| | 13 Case 13 scenario (abdominal pain RUQ)
Doorway information about patient
The patient is a 45-year-old woman who comes to the office due to acute right upper quadrant abdominal pain.
Vital signs
. Temperature ; 38.3’C (101F)
. Blood pressure : 130/80 mmHg
. Pulse ; 100/min
. respirations : 20/min
Basic differential diagnosis
Gastrointestinal
. Acute cholecystitis
. Biliary colic
. Acute hepatitis
. Peptic ulcer (perforation)
. Acute pancreatitis (biliary pain)
Pulmonary
. Right lower lobe pneumonia
Cardiovascular
. Myocardial infarction
. Heart failure with hepatic congestion
Miscellaneous
. Herpes zoster (shingle)
—————
Case 13 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 woman with acute abdominal pain
History of present illness
. Sudden onset 2 hour ago , 30 minutes after eating
. Progressively worsening
. Right upper abdomen with radiation to back and right shoulder
. Severity 8-9/10
. “Stabbing” sensation
. Worse with deep breathing , not relieved with antacids
. Associated symptoms :
- Nausea and vomiting without blood or bile; feel warm , but you idid not check temperature
- No diarrhea
. Similar pain 3-4 times over the last 5 months ; usually after meals and sometimes better with antacids
Do not volunteer this information unless asked about diet or fatty foods : You eat a lot of fast food because you are busy at work and do not have time to cook.
Review of systems
. No jaundice , cough , shortness of breath , itching , or chest pain
Past medical history
. No prior medical problems
. C-section 20 years ago
. Medications : Over -the -counter antacids
. Allergies : None
. Immediate family members are healthy
. Occupation ; Accountant
. Married , live with husband and 1 child
. Tobacco : 1 pack of cigarettes a day for 25 years ; trying to cut down
. Alcohol ; 2-3 beers a day for 15 years
. Recreational drugs : No
Physical examination
Abdomen:
. Right upper quadrant discomfort with deep palpation ; slightly worse with deep breath
. Abdomen non-distended
. Normative bowel sounds throughout
. No hepatosplenomegaly
. No abdominal bruits
The remainder of the examination is normal.
—————
Case 13 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 precipitating factors
. Asked about the course of pain over time
. Asked about any aggravating or relieving factors
. Asked about nausea and vomiting
. Asked about fever and chills
. Asked about cough and breathing problems
. Asked about any chest pain
. Asked about jaundice
. Asked about history of black stools
Past medical /family/social history
. Asked about similar episodes in the past
. Asked about past medial issues (acid peptic disease , gallstone , heart problems)
. Asked about previous hospitalizations and surgeries (especially gallbladder removal or appendectomy)
. Asked about family history of healthy issue (especially gallstone)
. Asked about current medications
. Asked about occupation
. Asked boy tobacco and alcohol use
. Asked about diet
Examination
. Washed heads before examination
. Examined without gown , not through gown
. Auscultated abdomen(before palpation)
. Palpated abdomen (Superficial and deep)
. Checked for rebound tenderness
. Percussed for liver span
. Elicited murphy sign
. Auscultated heart and lungs
Counseling
. Explained physical findings and possible diagnosis
. Explained further workup
. Discussed change in lifestyle , including quitting smoking , cutting down alcohol , healthier diet
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
. Acute cholecystitis
. Biliary colic
. Perforation of peptic ulcer
. Pancreatitis
. Acute hepatitis
Diagnostic study/studies
. CBC with differential count
. EKG
. Chest x-ray
. Ultrasound abdomen
. Serum amylase and lipase
. LFTs (albumin , AST,ALT, alkaline phosphatase , total and direct bilirubin)
—————
Case 13 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).
. 45-yo female with 2 hours of worsening RUQ abdominal pain radiating to the right scapula.
. 5 months of similar episodes (3-4/month) that resolved with antacids
. Stabbing pain starting 30 minutes after food with nausea and nonbiilious and non bloody vomitus.
. Pain worse with deep breathing and not improved with antacids.
ROS : No jaundice , cough , shortness of breath , itching , chest pain , or diarrhea
PMHx : None
PSHx : Cesarian delivery 20 years ago
Meds : OTC antacids PRN
Allergies : None
FHx : Parents and siblings are healthy
SHx : 1 PPD smoker for 25 years , 2 or 3 beers /day for 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, 38.3’C (101.0F) ; blood pressure , 130/80 mmHg ; pulse , 100/min ; and respirations , 20/min
. HEENT : PERRLA, EOMI, no jaundice
. Abdomen : RUQ discomfort with deep palpation ; non-distended , normative bowel sounds throughout ; no hepatosplenomegaly or bruits
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 cholecystitis
History finding(s)
. RUQ abdomen pain
. 5 month of similar episodes
. Pain radiating to right shoulder
. Pain worsened with deep breathing
Physical examination finding(s)
. Fever
. RUQ tenderness
. Positive Murphy sign
Diagnosis #2 : Acute pancreatitis
History finding(s)
. RUQ pain
. Nausea and vomiting
. Alcohol use
Physical examination finding(s)
. RUQ tenderness
. Fever
Diagnosis #3 : Peptic ulcer
History finding(s)
. Nausea and vomiting
. RUQ pain
. Alcohol /tobacco use
Physical examination finding(s)
. Fever
. RUQ tenderness
Diagnostic studies
. Ultrasound of RUQ of abdomen
. Serum amylase and lipase
. Liver function tests
. CBC with differential
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2018/08/15 03:31pm 
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