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-- 作者: JuanFe
-- 發表時間: 2018/06/05 11:03pm

[這篇文章最後由JuanFe在 2018/09/13 08:08am 第 7 次編輯]

1 Abdominal pain

2 Skin rash

3 Arm and leg weakness

4 Acute chest pain

5 Cough

6 fatigue and weight loss

7 diarrhea

8 sore throat

9 medication refill

10 constipation

11 importance

12 child fever

13 abdominal pain RUQ

14 prenatal visit

-------------------------------------------------------------------

15 shortness of breath

16 increase urination

17 jaundice

18 chest pain

19 abdominal pain RLQ

20 leg pain bilateral

21 vomiting

22 Acute chest pain

23 Frequent fall

24 Cough and chest pain

25 lower abdominal pain

26 Fatigue

27 hearing loss

28 Right knee pain

29 Blurred vision

-------------------------------------------------------------------

30 multiple bruises

31 burning during urination

32 difficulty swallowing

33 Refill medication for HIV

34 amenorrhea

35 right lower back and lower abdominal pain

36 insomnia

37 difficulty urination

38 panic attack

39 epigastric pain

40 hematemesis

41 dizziness

42 seizure

43 rectal bleeding


-- 作者: JuanFe
-- 發表時間: 2018/07/07 05:16am

[這篇文章最後由JuanFe在 2018/11/03 01:04pm 第 1 次編輯]

1 Case 1

Scenario (abdominal pain)

Doorway information

The patient is a 30-year-old woman who comes to the clinic due to abdomen pain

Vital signs
. Temperature : 38.5’C (101.3 F)
. Blood pressure : 120/75 mmHg
. Pulse : 98 /min
. Respiration : 22/ min

Basic differential diagnosis

Gastrointestinal

. Appendicitis
. Acute cholecystitis
. Pancreatitis
. Inflammatory bowel disease
. Irritable bowel syndrome
. Diverticulitis
. Bowel obstruction
. Acute gastroenteritis

Urinary

. Urinary tract infection / pyelonephritis
. Renal colic

Reproductive

. Pelvic inflammatory disease
. Pelvic abscess
. Endometriosis
. Ovarian cyst / torsion
. Ectopic pregnancy
. Spontaneous abortion

Miscellaneous

. Shingles
. Aortic dissection

—————

Case 1 sim. pt . instructions

If the doctor ask you about anything other then these , just say “no” , or provide an answer that a normal patient might give.

You are a 30-year-old women who comes to the clinic with abdomen pain.

History of present illness

. The pain started 12 hours ago
. Started slowly , progressively increasing
. “Sharp” pain ; 6-7/10 in severity
. Felt all mover lower abdomen , but worst right below the umbilicus
. Began after eating a large meal
. Moving around makes it worse
. No alleviating factors
. Fever since yesterday, with occasional chills today
. Intermittent nausea and vomiting
. Passing urine more frequently and having burning on urination
. No bowel problems

Review of the systems

. Last menstrual period was 3 weeks ago
. No discharge or abnormal bleeding form vagina
. Appetite and weight have not changed recently

Past medical /family /social history

. One urinary tract infection in the past ; was serious and required hospitalization
. Current medications is an oral contraceptive pill only
. No allergies
. Immediate family members are all healthy
. Occupation : Receptionist (接待員)
. Sexually active with multiple men
. Tobacco : no
. Alcohol : 2-3 drinks on weekend
. Recreational drugs: no

Ask this question : “Doctor , is this appendicitis ?”

—————

Case 1 checklist

Following the encounter , check which of the following items were performed by examinee.

History of present illness / review of system

. Asked about the location of pain
. Asked about the intensity of pain
. Asked about the quality of pain
. Asked about the onset and duration of pain
. Asked about the course pf pain over time
. Asked about any radiation of pain
. Asked about any aggravating or relieving factors
. Asked about associated symptoms , especially :

1 Vomiting
2 Fever
3 Urinary problems
4 Bowel problems
5 Vaginal bleeding / discharge

. Asked about last menstrual period
. Asked about appetite and changes in weight

Past medical/ family / social history

. Asked about similar episodes in the past
. Asked about past medical issue , hospitalization , and surgeries
. Asked about current medications
. Asked about medication allergies
. Asked about family health
. Asked about tobacco, alcohol, and  drug use
. Asked about sexual and reproductive history
. Asked about occupation

Examination

. Examinee washed hands before examination
. Examined without gown , not through gown
. Auscultated abdomen
. Palpated abdomen(superficial and deep)
. Checked for rebound tenderness
. Checked for costovertibral angle tenderness
. Performed posts sign and obstructor sign

Counseling

. Explained physical findings and possible diagnosis
. Explained further workup
. Discussed safe sexual practices and sue of condom
. Asked to perform rectal and vaginal 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 open-ended questions
. Asked non leading questions
. Asked one question at a time
. Listened to what you said without interrupting
. Used plain english rather than technical jargon
. Used appropriate transition sentences
. Used appropriate draping techniques
. Expressed empathy and made appropriated reassurances
. Asked whether you had any concerns/ questions

Differential diagnosis

. Pelvic inflammatory disease
. Pelvic abscess
. Urinary tract infection
. Appendicitis
. Ovarian torsion / rupture of cyst

Diagnostic study/ studies

. Rectal and vaginal examination
. CBC with differential count
. Urinalysis
. Pregnancy test
. Abdomen x-ray
. Abdomen ultrasound

—————

Case 1 clinical summary

Clinical skill evaluation
Case 1 patient note

The following represents a typical note or this patient encounter . the details may vary depending on the information given by the simulated patient.

History : Described the history you just obtained from this patient, Include only information (pertinent positive and negatives ) relevant this patient’s problem(s)

. 30-yo remake with 12 hours of abdominal pain
. Ate a heavy meal at a barbecue restaurant a day ago.
. Developed acute-onset periumbilical abdomen 12 hours later; described as a sharp , lasting a few minutes at a time , radiating diffusely in the abdomen , made worse with movement , and relieved with rest.
. Dysuria , increased urinary frequency , fever to 38.5’C (101.3F) , chills , nausea ,and an episode of non bloody and non bilious vomiting.

ROS : No chest pain , shortness of breath , diarrhea , constipation
PMHx: Previous UTI with possible pyelonephritis
PSHx: None
Meds: None
Allergies : None
FHx: noncontributory
SHx: HAs had 2 sexual partners with unprotected intercourse in the past month

Physical examination : 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 signsL Temperature , 38.5C (101.3F) ; blood pressure , 120/75 mmHg, pulse 98/min; and respiration’s , 22/min
. Abdomen :Tenderness in the periumbilical , RLQ and LLQ regions
. No abdomen dissension or guarding
. Normative bowel sounds
. Negative Murphy sign, Rovsing sign , posts sign , and obturator sign
. No CVA tenderness
. Lungs : Clear to auscultation
. Heart : Normal heart sounds with no murmurs

Data interpretation : Based on what you have learned form the history and physical examination, list up to 3 diagnoses that might explain this patient;s complaint(s) , List your diagnoses form most to least likely . For some cases , fewer than 3 diagnoses will be appropriate . Then , enter the positive or negative findings form the history and the physical examination (if present) that support each diagnosis. Lastly , list initial diagnostic studies (if any) you would order for each listed diagnosis (e,g, restricted physical examination maneuvers ,laboratory tests , imaging , ECG ,etc.).

Diagnosis #1 : Appendicitis

History findings

. Diffuse , abdomen pain
. Fever , chills
. Nausea ,vomiting

Physical Exam finding(s)

. Diffuse abdomen tenderness
. Fever

Diagnosis #2 : UTI

History findings

. Dysuria
. Increased urinary frequency
. Fever

Physical Exam findings

. Fever

Diagnosis #3 : Pelvic inflammatory disease

History findings

. Multiple sexual partners with unprotected intercourse
. Nausea, vomiting

Physical Exam findings

. Diffuse abdominal tenderness
. Fever

Diagnostic Studies

. Pregnancy test
. Urinalysis with culture
. CT scan of abdomen


-- 作者: JuanFe
-- 發表時間: 2018/07/07 05:19am

[這篇文章最後由JuanFe在 2018/10/15 04:11pm 第 3 次編輯]

2 case 2

Scenario (rash)

Doorway information about patient

The patient is a 27-year-old woman who comes to the office due to a rash.

Vital signs
. Temperature : 36.8’C(98.3F)
. Blood pressure : 120/75 mmHg
. Pulse : 78/min
. Respirations: 16/min

Basic differential diagnosis

. Infections
- Bacterial (eg, cellulitis)
- Viral (eg,herpes zoster/shingles)
- Fungal (eg,tine corporis)
- Parasitic (eg, scabies)

. Psoriasis
. Acne vulgaris
. Rosacea
. Immune / autoimmune (eg, systemic lupus erythematous , erythema multiforme)
. Stasis dermatitis
. Bullous disorders (eg , bullous pemphigoid , dermatitis herpetiformis)

—————

Case2 sim. pt. instructions

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 27-year-old woman who comes to the office with a rash

History of present illness

. the rash began 1 week ago
. Started after working in the garden
. Located on the face and neck
. Flat, with no bumps or blisters
. No associated itching , burning , pain
. Felt feverish but did not check temperature
. Rash getting larger but not spreading to other areas of the body
. Worse after going out on the sun, no alleviating factors
. No recent travel or sick contacts
. Also noticed joint pain and stiffness for about an hour in the morning , starting 4 days ago

Review of the system

. Last menstrual period was 2 weeks ago ; regular menses

Past medical /family/social history

. Intermittent joint pains in the past that resolve spontaneously ; never was evaluated by a doctor
. no medications except aspirin 7 days ago for a headache
. No surgeries
. No pregnancies
. Father is 55 and healthy ; mother is 54 and has “rheumatism” ; sister is28 and has hypothyroidism
. Single
. Works as a computer operator in a chemical manufacturing facility
. 1 sexual partner in the last month ; regular condom use
. Tobacco: No
. Alcohol: no
. Recreational drugs : No

Physical examination

. Skin: Multiple , well-circumscribed lesions on face and neck without vesicles ; no tenderness to touch

—————

Case2 sim. pt checklist

Following the encounter , check which of the following items were performed by the examinee

History of present illness/review of system

. Asked about the location of rash
. Asked about whether the rash was initially flat or raised /blistered
. Asked whether the rash has changed over time or involved new areas
. Asked about any aggravating or relieving factors
. Asked about any causative factors
. Asked about associated symptoms , especially
- Itching or burning
- Pain
- Breathing problems or chest pain

. Asked about redness of eyes
. Asked about any joint pains
. Asked about fever
. Asked whether any close contacts have similar rash
. Asked about rennet travel
. Asked about any animal contact
. Asked about insect bites or outdoor activities in the recent past

Past medical / family / social history

. Asked about similar epodes of rash in the past
. Asked about past medical issue , hospitalizations ,a dn surgeries
. Asked about current medications
. Asked about medication allergies
. Asked about family health
. Asked bout tobacco, alcohol , and drug use
. Asked about sexual and reproductive history
. Asked about occupation

Examination

. Examinee washed heads before examination
. Examined without gown , not though gown
. Looked inside mouth for oral ulcers
. Examined hand joints
. Auscultate heart and lungs
. Examined face and neck for rash

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 open-ended questions
. Asked non leading questions
. Asked one question at a time
. Listened to what you said without interrupting
. Used plain English rather than technical jargon

—————

Clinical Skills evaluation

The following represents a typical note for this patient encounter . the details 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 positive and negatives ) relevant to this patient’s  problem(s)

. 27-yo female with 1 week of rash,
. Gardened for 3 hours a week ago and developed a rash on her face and neck a few hours later .
. Rash has increased in size but dose not involve other areas of the body.
. Morning joint pains and subjective fever.

ROS: no chest pain , shortness of breath , diarrhea , constipation , sick contacts , or recent travel
PMHx : Episodes of joint pain and stiffness in the past , with spontaneous resolution
PSHx : None
Meds : None
Allergies : Noen
FHx : Mother has possible rheumatoid arthritis.
SHx: HAs 1 sexual partner and uses condoms

Physical examination : Describe any positive and negative findings relevant to this patient’s [problem(s) . Be careful yo include only those parts of the examination performed i this encounter.

