| | 30 Case 30 scenario ( multiple bruises )
Doorway information about patient
The patient is a 32-year-old woman who comes to the emergency department due to multiple bruises
Vital signs
. Temperature : 37.4’C(99.3F)
. Blood pressure : 120/80 mmHg
. Pulse : 90/min
. Respiration : 16/min
Basic differential diagnosis
. Accident
. Physical assault
. Spousal abuse
. Bleeding disorders
. Collagen vascular disorders
—————
Case 30 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 32-year-old woman who is brought to the emergency department by your husband due to bruises
History of present illness
. Bruises on the right are between the shoulder and elbow
. When asked how you sustained the injury , say , “ My husband told me that I fell down the stairs”
. If the examinee asks for further clarification, say that you have been hit by your husband
. Husband hits you whenever he has a “ rage episode “ - usually once a week
. He dose not hit your children , although they are afraid to go near him wen he has a rage episode
. Husband is an alcoholic , and he almost always has a bottle of bourbon by his side
. Both of your parents live in the same town as you do but they are not aware of the abuse
. You feel that your husband loves you; you love your husband , but are always on edge when he is around and you do not feel safe
. There have been 2 episodes when you thought height kill you (there is a shotgun in the house and you are afraid he might use it)
. You feel that it would be very difficult for you to leave him
. You have never reported the matter to any government of social agency and of not with to do so
. You have a satisfying sexual relationship with him , and you are monogamous
. If the examinee explains that you need not endure such a relationship in which you are always in mortal fear, say that you will think about reporting it to the social welfare agencies and ask for an emergency contact number for the emergency department
Past medical / family / social history
. No prior medical problems
. No medications
. No drug allergies
. Mother and father are healthy
. Married 7 years , live with spouse
. 2 children , bout age 6 and girl age 5
. Tobacco: No
. Alcohol : No
. Recreational drugs : No
Physical examination
Multiple bruises at right upper arm in various stages f healing . Examination is otherwise normal.
—————
Case 30 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 how the injuries occurred
. Asked an open-ended question regarding the abuse
. Asked this happens regularly
. Asked how you feel about your husband
. Asked how your husband feels about you
. Asked if you feel safe at home
. Asked if there are nay weapons at home
. Asked about your sexual relationship with your husband
. Asked if you had emergency plan to leave the house if the need were to arise
. Asked bout any other injuries that you had
. Asked if your daily is aware that you are being abused
. Asked about your husband’s alcoholism
. Asked about child abuse at home
Past medical /family/social history
. Asked about past medical issues , hospitalizations , and surgeries
. Asked about current medications
. Asked about allergies
. Asked about tobacco , alcohol , and recreational drug use
. Asked about sexual history
. Asked about occupation
. Asked about personal supports (eg, friends, family)
Examination
. Washed heads before examination
. Examined without gown , not through gown
. Examined shoulder and elbow on affected side
. Check for the injuries
Counseling
. Explained physical findings
. Explained further workup(eg,x-ray)
. Discussed the need for an emergency action plan
. Discussed finding additional support groups in the community
. Gave you emergency contact number and offered ongoing support
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
. If husband is present , discussed the need to ask additional questions privately
. Did not pressure you to leave your husband , report abuse to authorities , or take additional actions you did not want to take
. Listened to what you said without interrupting me
. Used plain English rather than technical jargon
. Used appropriate transition sentences
. Used appropriate draping techniques
. Expressed empathy and gave appropriate reassurances
. Asked whether you have any concerns/questions
Differential diagnosis
. Spousal abuse
Diagnostic study/studies
. X-ray in involved area(s)
—————
Case 30 clinical summary
Clinical Skills Evaluation
Case 30 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).
. 32-yo woman with bruises on the right upper extremity
. caused by multiple incidence of altercation/ abuse by her husband
. Husband has frequent “ rage episodes : associated with alcohol abuse
. Patient has not reported abuse to civil authorities of family member
ROS : Negative
PMHx : Noncontributory
PSHx : None
Meds : None
Allergies : None
FHx : Mother and father are healthy
SHx : Married 7 years , lives with spouse and 2 children ; no tobacco , alcohol , or illicit drug 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 , 37.4’C (99.3F) ; blood pressure ,120/80 mmHg; pulse , 90/min; and respirations , 16/min
. HEENT : PERRLA , EOMI , normal ENT examination , no head trauma
. Neck : No visible injuries
. Musculoskeletal ; Multiple bruises in various stages of hearing on right upper arm
. Neurologic L CN II-XII grossly intact , UE and LE motor strength and reflexes normla and symmetric
. Psychologic : Awake and alert , affected apprehensive but with appropriate range , clear speech
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 : Intimate partner abuse
History finding(s)
. Recurrent spouse assault
. Spouse with history of alcohol abuse
Physical examination finding(s)
. Multiple bruises in various stages of healing
Diagnostic studies
. x-rays of shoulder, humerus , and elbow
. CBC
. PT/PTT/INR
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2018/09/13 07:55am 
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