| | 40 Case 40 scenario ( vomiting blood )
Doorway information about patient
The patient is a 45-year-old ma who comes to the emergency department due to vomiting blood
Vital signs
. Temperature : 36.7’C(98F)
. Blood pressure : 100/60 mmHg
. Pulse : 90/min
. Respirations : 18/min
Basic differential diagnosis
. Peptic ulcer
. Esophageal and gastric varices
. Mallory-Wises tear
. Gastritis
. Erosive esophagitis
. Gastric malignancy
. Vascular ectasia
—————
Case 40 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 45-tear-old man who comes to the emergency department with bloody vomiting
History of present illness
. Acute one of symptoms 2 hours ago
. Burning epigastric pain (8/10 severity ) radiating t the back , immediately followed by vomiting with cupful of bright blood
. Came to the emergency department following a second , similar episode 30 minutes ago
. Associated symptoms include:
- Dizziness/ lightheadedness
- Dark black stools occasionally in the last month
. History of heartburn for the last 2 years , worse in the last 2 months . Midepigastric pain 3-4 times a week after meals , especially when you also consume coffee or alcohol; symptoms last 10-15 minutes and are relieved with antacids
. Ask the doctor : “ Will I die for this bleeding ? Is it cancer ?”
Review of systems
. No fever or chills
. No weight loss
. No shortness of breath
. No jaundice , diarrhea , or constipation
. No urinary symptoms
. Heavy work stress
Past medical / family / social history
. Hypertension
. Tension headaches
. No surgeries or hospitalization
. Medications ; Hydrochlorothiazide 50mg daily , ibuprofen 400 mg 3 times a day as needed
. No drug allergies
. Father , mother , and 2 siblings are healthy
. Married ,live with wife and 2 children
. Occupation : Sale manager at a marketing company
. Smoking : 2 pack a day for last 25 years
. Alcohol : 2 beers a day for last 25 years
. Recreational drugs : None
Physical examination
HEENT :
. No jaundice or pallor
. Oropharynx clear
Neck :
. Supple without thyromegaly or lymphadenopathy
Lungs :
. Clear to auscultation bilaterally
Heart :
. Regular rhythm and rate
. No murmurs , gallops, or rubs
Abdomen :
. Non-tender , non-distended
. Normative bowel sounds throughout
. No hepatosplenomeagly
. No bruits
—————
Case 40 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 inset and frequency of vomiting
. Asked about the color of the vomit and quantity of blood vomited
. Asked about any recent/ prior symptoms (eg , heartburn , coughing , retching)
. Asked about associated abdominal pain ( location , radiation , quality , severity , aggravating / relieving factors)
. Asked about other associated symptoms , especially :
- Fever
- Dizziness
- Melena or bright red blood in stool
. Asked about hematuria or any otters unusual bleeding /bruising
Past medical /family/social history
. Asked about similar episodes in the past
. Asked about other medical issues (especially liver problems , stomach ulcers)
. Asked about past 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 occupation
Examination
. Washed heads before examination
. Examined without gown , not through gown
. Examined eyes for pallor and jaundice
. Examined mouth and pharynx
. Palpated neck and supraclavicular region for lymph nodes
. Examined heart and lungs
. Examined abdomen (auscultation , superficial and deep palpation , percussion of liver)
. Examined extremities
Counseling
. Explained physical findings and possible diagnosis
. Explained further workup
. Discussed smoking cessation (briefly)
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
. Gastric ulcer
. Duodenal ulcer
. Gastritis
. Erosive esophagitis
. Gastric malignancy
Diagnostic study/studies
. CBC with differential count
. Serum electrolytes (Na , K , HCO3 , Cl , BUN , creatinine)
. Coagulation studies (PT, aPTT)
. Upper GI endoscopy
. Liver function tests
—————
Case 40 clinical summary
Clinical Skills Evaluation
Case 40 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).
. 45-yo man with acute onset of 2 episodes of hematemesis with a cup of bright red blood and dizziness
. Midepigastric pain radiating to the back
. 2 years of heartburn and chronic midepigastric pain after meals , last 15-20 minutes and relieved with antacids.
. Symptoms worse with caffeine and alcohol intake
. Occasional black stools in the past month
ROS : No jaundice , fever, chills , shortness of breath , weight los, urinary symptoms , diarrhea , or constipation
PMHx : HTN , tension headaches
PSHx : None
Meds ; Hydrochlorothiazide 50mg daily , ibuprofen 400 mg 3 times daily as needed
Allergies ; None
FHx : Father , mother , and sibling s are ha;thy
SHx : 2 PPD smoker for 25 years ,2 beers a 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 , 36.7’C (98.1F) ; blood pressure , 100/60mmHg; pulse , 90/min ; and respirations , 18/min
. HEENT : No jaundice or pallor , oropharynx clear
. Neck : Supple without thyromegaly or lymphadenopathy
. Lung s; Clear to auscultation bilaterally
. Heart ; RRR without murmurs , gallops, or rubs
. Abdomen : Non-tender , 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 : Bleeding gastric ulcer
History finding(s)
. Hematemesis
. Midepigastric pain
. Occasional black stools
. NSAID use
Physical examination finding(s)
. Hypoetsnion
Diagnosis #2 : Gastritis
History finding(s)
. Hematemesis
. Midepigastric pain
. History of NSAID use
Physical examination finding(s)
. None
Diagnosis #3 : Esophagitis
History finding(s)
. History of heartburn
. Hematemesis
. Chronic tobacco / alcohol use
Physical examination finding(s)
. None
Diagnostic studies
. CBC with differential
. Upper GI endoscopy
. PT, aPTT
. Basic metabolic panel
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2018/09/13 08:04am 
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