. Vital signs : Temperature : 36.8’C (98.3F) , blood pressure : 120/75mmHg , Pulse : 78/min, respirations : 22/min
. Face / neck : Multiple , well-circumscribes , erythematous macule without tenderness on palpation
. Skin : No clines , vesicles , or cysts in rash area .
. Joints : Normal range of motion in all joints without tenderness , edema , or erythema
. HEENT : no pallor , jaundice or eye lesion
. Lungs : CTA (C-lear T-o A-uscultate) bilaterally
. Heart ; RRR without M/G/R

Data interpretation: Based in what you have learned form the history and physical examination , lists up to 3 diagnosis that might explain this patient’s complaint(s) , List your diagnosis form most to least likely . For some cases , fewer than 3 diagnosis will be appropriate . then , enter the positive or negative diagnosis .Lastly , list initial diagnostic studies (if any) you would order for each listed diagnosis (eg , restricted physical exam maneuvers ,laboratory tests , imaging , ECG , eft.) .

Diagnosis #1 : SLE

History finding(s)

. Cutaneous photosensitive rash
. Fever
. Joint pain

Physical Examination finding(s)

. Discoid lupus rash

Diagnosis #2 : Rheumatoid arthritis

History findings

. Joint pain and morning stiffness
. Fever
. Family history

Physical Exam findings

. None

Diagnosis #3 : Photodermatitis

History finding(s)

. History of sun exposure followed by rash

Physical Exam finding(s)

. Photosensitive rash on face and neck
. No progression of rash to other areas

Diagnosis Studies

. ANA and anti-ds DNA
. Rheumatoid factor and ESR
. Skin biopsy


-- 作者: JuanFe
-- 發表時間: 2018/07/07 05:20am

3 Case 3

Scenario (arm and leg weakness)

Doorway information about patient

The patient is a 65-year-old woman who comes to the emergency department due to are and leg weakness.

Vital signs
. Temperature
. Blood pressure : 160/90 mmHg
. Pulse : 78/min
. Respirations : 22 /min

Basic differential diagnosis

Neurologic

. Stroke
. Transient ischemic attack (TIA)
. Subarachnoid hemorrhage
, Subdural hematoma
. Intracranial mass
. Guillain -Barre syndrome
. Spinal cord lesion
. Complex migraine

Metabolic

. Hypoglycemia
. Hypothyroidism
. Adrenal insufficiency
. Electrolyte disorders

Musculoskeletal

. Myopathy

Miscellaneous

. Conversion disorder
. Heart-Reflated illness

—————

Case 3 sim. pt. instructions

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 65-year-old woman who comes to the emergency department with 1 hour of right arm and leg weakness.

History of illness

. The symptoms started an hour ago with weakness in the right  arm and leg
. Gradually increasing numbness
. Moderate (5/10 in severity) headache that felt”all over “ the head
. Nausea but no vomiting
. No slurred speech or difficulty swallowing
. No blurred or double vision.
. No recent fall or loss consciousness
. no symptoms like this in the past.

Review of systems

. No fever
. No chest pain or palpitations
. No diarrhea
. No urinary symptoms
. No seizures

Past medical/family/social history

. High blood pressure for 25 years
. High cholesterol
. Heart attack 6 years ago; heart bypass surgery at that time
. Medications : Simvastatin 20 mg daily, aspirin 81mg daily, atenolol 50 mg daily
. Medication allergies : None
. Both parents had hypertension and died in their 60s of heart attacks
. Widow (husband died 8 years ago); lives alone
. Bought to the hospital by neighbor (“Steve”) who si closet contact and is “Like a son to me”
. Tobacco: 2 pack of cigarettes a day for 35 years and quit 6 years ago
. Alcohol : 1-2 drinks , once a month
. Recreational drugs : None

Physical examination

Neurological:
. Weaker on the right side of the body
. Unable to lift right leg or arm without assistance
. Unable to stand
. Cranial nerves are normal
. Reflexes are slightly exaggerated on the right
. Babinski: Upping on right and downgoing on the left
. Sensation is normal on both sides of body

The rest of the examination is normal

Ask this question : If the examinee dose not discuss the possibility of a stroke , ask , “Doctor , is it a stroke?”

—————

Cases3 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 weakness
. Asked where the weakness is felt
. Asked if the weakness is changing over time
. Asked how you felt prior to onset of the weakness
. Asked about associated symptoms

- Sensory changes or numbness
- Loss of consciousness
- Seizures/jerky movements
- Fever
- Nausea/vomiting
- Chest pain, palpations
- Problems with speech or swallowing
- Visual changes (eg , blurred vision, double vision)
- Incontinence / Bowel or bladder dysfunction

. Asked about a history of frequent fall/spells
. Asked about any history if recent head trauma

Past / family/ social history

. Asked about similar symptoms in the past
. Asked about past/other medical issues (especially hypertension, diabetes mellitus , hypercholesterolemia, myocardial infarction, strokes ,migraine headaches)
. Asked about previous hospitalizations and surgeries
. Asked about current medications
. Asked about medication allergies
. Asked about any family history of stoke , heart attacks , or aneurysms
. Asked about alcohol intake
. Asked about living situation

Examination

. Examinee washed hands before examination
. Examined without gown , not though gown
. Checked cranial nerves II-XII
. Tested muscle power bilaterally
. Checked deep-tendon reflexes in bother the upper / lower extremities
. Checked for sensory modalities proximally and distally
. Checked coordination and gait
. Listened for carotid bruits
. Checked for neck stiffness
. Auscultated heart

Counseling

. Explained the 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 open-ended questions
. Asked non-leading questions
. Asked one question at a time
. Listened to what you said without interrupting
. Used plain English rather than technical jargon
. Used appropriated transition sentences
. Used appropriate draping techniques
. Expressed empathy and made appropriate reassurances
. Asked whether you had any concerns./questions

Differential diagnosis

. Stroke
. Transient ischemic attack
. Subarachnoid hemorrhage

Diagnosis study

. CBC with differential
. Basic metabolic panel (or glucose and electrolytes)
. CT scan of the head without contrast
. Doppler ultrasound of the carotid arteries
. ECG
. Transesophageal echocardiogram

—————

Clinical Skill Evaluation
Case 3 Patient Note

The following represents a typical note for this patient encounter .  the details may vary depending on the information given by the simulated patient.

History: Describe the history you just obtained from this patient. Include only information (patent positives and negatives) relevant to this patient’s problem(s)

. 65-yo female with an hour of acute-onset , right -sided weakness and headache.
. Gradually progressing symptoms over the pats hour.
. Nausea without vomiting.
. No history of fall or syncope.

ROS: no fever , chest pain , shortness of breath , vision changes , dysarthria , seizures
Max : HTN , hypercholesterolemia , CAD
PSHx : CABG 6 years ago
Meds : Aspirin , simvastatin , atenolol
Allergies : None
FHx : Mother and father had HTN and died of MI , Brother has HTN and hypercholesterolemia
SHx : Smoked 2 PPD for 35 years but quit 6 years ago

Physical examination : 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 : 36.8’C (98.2 F) , Blood pressure : 160/90 mmHg , pulse : 78 /min , respirations : 16/min.
. Lungs :  CTA bilaterally
. Heart : RRR without M/G/R
. Neurological ; A&Ox3 , CN 2-12 intact , motor 5/5on LUE and LLE but 3/5 in RUE and RLE , sensory grossly intact , DTR 2+ on left but 3+ in RUE and RLE , upping toes on right and downing on left , gait unable to be assessed.

Data interpretation: Based on what you have learned from the history and physical examination ., .lsit up to 3 diagnosis that might explain this patients complaint(s) , list your diagnosis form most to least likely . for some cases , fewer than 3 diagnosis will  be appropriate . then , enter the positive or negative findings form the history and physical examination (if present) that support each diagnosis . lastly ,list initial diagnostic studies (if any ) you would order for each listed diagnosis (eg , restricted physical examination maneuvers , laboratory tests , imaging , ECG , etc.).

Diagnosis #1 ; Evolving stroke

History finding(S)

. Acute -onset weakness
. Gradually progressing symptoms

Physical Exam finding(s)

. Right hemiparesis
. Eight-side hyperflexia
. Right Babinski rifles present

Diagnosis #2: TIA or reversible ischemic neurological deficit

History finding(s)

. Acute-onset weakness

Physical Exam finding(S)

. Right hemiparesis
. Right-sided  hyperreflexia
. Right Babinski reflex present

Diagnosis #3 : Subarachnoid hemorrhage

History finding(s)

. Headache
. Nausea
. Acute-onset weakness

Physical Exam finding(s)

. Right hemiparesis
. Right-sided hyperreflexia
. Right Babinski reflex present

Diagnosis Studies

. CT scan of head without contrast
. Transesphageal echocardiogram
. Carotid Doppler
. CBC with differential


-- 作者: JuanFe
-- 發表時間: 2018/07/31 03:21am

[這篇文章最後由JuanFe在 2018/08/15 03:39pm 第 1 次編輯]

4 Case 4 scenario (acute chest pain)

Doorway Information About patient

The patient is a 29-year-old woman with known sickle cel anemia who comes to the emergency department due to chest pain

Vital signs

. Temperature : 38.5’C (101.3F)
. Blood pressure: 120/75 mmHg
. Pulse : 110/min
. Respirations : 22/min

Clinical images

Electrocardiogram T-S slightly upward ?

Basic differential diagnosis

Hematologic

. chest syndrome due to sickle cell anemia

Cardiovascular

. Pericarditis
. Acute coronary syndrome

Pulmonary

. Pneumonia
. Pulmonary thromboembolism

Musculoskeletal

. Costochondritis
. Salmonella osteomyelitis

Other

. Panic attack

—————

Case 4 sim pt. instructions

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 29-year -old women who comes to the emergency department with chest pain.

History of present illness

. Pain started 12 hours ago
. Pain located in the middle of the chest and dose not move.
. Pain started slowly bit is increasing and is now 7-8/10 in severity.
. Pain worse with any movement or deep breathing.
. Took acetaminophen , which reduced the pain slightly.
. Fever as high as 38.3’C (101F) . caught with green sputum , and imild shortness of breath for the last 3 days.
. No blood in the sputum or recent chest trauma.

Review of the systems

. No used , vomiting , diarrhea , or abdominal pain.
. No leg pain or swelling
. No back pain
. No urinary symptoms
. Last menstrual period was 2 weeks ago

Past medical / family / social history

. Sickle cell anemia: Diagnosed in childhood ; had mild pain episodes at that time. 1 transfusion(age 18). Admitted once for abdominal pain 5 years ago that resolved with supportive care in hospital.
. No surgires
. No pregnancies
. Medications : Birth control pill , acetaminophen as needed
. Allergies ; No drug allergies
. Mother also has sickle cell anemia; brother and father are healthy
. Occupation ; Teacher
. Single , sexual active with 1 boyfriend and use condoms regularly
. Tobacco : No
. Alcohol : No
. Recreational drugs : No

Physical examination

Head and neck:

. No redness or exudates in the mouth /pharynx
. No enlarged lymph nodes

Chest/lungs:

. No tenderness to palpation of the chest wall
. Clear to auscultation bilaterally

Heart;

. Regular rhythm with borderline tachycardia
. No murmurs

Abdomen:

. Nontender , non distended
. Normative bowel sound throughout
. Tympanic to percussion
. No hepatosplenomegaly

Extremities:

. No cyanosis
. No tenderness in the legs

You should also try to breath a little faster than normal to rate near 20/min . the rest of the examination is normal.

—————

Case 4 sim. pt. checklist

Following the encounter , check which of the following items were performed by the examinee.

