| | 35 Case 35 scenario ( right lumbar lower abdominal pain )
Doorway information about patient
The patient is a 35-year-old woman who comes to the office due to acute right lumbar and lower abdominal pain
Vital signs
. Temperature : 38.3’C (100.9F)
. Blood pressure : 110/70 mmHg
. Pulse : 100/min
. Respirations : 16/min
Basic differential diagnosis
. Renal colic
. Ovarian torsion
. Urinary tract infection /pyelonephritis
. Pelvic inflammatory disease
. Mittelschmerz
. Appendicitis
. Threatened abortion
. Ectopic pregnancy
. Dysmenorrhea
. Endometriosis
. Fibroids
—————
Case 35 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 35-year-old woman who has low back and abdominal pain
History of present illness
. 1 day of right low back pain that radiates to pelvis and lower abdomen
. Sharp pain ; 7/10 severity
. Progressively worsening and is not affected by positional charges
. Preceded by burning with urination for 2-3 days
. Associated with fever , chills , nausea (without vomiting) ,. and intermittent blood in urine
. At the end of the interview say , “ aim in a lot of pain . please make it stop.”
Review of systems
. Last menstrual period 3 weeks ago
. No vaginal discharge
. No chest pain or shortness of breath
. No diarrhea or consipation
Past medical / family / social history
. 2 pregnancies with uncomplicated vaginal delivery(G2P2)
. Pelvic inflammatory disease 2 year ago
. UTI twice 2 years ago treated with antibiotics
. No surgeries or hospitalization
. Medications : None
. No drug allergies
. Father , mother and sister are healthy
. Occupation : Bank teller
. Single , live with a children
. Sexually active with boyfriend and do not usually use condoms
. Tobacco : 1 pack a day for last 15 years
. Alcohol L Occasional beer or wine
. Recreational drugs : None
Physical examination
Abdomen :
. Diffused abdominal discomfort during the examination but no focal tenderness
. Non-distended
. Normative bowel sounds
. No hepatosplenomegaly
. Mild CVA tenderness on the right
. Negative psoas test
—————
Case 35 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 if pain and course over time
. Asked bout the location and radiation of pain
. Asked bout the quality and intensity of pain
. asked bout nay aggravating or relieving factors
. Asked bout associated symptoms , especially :
- Fever and chills
- Nausea and vomiting
- Constipation or diarrhea
- Urinary symptoms (eg, burning , blood in urine, frequency)
- Vaginal bleeding/ discharge
. Asked about last menstrual period and menstrual cycle
. Asked bout sexual practices and use of contraception
Past medical /family/social history
. Asked about similar episodes in the past
. Asked about past medical issues (especially urinary tract infections , pelvic inflammatory disease , kidney stones)
. Asked about hospitalizations and surgeries
. Asked about current medications
. Asked bout medication allergies
. Asked about family health
. Asked about occupation
. Asked about tobacco , alcohol , and recreational drug use
Examination
. Washed heads before examination
. Examined without gown , not through gown
. Auscultated abdomen
. Palpated abdomen (superficial and deep)
. Tested for rebound tenderness and rigidity
. Tested for constovertebral angle tenderness
. Tested for signs of appendicitis (eg , psoas test)
Counseling
. Explained physical findings and possible diagnosis
. Discussed the need for pelvic examination
. Explained further workup
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
. Renal colic
. UTI/ acute pyelonephritis
. Pelvic inflammatory disease
. Uterine fibrosis
. Appendicitis
Diagnostic study/studies
. Pelvic examination
. Pregnancy test
. CBC with differential count
. Urinary and culture
. Abdomen ultrasound
. Urine PCR for gonorrhea and chlamydia
—————
Case 35 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).
. 35-yo woman with 1 day of ship right flank pain radiating to the right pelvis and lower abdomen
. Pain is 7 on scale of 10
. Progressive , worsening pain without relief and unaffected by position
. Dysuria , fever , chills , nausea , and occasional hematuria
ROS : No vaginal discharge , chest pain , shortness pf breath , diarrhea , or constipation
PMHx : G2P2 , PID 2 years ago , UTI 2 years ago
PSHx : None
Meds : None
Allergies ; None
FHx : Father , mother , and sister are healthy
SHx : 1 PPD smoker for 15 years , occasional 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 (100.9’F) ; blood pressure , 110/70 mmHg; pulse 100/min; and respirations , 16/min
. Abdomen : Diffuse abdominal discomfort without focal tenderness , non-distended , normative bowel sounds , no hepatosplenomegaly , mild CVA tenderness son the right , negative psoas test
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 : Nephrolithiasius with hydronephrosis
History finding(s)
. Frank pain radiating to lower abdomen
. No comfort with any position change
Physical examination finding(s)
. Fever
. CVA tenderness
Diagnosis #2 : Pyelonephritis
History finding(s)
. Dysuria
. Hematuria
. Fever
Physical examination finding(s)
. CVA tenderness
. Fever
Diagnosis #3 : Pelvic inflammatory disease
History finding(s)
. Previous PID
. Sexually active without condom use
. Lower abdominal pain
Physical examination finding(s)
. None
Diagnostic studies
. Pregnancy test
. Pelvic examination
. CBC with differential
. Urinalysis and urine culture
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2018/09/13 07:59am 
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