| | 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
—————
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
—————
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
—————
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
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2018/09/13 07:52am 
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