History of present illness/ review of the system

. Asked about the location of pain
. Asked about the intensity of pain
. Asked about the quality of pain
. Asked about the origin and duration off pain
. Asked about the progression of pain
. Asked about any radiation of pain
. Asked about any radiation of pain
. Asked about the aggravating/ relieving factors
. Asked about associated symptoms , especially:
- Nausea
- Fever
- cough
- Shortness of breath
. Asked about precipitating gators of sickle cell crisis (eg, diarrhea a, dehydration , stress)
. Asked boy history of chest trauma
. Asked about nay leg pain / swelling / redness
. Asked about blood in the urine
. Asked bout prior blood transfusion

Past medical / family / social history

. Asked about any similar problems in the past
. Asked about other past medical issues
. Asked about previous hospitalizations and surgeries
. Asked about menstrual / reproductive history
. Asked about current medications (prescription and over the counter)
. Asked about any medication allergies
. Asked about family history of sickle cell anemia , heart problems , and blood clots
. asked about tobacco , alcohol , and drug use
. Asked about occupation

Examination

. Examinee chased hands before examination
. Examined without gown , not through gown
. Examined the oral cavity
. Examined for enlarged lymph nodes
. Performed inspection and palpation of the chest
. Performed palpation of area
. Auscultated the lungs and heart
. Palpated abdomen (superficial and deep)
. Examined hands and fingers
. Examined legs for tenderness

Counseling

. Explained the physical findings and possible diagnosis
. Explained the complications of sickly cell disease (infections , hypoxia can precipitate pain)
. Exclaimed further workup
. Discussed the importance of avoiding hypoxemia and maintaining hydration

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 het you said and maintained good eye contact
. Asked few open-ended questions
. Asked non-leading questions
. Asked one question at a time
. Listened to what you said without interrupting
. Used plain English rather than technical jargon
. Used appropriate transition sentences
. Used appropriate draping techniques
. Expressed empathy and made appropriate reassurances

Different diagnosis

. Chest syndrome due to sickle cell anemia
. Pneumonia
. Costochondritis
. Pericarditis
. Pulmonary thromboembolism
. Salmonella osteomyelitis

Diagnostic study / studies

. CBC with differential
. Urinalysis
. Sputum Gram and culture
. Blood cultures
. Chest x-ray
. ECG (provided with doorway information)

—————

Case 4 clinical summary

Clinical Skill Evaluation
Case 4 Clinical Note

The following represents a typical note for this patient encounter. The details may vary depending on the information given by the simulated patient.

History ; Describe the history you just obtained form this patient o. Include only information (pertinent positive and negatives) relevant to tis patient’s problem(s).

. 29-yo female with history of sickle cell anemia and 12 hours of acute -onset chest pain.
. Grade; increase in pain to 7-8 on a scale of 10 over the past 12 hours.
. Pain is worse with movement and respiration and improved with acetaminophen.
. 3 days of fever to 38.3’C (101F) , cough productive of green sputum , and mild shortness of breath.

ROS: No nausea , vomiting, trauma to chest , dysuria , diarrhea , leg swelling , or leg pain.
PMHx : Admitted once 5 years ago for abdominal pain that resolved
PSHx : None
Meds : Birth control pills , Tylenol PRN
Allergies : Noen
FHx : Mother has sickle cell anemia
SHx : Denies use of tobacco, alcohol , and elicit drugs , Had a blood transfusion as a child.
ECG shows sinus tachycardia with no diagnostic abnormalities

Physical examination:
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 , 38.5’C (101’3F); blood pressure , 120/75 mmHg; pulse , 110/min; and respirations , 2/min
. HEENT : Oropharynx without erythema or exudates
. Neck : No cervical lymphadenopathy , trachea midline
. Lungs : CTA bilaterally , no chest tenderness to palpation
. Heart : RRR without M/R/G
. Abdomen : Contender , non distended , normative bowel sounds thought ; tympanic to percussion , no hepatosplenomegaly
. Extremities : No cyanosis, clubbing , or edema ; no swelling or tenderness in the legs

Data interpretation; Based on what you have learned form the history and physical examination, List up to 3 diagnosis that might explain this patient’s complaints(s). List your diagnosis form poset to least likely . For some cases , fewer than 3 diagnosis will be appropriated  then , enter the positive ro negative findings form the history and the physical examination (if present) that support each diagnosis . Lastly ,list initial diagnostic studies (if nay) you would order for each listed diagnosis(e.g., restricted physic examination maneuvers, laboratory testes , imaging , ECG, etc)

Diagnosis #1 : Acute chest syndrome

History finding(s)
. Acute -onset chest pian
. Shortness of breath
. History of sickle cell anemia

Physical Exam finding(s)
. No chest pain or palpation
. Fever

Diagnosis#2 : Pneumonia

History finding(s)
. Fever
. Cough productive of green sputum
. Shortness of breath

Physical Exam finding(s)
. Fever
. Tachypnea

Diagnosis#3 ; Pulmonary embolism

History finding(s)
. Pleuritic chest pain
. Fever
. Shortness of breath
. Birth control pills

Physical Exam finding(s)
. Fever
. No chest tenderness ot palpation

Diagnostic Studies
. chest x-ray
. ABG
. Blood cultures
. CBC with differential


-- 作者: JuanFe
-- 發表時間: 2018/07/31 03:22am

[這篇文章最後由JuanFe在 2018/08/15 04:00pm 第 2 次編輯]

5 Case 5 scenario (cough)

Doorway information about patient

The patient is a 35-year -old man who comes to the office due to cough

Vital signs
. Temperature : 38.5’C(101.3F)
. Blood pressure : 120/75 mmHg
. Pulse : 98/min
. Respirations :  20/min

Basic differential diagnosis
. Common cold
. Acute sinusitis
. Allergic rhinitis
. Acute bronchitis
. Pneumonia
. Pertussis
. Pulmonary embolism
. Drugs (ACE inhibitors)
. Asthma
. Congestive heart failure
. Chronic obstructive pulmonary disease (COPD) exacerbation

—————

Case 5 sim. pt. instructions

f the patient asked you about anything other than these , just say “ no “ , for provide an answer that a normal patients might give.

You are a 35-tear-old man who  comes to the office with a cough.

History of present illness:

. the cough started 5 days ago
. Yellow sputum (“ teaspoon size” at a time)
. Cough is worse at n eight and is keeping you awake.
. Other symptoms include sore throat , sinus congestion , running nose, mild frontal headache
. No blood in the sputum , chills m night sweats , chest pain , shortness of breath, or wheezing
. Symptoms slightly better with over-the -counter cough medicine (guaifenesin/dextromethorphan)
. Temperature at home was 37.9’C(100.2F)
. 8 year-old son was recently sick with similar symptoms

Past medical/family/social history:

. Asthma l had it since childhood with mild intermittent symptoms
. Seasonal allergies; mainly in the fall and spring
. No surgieres
. Medications ; Albuterol inhaler as needed (2-3 times a month)
. Allergies : No medication allergies , but allergic to cats
. Father is 60 and has asthma ; mother is 59 and is healthy ; no siblings
. Married , live with spouse and 2 children
. Occupation : Paramedic
. Tobacco : 1 pack per day for 10 years
. Alcohol : 1-2 drinks on social occasions
. Recreational drugs : None

Physical examination

Head and neck :
. No redness or exudates in the mouth
. No sinus tenderness to percussion
. No enlarged lymph nodes

Chest/lungs:
. Clear to auscultation bilaterally

heart:
. Regular rate and rhythm; No murmurs

You should also try to breath a little faster to a rate near 20 /min . the rest of the examination is normal

—————

Case 5 sim. pt. checklist

Following the encounter , check which of the following itms were performed buy the examinee.

History of present illness/ review of systems

. Asked about the onset of cough
. Asked about the duration of cough
. Asked about whether cough is dry or productive
. Asked for descriptions of  sputum(color, quantity)
. Asked about any problem with breathing
. Asked about wheezing
. Asked about associated symptoms , especially:
- Chest pain
- Fever and chills
- Sinus congestion/pain
- Running nose
- Sore throat
. Asked about contacts with ill persons(workplace and home)

Past medical / family / social history

. Asked about similar episodes in the past
. Asked about past medical issues(asthma , chronic allergies)
. Asked about previous hospitalization and surgeries
. Asked about medications (prescription and over the counter)
. Asked about allergies
. Asked about family health
. Asked about occupation
. Asked about tobacco , alcohol, and drug use

Examination

. Examinee washed hands
. Examined without gown , not though gown
. Examined nose and throat
. Checked neck for lymph nodes
. Palpated sinus
. Listened to lungs
- Asked you to say 99 repeatedly(palpated for tactile vocal fremitus).
. Tapped on lungs (percussion)
. Auscultated heart

Counseling

. Explained physical findings and possible diagnosis.
. Emplane the further workup
. Discussed quitting smoking
. Discussed simple measures for comfort (eg, over the counter medications, fluids , humidifier air)

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 few open-ended questions
. Asked non-leading questions
. Asked one question at a time
. Listened to what you said without interrupting
. Used plain english reader 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 had any concerns / questions

Differential diagnosis

. Common cold
. Acute sinusitis
. Acute bronchitis
. Pneumonia

Diagnostic study/studies

. CBC with differential count
. Sputum Gram stain and culture
. Chest x-ray (posterior anterior and lateral view)

—————

Case 5 clinical summary

Clinical Skills Evaluation
Case 5 Patient Note

The following represents a typical note for this patient encounter . the details 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 male with 5 days of worsening cough
. Sore throat, fever , rhinorrhea, and frontal headache.
. Cough productive of approximately 1 tsp of yellow sputum without hemoptysis
. recent sick contact : 8-yo son.

ROS : No chills , night sweats , chest pain , shortness of breath , wheezing , or abdominal pain
PMHxL Mild asthma, seasonal allergic  rhinitis.
PSHx: None
Meds ; Albuterol MDI PRN
Allergies: Cats
FHx : Father has asthma
SHx : has smoked 1 PPD for past 10 years and drinks occasionally

Physical examination :
Describe any positive and negative findings relevant to this patient’s problem(s). be careful in include only those parts of the examination performed in this encounter.

. Vital designs: Temperature , 38.3’C(101F) ; blood pressure , 120/75 mmHg ; pulse, 98/min ; restorations , 20/min
. HEENT : Oropharynx without erythema or exudates. no sinus tenderness to percussion
. Neck : No cervical lymphadenopathy , trachea midline
. Lungs; CTA bilaterally
. Heart : RRR without M/R/G

Data interpretation:
Based on what you have learned form the history and physical examination, list up to 3 diagnosis that might explain this patient’s complaint(s). List your diagnosis from most to least likely . for some cases , fewer than 3 diagnoses will be appropriate . Then , enter the positive or negative findings form he history and the physical examination (if present) that support each diagnosis. Lastly , list initial diagnostic studies (if nay) you would order for each listed diagnosis (e.g.,restricted physical exam maneuvers , laboratory tests, imaging , ECG , etc.).

Diagnosis #1 : Acute sinusitis

History finding(s)
. History of allergic rhinitis
. Frontal headache
. Fever

Physical Exam finding(s)
. Fever

Diagnosis # 2 : Pneumonia

History finding(s)
. Fever
. Cough productive of yellow sputum
. Smoking history

Physical Exam finding(s)
. Fever
. Tachypnea

Diagnosis # 3 : Acute bronchitis

History finding(s)
. Cough
. Fever
. Smoking history

Physical Exam finding(s)
. Fever

Diagnostic Studies
. Chest x-ray
. Sputum Gram stain and cultures
. CBC with differential


-- 作者: JuanFe
-- 發表時間: 2018/08/15 03:22pm

6 Case 6 scenario (fatigue and weight loss)

Door way information about patient

The patient is a 50-year-old man who comes to the office due to fatigue and weight loss.

Vital signs
. Temperature : 36.7’C (98.1F)
. Blood pressure : 120/76 mmHg
. Pulse : 78 /min
. Respirations : 18 /min

Basic differential diagnosis

Infection
. HIV
. Tuberculosis

Metabolic disorders
. Diabetes
. Thyroid disorder
. Adrenal insufficiency

Malignancy
. Solid tumor
. Hematologic malignancy

Gastrointestinal
. Hepatitis
. Malabsorption

Other
. Depression
. Eating disorder
. Medication side effect

—————

Case 6 sim. pt. instruction

If the doctor asks you about anything otters than these , just say “no,” or provide an answer that a normal patient might give.

