| | 43 Case 43 scenario ( rectal bleeding )
Doorway information about patient
The patient is a 23-year-old man who comes to the emergency department due to rectal bleeding
Vital signs
. Temperature : 38.3’C(101F)
. Blood pressure : 110/60 mmHg
. Pulse : 90/min
. Respirations : 18/min
Basic differential diagnosis
Young patients
. Anal fistula /fissure
. Hemorrhoid
. Inflammatory bowel disease
. Infectious colitis
. Neoplasm
. Vascular ectasis
Elderly patients
. Diverticulitis
. Angiodysplasia
. Malignancy / polyp
. Ischemia colitis
. Inflammatory bowel disease
—————
Case 43 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 23-year-old man who comes to the emergency department with rectal bleeding
History of present illness
. Symptoms started with small blood speaks in stools for the last month ; have been passing frank blood for the past 3 days
. Chronic constipation for past 5 years . Often have to strain while defecating and sometimes has severe pain with bowel movements . Diet low in fruits and vegetables
. Bowel movements have increased in frequency recently to 3 times a day
. Associated symptoms:
- Crampy , mild pain (2-3/10) in lower abdomen
- No nausea or vomiting ; no black , tarry stools
- Mild fever (37.8’C[100F]) without chills for the past 4-5 days
- No recent change in weight or appetite
Past medical / family / social history
. No similar episodes in the past
. No otters medical issues , surgeries , or hospitalization
. No medications
. No drug allergies
. Father died of colon cancer at age 65; other family history its unknown
. Single , with multiple , recent female sexual partners ( Do not always use condoms) , no history of sex with men
. Occupation: Restaurant manager and bartender
. Smoking : No
. Alcohol : 1-2 drinks a week
. Recreational drugs : No
Physical examination
HEENT :
. No scleral icterus or pallor
Heart :
. Regular rate and rhythm
. No murmurs
Lungs :
. Clear to auscultation
Abdomen :
. Soft , Non-tender , no -distended
. Normal bowel sounds
—————
Case 43 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 description of the bleeding (eg, color [red/purple/black], quantity , blood on feces or mixed in)
. Asked about the onset and course over time
. Asked about pain during defecation and tenuous
. Asked about abdomen pain
. Asked about any prior gastrointestinal bleeding
. Asked about nausea and vomiting
. Asked about usual and recent bowel and dietary habits
. Asked about appetite and changes in weight
. Asked about fever and chills
Past medical /family/social history
. Asked bout otters medical issues
. Asked bout past hospitalizations and surgeries
. Asked about current medications (especially aspirin)
. Asked about medication allergies
. Asked about family health (especially gastrointestinal malignancy)
. Asked out tobacco , alcohol , and recreational drug use
. Asked occupation
. Asked about sexual history
Examination
. Washed heads before examination
. Examined without gown , not through gown
. Examined abdomen (inspection, auscultation , superficial and deep palpation)
Counseling
. Explained the physical finding and possible diagnosis
. Explained further workup
. Discussed the need for rectal 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
. Inflammatory
. Anal fistula / fissure
. Hemorrhoid
. Proctitis
. Infectious colitis
. Neoplasm
Diagnostic study/studies
. Rectal examination
. Facal occult blood test
. CBC
. Coagulation studies (PT/aPTT)
. Anoscopy
. Sigmoidoscopy / colonoscopy
. Abdomen x-ray
—————
Case 43 clinical summary
Clinical Skills Evaluation
Case 43 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).
. 23-yo man with rectal bleeding
. Mild symptoms for 1 month , passing frank blood last 3 days.
. Associated with crampy pain and low-grade fever
. History of chronic constpation
ROS : No change in weight or appetite , no nausea or vomiting
PMHx : Unremarkable
PSHx : None
Meds : None
Allergies : None
FHx : Father died of colon cancer at age 65
SHx : Single , works as restaurant manager and bartender , sexually active with multiple female partners, light alcohol intake , no tobacco or 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 , 38.3’C(100.9F) ; blood pressure , 110/60mmHg ; pulse , 90/min; and respirations , 18/min
. HEENT : No scleral icterus or pallor
. Heart : RRR with no murmur
. Lungs ; Clear to auscultation
. Abdomen : Soft , non-tender, normal bowel sounds
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 : Hemorrhoid
History finding(s)
. Visible lower gastrointestinal bleeding
. Chronic constipation and low-fiber intake
Physical examination finding(s)
. None
Diagnosis #2 : inflammatory bowel disease
History finding(s)
. Visible lower gastrointestinal bleeding
. Vampy abdominal pain
Physical examination finding(s)
. Fever
Diagnosis #3 : Rectal cancer
History finding(s)
. Visible lower gastrointestinal bleeding
. First-degree family history of colon cancer
Physical examination finding(s)
. None
Diagnostic studies
. Rectal examination
. CBC
. Electrolytes and blood glucose
. PT/ aPTT
. Anoscopy
. X-ray of abdomen
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