| | 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)
—————
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
—————
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
—————
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
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