You are a 50-year-old man who comes to the office with fatigue

History of present illness

. The symptoms stated 5 months ago
. Symptoms were initially mild but have been worse over the last 3 months
. Generalized weakness but no focal weakness
. Symptoms are associated with intermittent “ gas pain “ around the umbilicus
. Feel full after eating only small meals

(Include the following information only of asked what may have caused / trigged your symptoms.)

. Symptoms got worse after your spouse died 3 months ago
. Decreased appetite with a 13.6-kg(30-lb) weight loss
. Decreased interest in activities
. Difficulty falling asleep at night ; also waking up frequently at night and unable to get back to sleep
. No thoughts about suicide , but have feelings of guilt
. Difficulty concentrating on tasks
. Thinking that your family dose not understand what you are going though and feeling isolated form many of your friends

Review of systems

. No fever , chills
. No nausea, vomiting , diarrhea , or constipation
. No chest pain, or shortness of breath
. No jaundice
. No numbness, tingling , or tremor

Past medical / family / social history

. No prior medical problems
. No surgeries
. No medications
. No drug allergies
. Mother died at age 60 of pancreatic cancer ; after died at age 55 of heart attack ; no siblings
. Widower, living aloe
. 2 children (ages 28, 25)
. Occupation : restaurant manager
. Tobacco: No
. Alcohol : 2-3 drinks on social occasions
. Recreational drugs: No

Physical examination

Head and neck:
. No readiness or exudates in the mouth
. No enlarged lymph nodes
. No thyromegaly

Chest / Lungs :
. No tenderness to palpation of the chest wall
. Clear to auscultation bilaterally

Heart:
. Regular rate and rhythm
. No murmurs

Abdomen:
. Non tender, non distended
. Normative bowel sounds throughout
. Tympanic to percussion
. No hepatoslenomegaly
. No jaundice

Extremities:
. No cyanosis , clubbing , edema

Neurological:
. Normal motor strength and deep-tendon reflexes

—————

Case 6 sim. pt. check list

Following the encounter , check which  of the following items were performed by the examinee

History of present illness/review of the system

. Asked  about the onset and progression of weakness. fatigue (open-ended question)
. Asked about associated symptoms , especially:
- Fever , chills , night sweats
- Enlarged lymph nodes
- Temperature intolerance (hot or cold)
- Chest pain, cough , and shortness of breath
- Nausea and vomiting
- Change in appetite and weight
- Difficulty swallowing
- Abdominal pain
- Jaundice
- Blood in stools or black stools
- Insomnia/sleep
. Enquired about any precipitating factors
. Asked about mood/emotional state
. Asked about interest in life
. Asked about any guilt feelings
. Asked about any ideas , plans , attempts for suicide

Past medical / family / social history

. Asked about similar episodes in the past
. Asked about past medical issue
. Asked about previous hospitalization and  surgeries
. Asked about medications
. Asked about medication allergies
. Asked about family health
. Asked about occupation
. Asked about tobacco, alcohol, and drug use

Examination

. Examinee washed hands
. Examined without gown , not though gown
. Examined eyes
. Examined oral cavity
. Examined neck for thyromegaly and lymphadenopathy
. Auscultated test (heart and lungs)
. Palpated abdomen , both superficially and deeply
. Checked leg for edema
. Check muscle power
. Looked for ankle jerk / reflex

Counseling

. Explained the physical findings and possible diagnosis
. Explained further workup
. Inquired regarding need for any additional emotional support

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 open-ended questions
. Asked non leading questions
. Listened to what you said without interrupting
. Used plain English rather than technical jargon
. Used appropriate draping techniques
. Summarized the history and explained physical findings
. Expressed empathy and gave appropriate reassurances
. Asked whether you had any concerns/ questions

Differential diagnosis

. Occult malignancy
. Hyper/hypothyroidism
. Depression

Diagnostic study/ studies

. Rectal examination and stool examination for occult blood
. CBC with differential
. Glucose and electrolytes
. TSH
. Liver function tests

—————

Case 6 clinical summary

Clinical Skill Evaluation
Case 6 Patient Note

The following represents a typical note for this patient encounter . the details may vary depending on the information given by simulated patient

History : Describe the history you just obtained form this patient. Include only information (pertinent positive and negatives) relevant to this patient’s problem(s).

. 50-yo male with 5 months of increased fatigue.
. Spouse died 3 months ago and symptoms have worsened since then.
. 13.6-kg (30-lb) weight loss, decreased appetite , periumbilical abdominal pain , early satiety.
. Loss of interest in activities and terminal insomnia but not suicidal

ROS: No dysphagia , fever , chills , night sweats , chest pain , shortness of breath, or cough
PMHx: None
PSHx: None
Meds: None
Allergies: None
FHx: Mother died at age 60 form pancreatic cancer , after died at age 55 form heart attack
SHx: Denies tobacco use

Physical examination: 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 (98F) ; blood pressure , 120/76 mmHg ; pulse , 78/min : and respirations , 18/min
. Head / neck : No redness or exudates in the mouth , no enlarged lymph nodes , no jaundice , no thyromegaly
. Chest /lungs: No tenderness to palpation of the chest wall , clear to auscultation bilaterally
. Heart : RRR
. Abdomen : Non tender , non distended , normative bowel sounds throughout ; tympanic to percussion ; no hepatosplenomegaly
. Extremities : No cyanosis , clubbing, or edema
. Neurological : Motor 5/5 throughout , DTR 2+ bilaterally

Data interpretation : Based on what you have learned form the history and physical examination, list up to 3 diagnosis that might explain this patient’s complaint(s). List your diagnosis form most to least likely. For some cases , fewer than 3 diagnosis will be appropriate . then , enter the positive or negative findings form the history and the physical examination (if present) that support each diagnosis. Lastly , list initial diagnostic studies(if any) you would order for each listed diagnosis (e.g., restricted physical exam maneuvers , laboratory tests, imaging, ECG, etc.).

Diagnosis #2 : Depression

history finding(s)
. Fatigue
. Weight loss
. Death of spouse
. Terminal insomnia

Physical Exam finding(s)
. None

Diagnosis #1 : GI malignancy (eg , colon cancer, Gastric cancer )

History finding(s)
. Fatigue
. Weight loss
. Early satiety

Physical exam finding(s)
. None

Diagnosis #3 : hyperthyroidism

History finding(s)
. Weight loss
. Fatigue

Physical Exam finding(s)
. None

Diagnosis Studies
. TSH and T4
. CBC with differential
. Rectal examination with FOBT
. Colonoscopy
. CT scan ion the abdomen


-- 作者: JuanFe
-- 發表時間: 2018/08/15 03:23pm

7 Case 7 & scenario (diarrhea)

Doorway information about patient

The patient is a 35-year-old man who comes to the office due to acute diarrhea.

Vital signs
. Temperature: 36.7’C(98.1F)
. Blood pressure: 110/65 mmHg
. Pulse : 100 /min
. Respirations: 18/min

Basi differential diagnosis

. Viral gastroenteritis
. Bacterial gastroenteritis & food-borne pathogens
. Medication induced
. Giardiasis
. Clostridium difficle colitis
. Inflammatory bowel disease
. Irritable bowel disease
. Malabsorption
. HIV

—————

Case 7 sim. pt. instructions

If the doctor asks you about anything otters than these . just say “no” , or provide an answer that a normal patient might give.

You are a 35-year-old man who has diarrhea.

History of present illness

. Onset 1 day ago , 6-8 hours after meal
. Ate salad and shrimp at a local seafood restaurant
. Loose , watery stop,s with no blood or mucus
. 6 or 7 bowel movements in 24 hours
. Associated symptoms:
- Diffuse abdominal cramps
- Nausea and vomiting
- Difficulty keeping down solids or liquids
- no fever or chills
. Nothing seems to make it worse , and you have not tried any over-the-counter treatments
. 2 friends who ate with you have similar symptoms
. No recent travel

Review of system

. Sinus infection 2 weeks ago , treated with amoxicillin (last dose 2 days ago)
. No chest pain or shortness of breath
. No urinary symptoms
. No back pain

Past medical / family / social history

. No significant past medical problems or surgeries
. No other medications (otters than amoxicillin)
. No medication allergies
. Bother parents and siblings (2 brothers) are healthy
. Single , live  alone
. Occupation : Software engineer
. Smoking : No
. Alcohol : no
. Recreational drugs: No

Physical examination

Head and neck:
. No erythema or exudates in the mouth / pharynx
. Dry mucous membranes
. No enlarged lymph nodes

Skin:
. No jaundice

Chest/lungs:
. Clear to auscultation bilaterally

Heart :
. regular rhythm without murmurs , gallops , or rubs

Abdomen:
. Non tender, non distended
. Normative bowel sounds throughout
. Tympanic to percussion
. No hepatosplenomegaly

—————

Case 7 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 to clarify characteristics of diarrhea
- Increased frequency ? Increased volume ? Altered consistency ?
. Asked about the frequency of diarrhea
. Asked about associated symptoms (eg,vomiting , fever , abdominal pain, anorexia, prior constipation , myalgia , tenesmus)
. Asked about any blood or mucus in stools
. Asked about any recent travel
. Asked whether any otters family members or other contacts are sick
. Asked about exposure to suspicious foods (eg, unpasteurized /undercooked food , unusual foods , dairy products , seafood)

Past medical / family/ social history

. Asked about prior episodes of diarrhea and gastrointestinal illness
. Asked about otters medical issue
. Asked  bout medications (especially antibiotics) and medication allergies
. Asked  about recent and previous hospitalizations
. Asked boy any  abdomen surgeries
. Asked bout occupation
. Asked boy tobacco , alcohol , and drug use
. Asked about family history (especially gastrointestinal disease)

Examination

. Examinee washed heads
. Examined without gown , not though gown
. Auscultated abdomen
. Palpated abdomen superficially
. Palpated abdomen deeply
. Examination of skin for any rashes
. Examination of oral cavity
. Respiratory examination
. Cardiac auscultation

Counseling

. Explained the physical findings and possible diagnosis
. Explained further workup
. Discussed need for rectal examination
. Discussed fluids and otters basic interventions

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 heat you said and maintained good eye contact
. Asked open-ended questions
. Asked non-leading questions
. Asked one question at a time
. Listened to what you said without interrupting
. Used plain English rather than technical jargon
. Used appropriate transition sentences
. Used appropriate draping techniques
. Summarized the history and explained physical findings
. Asked whether you have any concerns / questions

Differential diagnosis

.Viral gastroenteritis
. Bacterial gastroenteritis
. Clostridium difficile diarrhea

Diagnostic study/ studies

. Rectal examination
. Fecal occult blood test
. CBC with differential count
. Basic metabolic panel (electrolytes , BUN , creatinine, glucose)
. Stool for C. difficile toxin
. Stool for fecal leukocytes

—————

Case 7 clinical summary

Clinical Skills Evaluation
Case 7 Patient Note

The following represents a typical note for this patient encounter . the details amy vary depending on the information given by the simulated patient.

history : Describe the history you jus obtained for  this patient . Include only information (permanent positives and negatives) relevant to this patient’s problem(s)

. 35-yo male with 1 day of diarrhea with 6-7 loose BM/day without blood or mucus.
. Ate seafood and salad at restaurant 6-8 hours before symptom onset.
. Recent sinus infection treated with amoxicillin , last dose 2 days ago.
. Diffuse crampy abdominal pain , nausea , vomiting , decreased PO intake.
, Two otters friends who ate at the restaurant have the same symptoms,

ROS : No fever , chills , chest pain , shortness of breath , burning with urination , rennet travel , or back pain.
PMHx : None
PSHx : None
Meds : None
Allergies : None
FHx : Noncontributory
SHx : Denies tobacco and alcohol use

Physical examination ; 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.

. Viral signs: Temperature , 36.7’C (98F) ; blood pressure , 110/65 mmHg : pulse , 100/min ; and respirations , 18/min.
. Head / neck : Oropharynx with dry mucous membranes but no erythema or exudates , no enlarged lymph nodes , no jaundice
. Chest /lungs : Clear to auscultation bilaterally
. Heart : RRR without M/G/R
. Abdomen : Contender , non distended , normoactive bowel sounds thought ; tympanic on percussion ; no hepatosplenomegaly

Data interpretation : Based on what you have learned form the history and physical examination , List up to 3 diagnosis that might explain this patient’s complaint(s). List your diagnosis form most to least likely . For some cases , fewer than 3 diagnosis will be appropriate . Then , enter the positive or negative findings forth history and the physical examination (if present) that support each diagnosis . Lastly , list initial diagnostic studies (if any) you would order for each listed diagnosis (e,g,,restricted physical exam maneuvers , laboratory test, imaging , ECG , etc.).

