| | [這篇文章最後由JuanFe在 2019/05/23 08:10pm 第 1 次編輯]
39 Case 39 scenario
Doorway information about patient ( epigastric pain )
The patient is a 53-year-old man who comes to the emergency department due to epigastric pain
Vital signs
. Temperature : 36.1’C
. Blood pressure : 120/70 mmHg
. Pulse : 84 /min
. Respirations : 16/min
Abdominal x-ray is as shown in the exhibit
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Basic differential diagnosis
. Peptic ulcer
. Gastritis
. Esophagitis(GERD)
. Carcinoma of esophagus , stomach , or pancreas
. Acute or chronic pancreatitis
. Cholecystitis
. Hepatitis
. Acute coronary event
—————
Case 39 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 53-year-old man who abdominal pain
History of present illness
. Intermittent abdominal pain for the past 2 years
. Located in midepigastric area and sometimes radiates to back
. Sharp quality ; 7/10 severity at worst
. Worse with meals and sometimes relieved with antacids; the pain also occurs in the middle of the night
. Associated symptoms :
- Decreased appetite with 6.8-kg(15-lb) weight loss in the last 6 months
- Abdominal bloating and feeling of fullness
- Occasional black stools
. Asked the doctor : ” Can you please stop this pain ? Is it durable?”
Review of systems
. No fever or chills
. No jaundice
. No shortness of breath
. No nausea , vomiting , diarrhea , or constipation
Past medical / family / social history
. Osteoarthritis of the knee for past 10 years
. Surgeries : None
. Medications : Ibuprofen 600 mg 3 times a day as needed , over-the-counter antacids as needed
. No drug allergies
. Father is healthy , mother died of pancreatic cancer at age 60, broth is healthy
. Occupation ; stockbroker
. Married , live with wife and 2 children
. Tobacco : No
Physical examination
Neck :
. Supple without thyromegaly or lymphadenopathy
Abdomen :
. Soft , non-tender, non-disveended
. Normative bowel sounds throughout
. No hepatosplenomegaly
. No bruits
—————
Case 39 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 pain
. Asked about the course over time
. Asked about the location and radiation of pain
. Asked about the quality and intensity of pain
. Asked about any aggravating or relieving factors (especially with relation of food)
. Asked bout associated symptoms , especially :
- Nausea
- Vomiting
- Heartburn
- Black stools or red blood in stools
- Jaundice
- Changes in appetite or weight
. Asked about dietary and bowel habits
. Asked about postprandial fullness or early satisfy
Past medical /family/social history
. Asked about similar episodes in the past
. Asked about previous medical issues , hospitalizations ,and surgeries
. Asked about current medications
. Asked bout medication allergies
. Asked bout family health
. Asked bout tobacco , alcohol , and recreational drug use
. Asked about occupation
Examination
. Washed heads before examination
. Examined without gown , not through gown
. Examined heart and lungs
. Examined abdomen (auscultation , superficial and deep palpation)
. Palpated axilla and above clavicle for lymph nodes
Counseling
. Explained physical findings and possible diagnosis
. 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
. Gastritis (NSAID gastropathy)
. Peptic ulcer
. GERD
. Gastric or pancreatic carcinoma
. Chronic pancreatitis
Diagnostic study/studies
. CBC with differential count
. Upper GI endoscopy
. Serum amylase and lipase
. Liver function tests (albumin , bilirubin, AST , ALT , alkaline phosphatase)
. Fecal occult blood test
. Abdomen ultrasound or CT scan
—————
Case 39 clinical summary
Clinical Skills Evaluation
Case 39 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).
. 53-yo man with 2 years of episodic midepigastric pain worse with food and sometimes relieved with antacids
. Pain also occurring at night and sometimes radiating to the back
. Pain is 7/10 severity
. Decreased appetite , feeling of a full stomach . abdominal bloating , occasional back stools , and a 6.7-kg(15-lb) weight loss in the past 6 months.
ROS : No jaundice , fever ,chills, vomiting , shortness of breath , diarrhea , or constipation
PMHx : Osteoarthritis of the knee for past 10 years
PSHx : None
Meds : Over-the -counter antacids as needed , ibuprofen 600mg 3 times a day as needed
Allergies : None
FHx : Father healthy , mother died at age 60 of pancreatic cancer
SHx : No tobacco use ; 2 beers day for 25 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 , 36.1C (97F) ; blood pressure , 120/70 mmHg; pulse , 84/min; and respirations ,16/min
. Neck : Supple without thyromegaly or lymphadenopathy
. Heart : RRR with no murmurs
. Lungs : Clear to auscultation and percussion
. Abdomen : Non0tender , non-distended , normative bowel sounds throughout , no hepatosplenomegaly , no bruits
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 : Peptic ulcer disease
History finding(s)
. Midepigastric pain
. Relief with antacids
. History of NSAID use
Physical examination finding(s)
. None
Diagnosis #2 : Chronic pancreatitis
History finding(s)
. Chronic midepigastric pain
. Pina radiating to back
. History of alcohol use
Physical examination finding(s)
. None
Diagnosis #3 : Gastric cancer
History finding(s)
. Midepigastric pain increased with food
. Nocturnal pain
. Weight loss
Physical examination finding(s)
. None
Diagnostic studies
. Abdominal X-ray (is normal)
. CBC with differential
. Serum amylase and lipase
. Upper GI endoscopy
. Liver function tests
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