| | 31 Case 31 scenario ( burning during urination )
Doorway information about patient
The patient is a 20-year-old woman who comes to the office due to burning during urination
Vital signs
. Temperature : 38.3’C (100.9F)
. Blood pressure : 110/80 mmHg
. Pulse : 82/min
. Respirations : 16/min
Basic differential diagnosis
. Cystitis
. Pyelonephritis
. Urethritis
. Vulvovaginitis
. Pelvic inflammatory disease
—————
Case 31 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 20-year-old woman who has burning with urination
History of present illness
. 4 day of burning with urination
. Fever to 38.3’C (101F) , chills , and rigors
. Urinating 10-12 times a day , sometimes with increased urgency and little urine
. Dull , intermittent pain in the lower pelvic area , greenish vaginal discharge , and occasional blood in the urine
. Similar episode 1 year ago; diagnosed as chlamydia and treated with doxycycline
. Last menstrual period was 2 weeks ago
. New sexual partner for the past 2 months
. You do not use condoms ad have no pain during intercourse
Review of systems
. No back pain
. No nausea , vomiting , diarrhea , or constipation
. No abnormal vaginal bleeding
Past medical / family / social history
. No otters significant past medical issue or surgeries
. Medications ; Oral contraceptive pill
. No drug allergies
. Father and mother are healthy ; no siblings
. Single , lives alone
. Occupation: college student
. Smoking : No
. Alcohol : Occasional heavy drink at parties
. Recreational drugs : no
Physical examination
Abdomen:
. Mild suprapubic discomfort with deep palpation
. Non-distended , normative bowel sounds
. No CVA tenderness
—————
Case 31 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 dysuria
. Asked about the frequency and urgency
. Asked about hematuria
. Asked about suprapubic , abdominal , and back pain
. Asked about fever and chills
. Asked about nausea and vomiting
. Asked about vaginal discharge and abdominal vaginal bleeding
. Asked bout pain during intercourse
. Asked about last menstrual period
. Asked bout sexual practices and contraceptive methods
Past medical /family/social history
. Asked about similar episodes in the past
. Asked about past medical issues , hospitalizations , and surgeries
. Asked about current medications
. Asked about medication allergies
. Asked about family health
. Asked about tobacco , alcohol , and recreational drug use
. Asked about sexual history
. Asked about occupation
Examination
. Washed heads before examination
. Examined without gown , not through gown
. Auscultated abdomen
. Palpated abdomen (superficial and deep), including suprapubic area
. Palpated / percussed back for constoverbral angle tenderness
Counseling
. Explained physical findings and problems diagnosis
. Explained further workup
. Explained need for pelvic 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
. Cystitis
. Pyelonephritis
. Urethritis
. Vulvovaginitis
. Pelvic inflammatory disease
Diagnostic study/studies
. Pelvic examination
. CBC with differential
. Urinalysis
. Culture of urine
. Urine PCR assay for gonorrhea and chlamydia
—————
Case 31 clinical summary
Clinical Skills Evaluation
Case 31 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).
. 20-yo woman with 4 days of dysuria , increased urinary frequency and urgency , fever , chills , and an episode of hematuria
. New sexual partner 2 months ago with no condom use
. Treated for chlamydia cervicitis a year ago with similar symptoms
. Intermittent suprapubic pain with green vaginal diachange
ROS : No back pain , nausea , vaginal bleeding , pain with intercourse , vomiting , diarrhea , or constipation
PMHx : None
PSHx : None
Meds : Birth control pills
Allergies : None
FHx : Father and mother are healthy
SHx : No smoking , occasion alcohol 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, 38.3’C (100.9F) ; blood pressure , 110/80 mmHg ; pulse , 82/min; and respirations , 16/min
. Abdomen : Mild suprapubic discomfort on deep palpation , non-distended , 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 : Cystitis
History finding(s)
. Increased urinary frequency and urgency
. Fever , chills
. Hematuria, dysuria
Physical examination finding(s)
. Suprapubic discomfort
. Fever
Diagnosis #2 : Pyelonephritis
History finding(s)
. Increased urinary frequency and urgency
. Fever , chills
. Hematuria, dysuria
Physical examination finding(s)
. Fever
Diagnosis #3 : Cervicitis
History finding(s)
. Fever
. Vaginal discharge
. New sexual partner with no condom use
. History of previous cervicitis
Physical examination finding(s)
. Fever
Diagnostic studies
. Pelvic examination
. Nucleic acid amplification test for chlamydia and gonorrhea
. Urinalysis
. Urine culture
. CBC with differential
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