Diagnosis #1 : Viral gastroenteritis

History finding(s)
. Diarrhea without fever
. No blood in stool
. Other sick friends who also ate at same place

Physical Exam finding(s)
. No fever

Diagnosis #2 : Bacterial gastroenteritis

History finding(s)
. Symptom onset 6-8 hours after eating at a restaurant
. Nausea , vomiting

Physical Exam finding(s)
. None

Diagnosis #3 : Clostridium difficile colitis

History finding(s)
. Symptoms starting 2 days after rennet amoxicillin use
. No blood in stool

Physical Exam finding(s)
. None

Diagnostic Studies
. Stool for leukocytes
. Stool for Clostridium difficile
. Rectal examination with FOBT


-- 作者: JuanFe
-- 發表時間: 2018/08/15 03:25pm

8 Case 8 scenario (sore throat)

Doorway information about patient

The patient is a 25 -year-old woman who comes to the clinic sue to a sore throat

Vital signs
. Temperature : 13.3’C (101F)
. Blood pressure : 120/70 mmHg
. Pulse : 90 /min
. Respirations : 22/min

Basic differential diagnosis
. Viral pharyngitis
. Bacterial pharyngitis
- Group A streptococcal pharyngitis
- Mycoplasma pneumonia
- Neisseria gonorrhea
. Epstein-Barr virus mononucleosis
. Allergies rhinitis / postnasal drip
. Chronic tonsillitis
. Primary HIV

—————

Case 8 cim. pt. instructions

if the doctor sales you about anything other than these ,just say “no,” or provide an answer that a normal patient might give.

you are a 25 -year-old woman who comes to the office with a sore throat

History  of present illness

. Onset 3 days ago
. Pain with swallowing food
. Associated symptoms:
- Headache
- Body ache
- Nasal congestion
- Dry cough
- Fever to 38.1’C(100.5F)
. Symptoms partially relieved with Tylenol/acetaminophen
. Boyfriend had similar symptoms 2 weeks ago but now better

Review of system

. No abdominal pain , pelvic pain , rash , chills , chest pain , or shortness of breath
. Last menstrual period was 2 weeks ago

Past medical / family/ social history

. Frequent episodes of tonsillitis in childhood
. 2 upper respiratory illnesses in the past 2 years
. No pregnancies
. No past surgeries
. No current medications
. No medication allergies
. Parents and sister are healthy
. Occupation : College student
. Sexually active with boyfriend (condoms for birth control)
. Smoking : No
. Alcohol : No
. Recreational drugs : No

Physical examination

Head and neck :
. Oropharynx with tonsillar exudates
. Tympanic membranes clear bilaterally
. No sinus tenderness
. No enlarged lymph nodes

Chest/lungs:
. Clear to auscultation  bilaterally

Heart :
. Regular rhythm without murmurs, gallops , or rubs

Abdomen ;
. Non tender , non distended
. Normative bowel sounds throughout
. Tympanic to percussion
. No hepatospenomegaly

—————

Case 8 sim. pt. check list

Following the encounter , check which of the following items were performed by the examinee

History of present illness / review or system

. Asked about the onset of sore throat
. Asked about the course of symptoms over time
. Asked about pain during swallowing
. Asked  about associated symptoms
- Coughing and breathing problems
- Nasal discharge/ congestion
- Sinus pain and postnasal drip
- Headache
- Fever and chills
- Nausea and vomiting
- Joint pains and muscle aches
- Swollen neck glands
- Abdominal pain (especially left upper quadrant and pelvic pain)
- Rash
- Vaginal discharge
. Asked about contacts with ill person

Past medical /family/social history

. Asked about similar episodes in the past
. Asked about otters past medical issues
. Asked about current medications
. Asked about medication allergies
. Asked about family health problems
. Asked  about occupation
. Asked about tobacco , alcohol , and recreational drug use
. Asked about sexual and reproductive history

Examination

. Washed hands before examination
. Examined without gown , not though gown
. Looked inside mouth
. Palpated cervical lymph nodes
. Examined both ears
. Palpated spleen and liver
. Palpated abdomen (superficial and deep)
. Auscultated heart
. Auscultated lungs
. Examined skin for rash

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 open-ended questions
. Asked non;eating questions
. Asked one question at a time
. Listened to what you said without interrupting
. 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

. Infectious mononucleosis
. Viral pharyngitis
. Bacterial (streptococcal) pharyngitis

Diagnostic study/workup

. CBC
. Monospot test
. Rapid streptococcal antigen test

—————

Case 8 clinical summary

Clinical Skills Evaluation
Case 8 Patient Note

The following represents a typical note for this patient encounter . the details amy 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).

. 25-yo female with 3 days pop sore throat.
. Initially , sore throat , sinus congestion , runny nose , fever , and dry cough
. Sore throat has worsened with pain when swallowing.
. Sick contact (boyfriend) had similar symptoms that resolved

ROS : No chills , chest pain ,shortness of breath , nausea , vomiting m or abdominal pain
PMHx : None
PSHx : None
Meds : None
Allergies : None
FHx : Noncontributory
SHx : Denies tobacco and alcohol use

Physical examination: 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 (101F); blood pressure , 120/70 mmHg; pulse , 90/min ; and respirations , 16/min
. HEENT : Oropharynx with tonsillar exudates , TM clear bilaterally
. Neck : no enlarged lymph nodes
. Chest / lungs ; clear to auscultation bilaterally
. Heart : RRR without M/R/G
. Abdomen : non tender , non distended , normative bowel sounds thought ; tympanic to percussion ; no hepatosplenomegaly.

Data interpretation : based on what you have learned form the history and physical examination, list up to 3 diagnosis that might explain this patient’s complaint(s) . List your diagnosis form most to least likely . for some cases , fewer than 3 diagnosis will be appropriate . then , enter the positive or negative findings form the history and the physical examination (if present) that support each diagnosis . Lastly , list initial diagnostic studies (if any) you would order for each listed diagnosis (e,g,, restricted physical exam maneuvers , laboratory tests , imaging , ECG , etc.).

Diagnosis #1 : Bacterial pharyngitis

History finding(s)
. Sore throat
. Fever

Physical examination finding(s)
. Fever
. Tonsillar exudates

Diagnosis #2 : Viral pharyngitis

History finding(s)
. Fever
. Sore throat
. Boyfriend with similar illness that resolved

Physical examination finding(s)
. Fever

Diagnostic studies
. Rapid strep test
. Throat culture if rapid strep test is negative


-- 作者: JuanFe
-- 發表時間: 2018/08/15 03:26pm

9 Case 9 scenario (medication refill)

Doorway information about patient

The patient is a 56-year-old man who comes to the office for a blood pressure check and medication refill

Vital signs
. Temperature : 36.1’C (97F)
. Blood pressure ; 150/90 mmHg
. Pulse : 80 /min
. Respirations : 16/min

Basic differential diagnosis

When patient come for follow-up of known conditions , the primary diagnosis is known . However, you should be aware of complications and associated conditions.

. Congestive cardiac failure
. Coronary artery disease (angina)
. Peripheral vascular disease
. Retinopathy
. Side effects of the medications

—————

Case 9 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 56-year - old man who needs a blood pressure recheck and medication refill.

history of present illness

. Diagnosed with hypertension and high cholesterol 10 years ago
. Taking medications regularly
. Currently medications include hydrochlorothiazide and simvastatin
. DO not volunteer this information unless asked specifically abut past treatment:
You were initially treated with lisinopril , but that was stopped due to a dry cough ; You were then treated with atenolol but developed erectile dysfunction
. Not exercising regularly and not always following dietary recommendations
. Checking blood pressure at home ranges form 140-150 systolic and 80-90 diastolic
. No headaches , palpations , blurry vision , chest pain , shortness of breath , nosebleeds , dizziness , or leg swelling.

Past medical / family / social history

. Medical history otherwise negative
. No surgeries
. No other medications
. No medication allergies
. Father has hypertension and  mother has diabetes
. Occupation : Accountant
. Smoking ; 1 pack /day for 30 years
. Alcohol ; 1 glass of wine on social occasions
. Recreational drugs : None

Physical examination

HEENT:
. Pupils are equally round and reactive to light and accommodation (PERRLA)
. Extra ocular movement are intact (EOMI)
. Funduscopic examination shows no papilledema , exudates or AV nicking

Neck:
. No enlarged lymph nodes
. No bruits
. Carotid pulse 2+ bilaterally

Chest/lungs:
. Clear to auscultation bilaterally

Heart :
. Regular rhythm without murmurs , gallops , or rubs

Extremities :
. No cyanosis , clubbing , or edema
. Radial and posterior tibial pulses 2+

—————

Case 9 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 when you diagnosed with high blood pressure
. Asked what medications you are taking and of you take them as prescribed
. Asked about any side effects or other issues with medications
. Asked about prior treatment and why it was changed
. Asked about symptoms that might indicate a problem , including:
- Headache
- Dizziness
- Nosebleeds
- Dyspnea , orthopnea, paroxysmal nocturnal dyspnea
- Palpations
- Chest pian
- Pedal edema
. Asked about home blood pressure checks
. Asked about diet and exercise habits

Past medical / family / social history

. Asked about otters medical issues , hospitalizations , and surgeries
. Asked about other medications
. Asked about medication allergies
. Asked about family health (especially cardiovascular daises)
. Asked about tobacco . alcohol , and recreational drugs use
. Asked about occupation

Examination

. Washed hands before examination
. Examined without gown , not through gown
. Measured blood pressure in both arms
. Examined eyes with ophthalmoscope
. Check carotid arteries (pulses and bruits)
. Checked jugular venous pressure
. Auscultated heart
. Auscultated lungs
. Palpated peripheral pulses

Counseling

. Complemented you for using medications as prescribed
. Complemented you for checking home blood pressure regularly
. Explained further workup
. Explained the importance of diet and regular exercise
. Explained likely complications of uncontrolled blood pressure

Communication skills and professional conduct

. Knocked beef entering the room
. Introduced self and greeted you warmly
. Used your name to address you
. Paid attention to what you said and maintain good eye contact
. Asked open-ended questions
. Asked non-leading questions
. Asked one question at a time
. Listened to what you said without interrupting
. 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

. Essential hypertension

Diagnostic study/studies

. Urinalysis
. Lipid profile
. Electrolytes
. BUN and creatinine
. Glucose
. ECG

—————

Case 9 clinical summary

Clinical Skill evaluation
Case 9 Patient Notes

The following represent a typical notes 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 problems(s)

. 56-yo man here for BP check and medical refill.
. BP ranges form 140-150 systolic and 80-90 diastolic at home 3x/week in morning and evening
. Not compliant with low salt diet , no regular exercise
. Compliant with medications.
. Cough with ACE inhibitor , ED with beta blocker

ROS : no headache , palpations, blurry vision , chest pain , shortness of breath , nose bleeds, dizziness , or leg swelling
PMHx : Hypertension and hypercholesterolemia for past 10 years .
PSHx: None
Meds : Hydrochlorothiazide 50 mg daily , simvastatin 20 mg daily
Allergies ; None
FHx ; father has hypertension , mother has diabetes
SHx: Smokes 1 PPD for 30 years . drinks occasionally

Physical examination : Describe nay 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 , 37’C (98.6F) ; blood pressure , 150/90 mmHg in both arms ; pulse , 90/min; and respirations , 16/min
. HEENT : PERRLA , EOMI , fund without papilledema , exudates , or AV nicking
. Neck : No enlarged lymph nodes , no bruits
. Chest /lungs : Clear to auscultation bilaterally
. Heart : RRR without M/G/R
. Extremities : No cyanosis , clubbing , or edema ; pulse 2+ bilaterally in carotid , radial , and posterior tibialis

Data interpretation :
based on what you have learned from the history and physical examination , list up to 3 diagnoses that might explain this patient’s compliant(s) .List your diagnosis form most to least likely . For  some cases , fewer than 3 diagnosis will be appropriate . then enter the positive or negative findings form the history and the physical examination (if present) that support each diagnosis . Lastly , list initial diagnostic studies (if any ) you would order for each listed diagnosis (eg , restricted physical examination maneuvers , laborite tests , imaging ECG)

Diagnosis #1 : essential hypertension , sub optimally controlled

history finding(s)
. Hypertension
. Poor dietary complicate
. No regular exercise

Physical examination finding(s)
. Elevated blood pressure to 150/90 mmHg
. No neck bruits
. Symmetrical peripheral pulses
. Normla funduscopic examination

Diagnostic studies
. Serum electrolytes and creatinine
. Lipid panel


-- 作者: JuanFe
-- 發表時間: 2018/08/15 03:27pm

10 Case 10 scenario (constipation)

Doorway information about patient

The paint is a 66-year-old man who comes to the clinic due to constipation

Vital signs
. Temperature ; 36.7’C (98F)
. Blood pressure : 120/70 mmHg
. Pulse : 70 /min
. Respirations : 16/min

Basic differential diagnosis

. Functional constipation
. Obstructive lesions (eg , bowel obstruction , carcinoma f colon)
. Metabolic disturbances (eg , hypothyroidism, diabetes mellitus , hypercalcemia)
. Neurologic dysfunction (eg , stroke , autonomic neuropathy , final cord trauma , multiple sclerosis, Parkinson disease)
. Medication-induced (eg , iron preparations , opiates , anticholinergics)

—————

Case 10 sim. pt. instructions

If the doctor asks you about anything other than ashes , just say “no,” or provide na answer that a normal patient might give.

