concerns/questions
Differential diagnosis
. Medication -induced
. Carcinoma of colon
. Uncontrolled hypothyroidism
. Functional constipation
. Undiagnosed diabetes
Diagnostic study/studies
. Rectal examination and stools for occult blood
. CBC with differential
. TSH
. Fasting blood sugar and /or hemoglobin A1c
. Colonoscopy
—————
Case 10 clinical summary
Clinical Skills Evaluation
Case 10 Patient notes
The following represents a typical note for this patient encounter . the details may vary depending on the information given by the simulated patient
History : describe the history you just obtained form this patient . Include only information (pertinent positives and negatives) relevant to this patient’s problem(s).
. 66-yo man here for constipation for 5 months with worsening over past 2 months
. Fatigue , 4.5-kg (10-lb) weight loss
. Change in bowel movement form 1 /day to 1 every other day
. Occasional black stools
ROS : No diarrhea , abdominal pain , nausea , vomiting , fever , chills , night sweats , or urinary problems
PMHx: Hashimoto’s thyroiditis , severe DJD of right knee
PSHx: None
Meds : Levothyroxine , hydrocodone / acetaminophen (started 2 months ago)
Allergies : None
FHx : Father died at age 67 of colon cancer
SHx : no smoking but drinks 1-3 glasses of wine /week
Physical examinations :” Describe any positive and negative findings relevant to this patient’s problem(s). Be careful to include only those parts of the examination preformed in this encounter.
. Vital signs: Temperature, 36.7’C(98F); blood pressure , 120/70 mmHgin both arms; pulse , 70/min; respirations , 16/min
. HEENT : No pallor or jaundice
. Neck : No enlarge lymph nodes
. Chest / lungs : clear to auscultation bilaterally
. Heart : Regular rate and rhythm without M/G/R
. Abdomen : Non-tender , non-distended , hypoactive bowel sounds thought , no hepatosplenomegaly
. Neurologic : Muscle strength 5/5 throughout , DTR 2 + bilaterally and symmetrical
Data interpretation : Based on what you have learned from the history and physical examination, list up to 3 diagnosis that might explain this patient’s complaint(s) . List your diagnoses from most to least likely . For some cases , fewer than 3 diagnosis will be appropriate . the , enter the positive and negative findings form the history and the physical examination (if present) that support each diagnosis . Finally , list initial diagnostic (if any) you would order for each listed diagnosis (eg,restricted physical examination maneuvers, laboratory tests , imaging ECG , etc).
Diagnosis #1 : Colon cancer
history findings(s)
. Worsening constipation
. Fatigue
. Weight loss
. Black stools
Physical examination finding(s)
. hypoactive bowel sounds
Diagnosis #2 : Functional constipation form medications
History finding(s)
. New drug (Lortab) started , with worsening of constipation
physical examination finding(s)
. Hypoactive bowel sounds
Diagnosis #3 : Hypothyroidism with suboptimal control
History finding(s)
. Fatigue
. Constipation
Diagnostic studies
. Rectal examination with stool for occult blood
. CBC with differential
. Serum TSH
. Colonoscopy
. Serum calcium
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2018/08/15 03:27pm 
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