You are a 66-year -old man with constipation.

history o present illness

. Onset 5 months ago
. Worse over the last 2 months
. Previously 1 film bowel movement a day , now every otters day
. Stool now become harder
. Straining , difficulty passing stool , sense of incomplete evacuation
. Occasional black stools; no red blood in stools
. eating fruits and vegetables regularly and have not changed diet recently

Review of systems

. Fatigue
. 10-lb weight loss over the last 2 months
. No fever , chills , night sweats
. No diarrhea , nausea , vomiting
. No urinary symptoms

Past medical / family / social history

. Arthritis of the right knee
. Hashimoto thyroiditis ; had normal blood work 1 year ago
. Never had colonoscopy but rectal examination was normal 2 years ago
. No surgeries
. Medications:
- Levothyroxine 100 mcg/day
- Hydrocodone/acetaminophen 5mg/650mg 1 pill 3 times /day 9started 2 months ago for knee pain
. No medication allergies
. After died of colon cancer at age 67 and mother is healthy
. Occupation; Supervisor at pharmaceutical company
. Tobacco : No
. Alcohol : 2-3 glasses of wine a week
. Recreational drug : No

Physical examination

HEENT :
. No pallor icterus

Neck :
. No enlarges lymph nodes

Chest /lungs :
. Clear to auscultation bilaterally

Heart :
. Regular rhythm without murmurs , gallops , or rubs

Abdomen :
. Non-tender, non-distended
. Hypoactive bowel sounds thought
. No hepatosplenomegaly

Neurologic :
. Muscle strength 5/5 throughout
. Reflexes 2+ symmetric

—————

Case 10 sim. pt. checklist

Following the encounter , check which for the following itms were performed by the examinee.

history of present illness / review of systems

. Asked an open-ended questions What do you mean by constipation)
. Asked about the onset of constipation
. Asked about the frequency of bowel movements
. Asked about amount and caliber of stool passed
. Asked about consistency of stool
. Asked about pain during defecation
. Asked about any blood in stools of black stools
. Asked about episodes of diarrhea
. Asked about nay nausea and vomiting
. Asked about abdominal pain or cramps
. Asked about urinary issue (polyuria, dribbling)
. Asked about intolerance to hot or cold temperatures
. Asked about loss of appetite and weight loss
. Asked about diet (especially fluids and dietary fiber)

Past medical / family /social history

. Asked about similar episodes in the past
. Asked about other medical issues
. Asked about previous hospitalizations and surgeries
. Asked about regular screening procedures (especially colon conner screening)
. Asked about current medications
. Asked about medication allergies
. Asked about family health (especially colon cancer)
. Asked about tobacco , alcohol , and recreational rug use
. Asked about occupation

Examination

. Washed hands before examination
. Examined without gown , not though gown
. Examined eyes for pallor
. Auscultated abdomen
. Palpated abdomen (superficial and deep)
. Checked muscle power and reflexes inlayer extremities

Counseling

. Explained the physical findings and possible diagnosis
. Explained further workup (include 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

. Medication -induced
. Carcinoma of colon
. Uncontrolled hypothyroidism
. Functional constipation
. Undiagnosed diabetes

Diagnostic study/studies

. Rectal examination and stools for occult blood
. CBC with differential
. TSH
. Fasting blood sugar and /or hemoglobin A1c
. Colonoscopy

—————

Case 10 clinical summary

Clinical Skills Evaluation
Case 10 Patient notes

The following represents a typical note for this patient encounter . the details 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).

. 66-yo man here for constipation for 5 months with worsening over past 2 months
. Fatigue , 4.5-kg (10-lb) weight loss
. Change in bowel movement form 1 /day to 1 every other day
. Occasional black stools

ROS : No diarrhea , abdominal pain , nausea , vomiting , fever , chills , night sweats , or urinary problems
PMHx: Hashimoto’s thyroiditis , severe DJD of right knee
PSHx: None
Meds : Levothyroxine , hydrocodone / acetaminophen (started 2 months ago)
Allergies : None
FHx : Father died at age 67 of colon cancer
SHx : no smoking but drinks 1-3 glasses of wine /week

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 preformed in this encounter.

. Vital signs: Temperature, 36.7’C(98F); blood pressure , 120/70 mmHgin both arms; pulse , 70/min; respirations , 16/min
. HEENT : No pallor or jaundice
. Neck : No enlarge lymph nodes
. Chest / lungs : clear to auscultation bilaterally
. Heart : Regular rate and rhythm without M/G/R
. Abdomen : Non-tender , non-distended , hypoactive bowel sounds thought , no hepatosplenomegaly
. Neurologic : Muscle strength 5/5 throughout , DTR 2 + bilaterally and symmetrical

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 : Colon cancer

history findings(s)

. Worsening constipation
. Fatigue
. Weight loss
. Black stools

Physical examination finding(s)

. hypoactive bowel sounds

Diagnosis #2 : Functional constipation form medications

History finding(s)

. New drug (Lortab) started , with worsening of constipation

physical examination finding(s)

. Hypoactive bowel sounds

Diagnosis #3 : Hypothyroidism with suboptimal control

History finding(s)

. Fatigue
. Constipation

Diagnostic studies

. Rectal examination with stool for occult blood
. CBC with differential
. Serum TSH
. Colonoscopy
. Serum calcium


-- 作者: JuanFe
-- 發表時間: 2018/08/15 03:28pm

11 Case 11 scenario (importance)

Doorway information about patient

The patient is a 50-year-old man who comes to the clinic due to importance

Vital signs

. Temperature : 36.7’C (98F)
. Blood pressure : 150/80 mmHg
. Pulse : 80/min
. respirations ; 16/min

Basic differential diagnosis

Cardiovascular
. Atherosclerotic vascular disease

Metabolic /endocrine
. Diabetes
. Hypogonadism
. Hyperprolactinemia

Neurotic
. Spinal cord disorders

Psychological
. Anxiety
. Depression
. Alcohol or otters substance abuse

Other
. Medications (eg, antihypertensives)

—————

Case 11 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 50-year-old man who has erectile dysfunction

History of present illness

. Onset 3-4 months ago
. Gradually increasing difficulty getting an erection
. Normal interest unisexual activity
. Increased stress over last 6 months due to financial problems

Do not volunteer this information unless asked : You have awakened with a nocturnal erection for several months.

Review of systems

. Mild fatigue
. No headaches or visual changes
. No pain in the extremities
. No nausea , vomiting , or abdomen pain

Past medical history

. Diabetes for 10 years (home glucose ranges 150-200 mg/dL)
. Hypertension
. Generalized anxiety disorder
. Surgeries : None
. medications : Atenolol 50 mg , daily (started 4 months ago), lisinporil 20 mg daily, metformin 500 mg twice daily , glyburide 10 mg daily, fluoxetine 20 mg daily
. Allergies : None
. Immediate family members are healthy
. Occupation : truck driver
. Married, live with wife
. Tobacco 1-2 cigarettes week 9only when gong out with friends)
. Alcohol : 2-3 beers a day for 25 years
. Recreational drugs : No

Physical examination

HEENT:

. PERRLA
. EMOI

Abdomen

. Non-tender, Non-distended
. Normative bowel sounds throughout
. No hepatosplenomegaly
. No bruits


Extremities

. Posterior tibial and dorsals pedis pulse 2+ in both lower extremities

—————

Case 11 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 symptoms
. Asked whether out is continuous or intermittent
. Asked whether it is getting worse
. Asked about any changes in sexual desire
. Asked about any problems with ejaculation
. Asked detailed sexual history including the number of sexual partners (if multiple , ask follow-up questions : Dose the dysfunction occur with one partner and not another?)
. Asked about nocturnal erections
. Asked about aggravating to triggering factors
. Asked about nay pain in the legs(claudication)
. Asked about anxiety and depression
. Asked about headache (pituitary tumors)
. Asked about trauma

Past medical /family/social history

. Asked about otters medical issue (especially hypertension , diabetes mellitus , sickle cell disease , pulmonary vascular disease),hospitalization , and surgeries
. Asked about current medications
. Asked about medication allergies
. asked about family health
. Asked about tobacco, alcohol, and drug use
. Asked about occupation

Examination

. Washed hands before examination
. Examined without gown , not though gown
. Palpated abdomen and listened for bruit
. Examined pulsations in lower limbs

Counseling

. Explained the physical findings aden possible diagnosis
. Explained the need for additional workup(include genitourinary examination)
. Discussed quoting smoking and reducing alcohol intake

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

. Medication induced
. Diabetes neuropathy
. Atherosclerotic vascular disease
. Anxiety

Diagnostic study/studies

. Genital examination
. Fasting blood sugar and hemoglobin A1c
. Complete blood count
. TSH , Serum prolactin , and testosterone

—————

Case 11 clinical summary

Clinical Skills Evaluation
Case 11 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).

. 50-yo man with 4 months of worsening erectile dysfunction.
. New blood pressure medication (atenolol) started 4 months ago.
. Increased stress for past 6 months , mild fatigue.
. Poorly controlled diabetes with glucose near 200 mg/dl most of the day.

ROS : No headaches , leg pain , visual disturbances , nausea , vomiting , or abdominal pain
PNHx: Diabetes ,hypertension, anxiety
Meds ; Metformin, glyburide, fluoxetine , atenolol (started 4 months ago)
Allergies : None
FHx : Parents and siblings are healthy
SHx : Occasionally smokes and has had 2 or 3 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, 36.7’C (98F) ; blood pressure , 150/80 mmHg ; pulse , 80/min ; respirations , 16/min
. HEENT : PERRLA, EOMI
. Abdomen : Non-tender , non-distended, normative bowel sounds throughout , no hepatosplenomegaly or bruits
. Extremities : Pulses 2+ in the bilateral lower extremities

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 : Medication-induced ED

History finding(s)
. Started beta blocker 4 months ago
. No nighttime erection
. Difficulty having daytime erection

Physical examination finding(s)
. None

Diagnosis #2 : testosterone deficiency

History finding(s)
. Fatigue
. Erectile dysfunction

Physical examination finding(s)
. None

Diagnosis #3 : Anxiety

History finding(s)
. History of anxiety
. Increased stress over past 6 months

Physical examination finding(s)
. No focal findings on examination

Diagnostic studies
. Serum glucose and hemoglobin A1c
. Serum testosterone and TSH


-- 作者: JuanFe
-- 發表時間: 2018/08/15 03:30pm

12 Case 12 scenario (child fever)

Doorway information about patient

You will be speaking with the mother of a 1-year-old with fever

Basic differential diagnosis

. Respiratory tract infection
. Ear infection
. Exanthematous disease
. Meningitis
. Urinary tract infection
. Gastroenteritis

—————

Case 12  sim.pt. instruction

This is a telephone encounter with the doctor , who is asking you questions on the phone input the child . 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 28-year-old woman who calls for evaluation of fever in your 1-year-old child

History of present illness

. Onset of fever 2 days ago
. Fever to 38.9’C (102F)
. Associated symptoms include dry cough , picking at the right ear , and vomiting ingested food without diarrhea
. Had 1 episode of rhythmic jerking in both arms , with loss of urine ; afterward was silent and irritable for few minutes an then slept
. Dose met appear drowsy or lethargic but has not been feeling well
. Acetaminophen decreases the fever to 37.2’C (99F) transiently ; tepid sponge bathes also provide some relief
. 3 year old sibling has no symptoms
. No recent travel

Review of systems

. No rash
. Passing normal yellow urine but cries while urinating

Past medical history

. No prior medical conditions , surgeries , or hospitalizations
. Full-term delivery without complications
. Breastfed until 2 months old , then changed to formula
. Able to stand , hold objects in the hand , and say “Mama” and “ Dada”
. Childhood vaccinations are up to date
. At 9-month well-child visit , was at 75 percentile for height and 60 percentile for weight
. Chile lives at home with mother , father , and 3-year-old sibling
. Medications : Acetaminophen , liquid as needed
. Allergies : None
. Parents and siblings are all healthy

—————

Case 12 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 and severity of fever
. Asked whether the fever is continuous or intermittent with spontaneous return to baseline
. Asked  whether the fever responds to any medications
. Asked about associated symptoms , including:
- Cough
- Ear discharge
- Nasal congestion / discharge
- Pain
- vomiting and diarrhea / bowel symptoms
- Urinary symptoms
- Rash
. Asked about association with seizures (and further details including description , onset , associated incontinence or urine / bowel)
. Asked about what happened after seizure : whether the child was irritable and if any body part was paralyzed
. Asked about any exposure to infected individuals and history of travel

Past medical /family/social history

. Asked about similar episodes i the past
. Asked about current medications and allergies
. Asked about past medical issues (ear infections , convulsions, urinary tract infections),surgeries , and hospitalizations
. Asked about motor and social development
. Asked about prenatal and perinatal history
. Asked about feeling habits
. Asked about family health (especially seizures)

Counseling

. Explained the possible diagnosis
. Explained further workup
. Advised to give fluid and antipyretic
. Discussed the need for a clinic visit for examination and testing

Communication skills and professional conduct

. 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
. Expressed empathy and gave appropriate reassurances
. Asked whether you have any concerns/questions

Differential diagnosis

. Febrile seizures
. Meningitis
. Acute otitis media
. Urinary tract infection

Diagnostic study/studies

. CBC with differential count and erythrocyte sedimentation rate
. Urinalysis
. Lumber puncture

—————

Case 12 clinical summary

Clinical Skills Evaluation
Case 12 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).

. Telephone encounter with motor of 1-yo child with 2 days of fever to 38.9’C (102F),cough , and pulling at the right ear
. 2 episodes of vomiting but no diarrhea.
. 1 episodes of vomiting but no diarrhea.
. Crying when passing yellow urine
. No lethargy
. No previous infections or hospitalizations
. No sick contacts; sibling has no symptoms
. Birth history remarkable, normal developmental milestones.
. Immunizations up to date.

ROS : No recent travel or rashes
PMHx : None
PSHx : None
Meds : Acetaminophen
Allergies : None
FHx : Parents and sibling are healthy

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.

. Not done as this is a telephone encounter

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 : Acute otitis media

History finding(s)
. Fever
. Pulling at right ear

Physical examination finding(s)
. None

Diagnosis #2 : Urinary tract infection

History finding(s)
. Fever
. Pain with urination

Physical examination finding(s)
. None

Diagnosis #3 : Febrile seizure

History finding(s)
. Fever
. Rhythmic tremor with fever that subside
. Shaking movements while passing urine

Physical examination finding(s)
. None

Diagnostic studies
. Office visit for ear examination
. Urinalysis
. CBC with differential


-- 作者: JuanFe
-- 發表時間: 2018/08/15 03:31pm

13 Case 13 scenario (abdominal pain RUQ)

Doorway information about patient

The patient is a 45-year-old woman who comes to the office due to acute right upper quadrant abdominal pain.

Vital signs
. Temperature ; 38.3’C (101F)
. Blood pressure : 130/80 mmHg
. Pulse ; 100/min
. respirations : 20/min

Basic differential diagnosis

Gastrointestinal
. Acute cholecystitis
. Biliary colic
. Acute hepatitis
. Peptic ulcer (perforation)
. Acute pancreatitis (biliary pain)

Pulmonary
. Right lower lobe pneumonia

Cardiovascular
. Myocardial infarction
. Heart failure with hepatic congestion

Miscellaneous
. Herpes zoster (shingle)

—————

Case 13 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-year-old woman with acute abdominal pain

History of present illness

. Sudden onset 2 hour ago , 30 minutes after eating
. Progressively worsening
. Right upper abdomen with radiation to back and right shoulder
. Severity 8-9/10
. “Stabbing” sensation
. Worse with deep breathing , not relieved with antacids
. Associated symptoms :
- Nausea and vomiting without blood or bile; feel warm , but you idid not check temperature
- No diarrhea
. Similar pain 3-4 times over the last 5 months ; usually after meals and sometimes better with antacids

Do not volunteer this information unless asked about diet or fatty foods : You eat a lot of fast food because you are busy at work and do not have time to cook.

Review of systems

. No jaundice , cough , shortness of breath , itching , or chest pain

Past medical history

. No prior medical problems
. C-section 20 years ago
. Medications : Over -the -counter antacids
. Allergies : None
. Immediate family members are healthy
. Occupation ; Accountant
. Married , live with husband and 1 child
. Tobacco : 1 pack of cigarettes a day for 25 years ; trying to cut down
. Alcohol ; 2-3 beers a day for 15 years
. Recreational drugs : No

Physical examination

Abdomen:
. Right upper quadrant discomfort with deep palpation ; slightly worse with deep breath
. Abdomen non-distended
. Normative bowel sounds throughout
. No hepatosplenomegaly
. No abdominal bruits

The remainder of the examination is normal.

—————

Case 13 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 location and radiation of pain
. Asked about the intensity of pain
. Asked about the quality of pain
. Asked about the onset and duration of pain
. Asked about the precipitating factors
. Asked about the course of pain over time
. Asked about any aggravating or relieving factors
. Asked about nausea and vomiting
. Asked about fever and chills
. Asked about cough and breathing problems
. Asked about any chest pain
. Asked about jaundice
. Asked about history of black stools

Past medical /family/social history

. Asked about similar episodes in the past
. Asked about past medial issues (acid peptic disease , gallstone , heart problems)
. Asked about previous hospitalizations and surgeries (especially gallbladder removal or appendectomy)
. Asked about family history of healthy issue (especially gallstone)
. Asked about current medications
. Asked about occupation
. Asked boy tobacco and alcohol use
. Asked about diet

Examination

. Washed heads before examination
. Examined without gown , not through gown
. Auscultated abdomen(before palpation)
. Palpated abdomen (Superficial and deep)
. Checked for rebound tenderness
. Percussed for liver span
. Elicited murphy sign
. Auscultated heart and lungs

Counseling

. Explained physical findings and possible diagnosis
. Explained further workup
. Discussed change in lifestyle , including quitting smoking , cutting down alcohol , healthier diet

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

. Acute cholecystitis
. Biliary colic
. Perforation of peptic ulcer
. Pancreatitis
. Acute hepatitis

Diagnostic study/studies

. CBC with differential count
. EKG
. Chest x-ray
. Ultrasound abdomen
. Serum amylase and lipase
. LFTs (albumin , AST,ALT, alkaline phosphatase , total and direct bilirubin)

—————

Case 13 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).

. 45-yo female with 2 hours of worsening RUQ abdominal pain radiating to the right scapula.
. 5 months of similar episodes (3-4/month) that resolved with antacids
. Stabbing pain starting 30 minutes after food with nausea and nonbiilious and non bloody vomitus.
. Pain worse with deep breathing and not improved with antacids.

ROS : No jaundice , cough , shortness of breath , itching , chest pain , or diarrhea
PMHx : None
PSHx : Cesarian delivery 20 years ago
Meds : OTC antacids PRN
Allergies : None
FHx : Parents and siblings are healthy
SHx : 1 PPD smoker for 25 years , 2 or 3 beers /day for 15 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, 38.3’C (101.0F) ; blood pressure , 130/80 mmHg ; pulse , 100/min ; and respirations , 20/min
. HEENT : PERRLA, EOMI, no jaundice
. Abdomen : RUQ discomfort with deep palpation ; non-distended , normative bowel sounds throughout ; no hepatosplenomegaly or 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 : Acute cholecystitis

History finding(s)
. RUQ abdomen pain
. 5 month of similar episodes
. Pain radiating to right shoulder
. Pain worsened with deep breathing

Physical examination finding(s)
. Fever
. RUQ tenderness
. Positive Murphy sign

Diagnosis #2 : Acute pancreatitis

History finding(s)
. RUQ pain
. Nausea and vomiting
. Alcohol use

Physical examination finding(s)
. RUQ tenderness
. Fever

Diagnosis #3 : Peptic ulcer

History finding(s)
. Nausea and vomiting
. RUQ pain
. Alcohol /tobacco use

Physical examination finding(s)
. Fever
. RUQ tenderness

Diagnostic studies
. Ultrasound of RUQ of abdomen
. Serum amylase and lipase
. Liver function tests
. CBC with differential


-- 作者: JuanFe
-- 發表時間: 2018/08/15 03:31pm

14 Case 14 scenario (prenatal visit)

Doorway information about patient

The patient is a 24-year-old woman who comes to the office for an initial prenatal visit

Vital signs
. Temperature : 37.1’C(98.8F)
. Blood pressure : 120/75 mmHg
. Pulse : 78/min
. Respirations : 20/min

—————

Case 14 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 25-year-old woman here for your first prenatal visit

. This is your first pregnancy (no prior miscarriage or abortion)
. Last menstrual period 12 weeks ago
. Positive home pregnancy test 6 weeks ago
. Have not felt any fetal movements yet
. Menarche at age 13 ; periods usually regular every 28-30 days with bleeding 4-5 days each month
. No morning sickness , vomiting , abdominal pain , vaginal bleeding , fever , rash , breathing problems , sleep disturbances , or swelling in the feet

Past medical history

. No prior medical problems
. No surgeries or hospitalizations
. Medications : None
. Medication allergies : None
. Up to date on all standard adult immunizations
. Immediate family members are all healthy
. Occupation : Homemaker
. Married , lived with husband
. Tobacco 1 pack a day for 5 years
. Alcohol : 1-3 beers a week for 3 years
. Recreational drugs : None

Physical examination

HEENT

. PERRLA, EOMI
. Oropharynx clear

Lungs :

. Clear to auscultation bilaterally

Heart :

. Regular rate and rhythm without murmurs, gallops , or rubs

Abdomen :

. Non-tender , Non-distended
. Normative bowel sounds throughout
. No hepatopslenomegaly
. No bruits

Extremities

. No cyanosis or edema


—————

Case 14 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 LMP
. Asked about how you first suspected and confirmed pregnancy
. Asked about obstetrical / reproductive history (pregnancy and abortions)
. Asked about gynecologic history (menarche, regular periods , contraception)
. Asked about any pregnancy -related problems (vomiting , fever , abdominal pain, vaginal bleeding)
. Asked about diet , appetite , and weight gain
. Asked about genitourinary symptoms (eg , discharge, lesions, dysuria)
. Asked about sleep

Past medical /family/social history

. Asked about past medical issues (especially heart conditions , autoimmune disorders , hypertension , diabetes , sexually transmitted infections ,ad n renal disease)
. Asked about previous blood transfusions
. Asked bit current medications
. Asked about medication allergies
. Asked about exposure to cats
. Asked about rubella immunization in the past
. Asked about family health (congenital or birth problems in the family)
. Asked about tobacco , alcohol , and drug use
. Asked about occupation

Examination

. Washed heads before examination
. Examined without gown , not through gown
. Examined eyes (for pallor)
. Examined oral cavity (for general hygiene)
. Examined legs (for edema and varicose viens)
. Auscultated heart and lungs
. Examined and auscultated abdomen (if <28 weeks of fundal grip ; if > 28 weeks do Leopold maneuvers)

Counseling

. Explained physical findings
. Discussed appropriate prenatal tests
. Advised you to stop usage of tobacco and alcohol
. Advised safe sexual practices
. Explained the need for prenatal vitamins , iron supplementation , and nutritious diet
. Explained the importance of regular antenatal visits

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

Diagnostic study/studies

. RH(D) blood type , antibody screen
. CBC (hemoglobin /hematocrit , MCV)
. HIV , VDRL/RPR, HBsAg
. Rubella and varicella titers
. Pelvic examination (with Pap test, if indicated)
. Chlamydia PCR
. Urinalysis and culture

—————

Case 14 clinical summary

Clinical Skills Evaluation
Case 14 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).

. 24-yo woman , G1P0A0 and LMP 12 weeks ago , who presents for her first prenatal visit.
. No fetal movements yet.

ROS : No mooning sickness , vomiting , abdominal pain , vaginal bleeding , fever , rash , breathing problems , sleep disturbances , or swelling in the feet
PMHx : None
PSHx : None
Meds : None
Allergies : None
FHx : parents and siblings are healthy
SHx : 1 PPD smoker for 5 years , 1-3 beers/ week fro 3 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 , 37.1 ‘C (98.8F) ; blood pressure , 120/75 mmHg ; pulse , 78 /min; and respirations , 20/min
. HEENT : PERRLA < EOMI , no jaundice , oropharynx clear
. Lungs : Clear to auscultation bilaterally
. Heart : RRR without murmurs, gallops , or rubs
. Abdomen : Non-tender , non-distended , normative bowel sounds throughout ; no hepatosplenomegaly ; no bruits
. Extremities : No cyanosis or edema

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 : Normal pregnancy

History finding(s)
. LMP 12 weeks ago
. Home pregnancy test positive 6 weeks ago

Physical examination finding(s)
. non-distended abdomen
. No edema

Diagnostic studies
. Rh(D)type , antibody screen
. CBC
. HIV, VDRL/RPR , HBsAg
. Rubella and varicella titers
. Pelvic examination
. Chlamydia PCR
. Urinalysis and culture


-- 作者: JuanFe
-- 發表時間: 2018/08/15 03:32pm

15 Case 15 scenario (shortness of breath)

Doorway information about patient

The patient is a 60-year-old man who comes to the emergency department due to acute shortness of breath.

Vital signs

. Temperature: 36.7’C(98F)
. Blood pressure : 110/70 mmHg
. Pulse : 90 /min
. Respirations : 26/min

Basic differential diagnosis

. Pulmonary embolism
. Congestive heart failure
. Chronic obstructive pulmonary disease exacerbation
. Pneumonia
. Spontaneous pneumothorax
. Asthma exacerbation
. Anxiety/panic attack

—————

Case 15 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 60-year-old man with acute shortness of breath.

History of present illness

. Onset 2 days ago
. Mild shortness of breath with strenuous work that has slowly worsened over the past year. but is now suddenly worse
. Not of breath with walking 1 block
. Occasional dry cough
. No fever , chills , or unusual fatigue
. No syncope or palpations
. No swelling in the legs
. Difficulty at night
. Worsen when lying down and better when sitting up

Do not volunteer this information unless asked :
You sleep on 2 pillows because you get short of breath when lying flat , also , you woke up in the middle of the night weigh shortness of breath and could not go back to sleep for 20 minutes.

Past medical history

. Spinal fusion surgeries 2 weeks ago for spinal stenosis that required 1 week in the hospital postoperatively
. Hypertension diagnosed 20 years ago
. Medications ; hydrochlorothiazide 25mg daily
. Medication allergies : None
. Father died of a heart attack at age 55; mother is alive and has hypertension ; no siblings
. Occupation : Computer software analyst
. Married , live with wife
. Tobacco ; 1 pack of cigarettes a day for 40 years
. Alcohol : 1-2 glasses of wine a day for 35 years
. Recreational drugs : None

Physical examination

HEENT :
. PERRLA , EOMI

Neck :
. Supple without lymphadenopathy
. No JVD
. No thyromegaly

Lungs :
. Clear to auscultation and percussion

Heart :
. Regular rate and rhythm
. No murmurs , gallops , or rubs

Extremities :
. No edema , cyanosis , or clubbing
. Pedal pulse 2+ bilaterally
. No calf tenderness to palpation

—————

Case 15 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 symptoms
. Asked about the course over time
. Asked about associated symptoms :
- Chest pain
- Orthopnea and paroxysmal nocturnal dyspnea
- Wheezing
- Coughing
- Fever and chills
- Palpitations
- Syncope
- Leg pain and swelling
. Asked about recent travel or prolonged immobilization (recent surgery)

Past medical /family/social history

. Asked about similar episode in the past
. Asked about past medical issue (especially high blood pressure ,heart problems , asthma , and chronic obstructive pulmonary disease)
. Asked about surgeries and hospitalizations
. Asked about current medications
. Asked about medication allergies
. Asked about occupation
. Asked about tobacco , alcohol , and drug use
. Asked about family history of blood clots and heart problems

Examination

. Washed heads before examination
. Examined without gown , not through gown
. Examined neck for jugular venous pressure
. Examined heart : inspection , palpation , auscultation
. Examined lungs : inspection , palpation , auscultation , percussion
. Examined the extremities for pulses and edema
. Checked calf muscle tenderness

Counseling

. Explained physical findings and possible diagnosis
. Explained further workup
. Discussed quitting smoking

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

. Pulmonary embolism
. Pneumonia
. Congestive heart failure
. Chronic obstructive pulmonary disease

Diagnostic study/studies

. CBC with differential count
. Chest x-ray
. ECG
. Ventilation / perfusion (V/Q) scan or  chest CT scan
. Echocardiogram

—————

Case 15 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).

. 60-yo man with 2 days of worsening shortness of breath.
. 1 years of gradually worsening shortness of breaths that acutely worsened 2 days ago.
. New 2 -pillow orthopnea , PND.
. Spinal fusion surgery 2 weeks ago.
. Occasional dry cough.

ROS: No chest pain , wheezing , fatigue , palpations , leg swelling , syncope , fever , or chills
PMHx : HTN
PSHx : Spinal fusion surgery
Meds : Hydrochlorothiazide 25 mg daily
Allergies : None
FHx: Father died of MI at age 55 , mother has HTN
SHx : 1 PPD smoker for 40 years , 1 or 2 glasses of wine /day for 35 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 , 110/70 mmHg; pulse , 90/min; and respiration , 26/min
. HEENT : PERRLA , EMOI , no jaundice
. Neck ; Supple without lymphadenopathy , no JVD , no thyromegaly
. Lungs ; clear to auscultation
. Heart : RRR without murmurs, gallops , or rubs
. Extremities ; No edema , pulse 2+ bilaterally , no cyanosis or clubbing , no lower extremities tenderness on palpation

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 :Pulmonary embolism

History finding(s)
. Acute worsening of dyspnea
. Tecent spinal fusion surgery

Physical examination finding(s)
. None

Diagnosis #2 : Congestive heart failure

History finding(s)
. 1 year of gradually worsening dyspnea
. Dyspnea worse with exertion
. Orthopnea and PND

Physical examination finding(s)
. None

Diagnosis #3 : COPD

History finding(s)
. History of smoking
. 1 year of gradually worsening dyspnea
. Cough

Physical examination finding(s)
. None

Diagnostic studies
. Chest x-ray
. CT anagram of chest
. CBC with differential
. Basic metabolic panel
. ECG , echocardiogram


-- 作者: JuanFe
-- 發表時間: 2018/08/15 03:33pm

16 Case 16 scenario (increase urination)

Doorway information about patient

The patient is a 40-year-old woman who comes to the office due to increased urination

Vital signs

. Temperature : 36.7’C (98F)
. Blood pressure : 110/70 mmHg
. Pulse : 86/min
. Respirations : 16/min

Basic differential diagnosis

Increased urine volume
. Diabetes mellitus
. Diabetes insipidus (central, nephrogenic)
. Psychogenic : polydipsia
. Diuretic use
. hypercalcemia

increased urinary frequency
. Urinary tract infection
. Overactive bladder
. Excess caffeine intake
. Vaginitis , urethritis


—————

Case 16 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 40-year-old women complaining of increased urinary frequency

History of present illness

. Onset 2  months ago
. Urination 8-10 times during the day and 2-3 times a night
. increased urinary volume
. Increased feelings of thirst for last month
. Associated symptoms:
- Fatigue
- 4.5-kg (10-lb) weight loss (despite increased appetite)
- No dysuria or urgency
- No fever or chills

Past medical/family/soical history

. Bipolar disorder diagnosis 20 years ago
. Minor head injury after falling off bicycle 3 months ago ; seen in emergency department and discharged without intervention
. No surgeries or hospitalizations
. Medications : lithium 60 mg twice daily
. Medication allergies : None
. Married , live with husband
. 2 pregnancies with normal vaginal delivery ; both children are healthy
. Both parents have type 2 diabetes mellitus l no siblings
. Tobacco : No
. Alcohol : No
. Recreational drugs : No

Physical examination

HEENT :
. PERRLA , EOMI
. Visual fields intact

Heart :
. Regular rate and rhythm
. No murmurs , gallops , or rubs

Abdomen :
. Soft and non-tender with normal bowel sounds
. No suprapubic or CVA tenderness

Neurologic :
. Muscle strength 5/5 throughout
. Sensation in tact in all 4 extremities
. reflexes 2+ in all 4 extremities

—————

Case 16 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 problem
. Asked about the frequency of urination
. Asked about nocturia
. Asked about nocturne
. Asked about urine volume
. Asked about burning on urination
. Asked about urgency and hesitancy of urination
. Asked boy increased thirst and fluid intake
. Asked about appetite  and changes in weight
. Asked about the trauma to the head

Past medical /family/social history

. Asked about similar problems in the past
. Asked about past medical issues , hospitalizations ,and surgeries
. Asked about psychiatric problems (history of bipolar disorder , schizophrenia)
. Asked about current medications
. Asked about family health(especially diabetes)
. Asked about tobacco , alcohol , and drug use
. Asked about occupation

Examination

. Washed heads before examination
. Examined without gown , not through gown
. Examined mucous membranes
. Examined heart and lungs
. Tested muscle power in both upper and lower limbs
. Tested sensation in the lower extremities
. Tested reflexes in the lower extremities
. Tested visual fields and examined funds
. Tested for suprapubic and costovertebral angle tenderness

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

. Diabetes mellitus
. Central diabetes insipidus
. Nephrogenic diabetes insidious (lithium side effect)
. Psychogenic polydipsia
. Hypercalcemia

Diagnostic study/studies

. Fasting blood sugar
. Urinalysis
. Serum electrolytes (Na,K, Cl , CO2 , BUN , Cr , and calcium)
. Urine and serum osmolality

—————

Case 16 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).

. 40-yo woman with 2 months of polyuria , polydipsia, nocturia , and polyphagia
. 2-3 month of 4.5-kg(10-lb) weight loss with fatigue
. No dysuria or urinary urgency

ROS : No fever or chills
PMHx : bipolar disorder diagnosed 20 years ago ; minor head trauma 3 months ago , seen in emergency department and discharged without intervention
PSHx : None
Meds : Lithium 600 mg 2 times daily
Allergies : None
FHx : Father and mother have diabetes
SHx : No history of tobacco or 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 , 36.7’C(98.1F) ; blood pressure , 110/70mmHg; pulse , 86/min; and respirations , 16/min
. HEENT : PERRLA , EOMI, intact visual fields
. Abdomen : Non-tender without suprapubic tenderness, np CVA tenderness
. Neurologic L muscle strength 5/5 throughout sensation grossly intact bilateral lower extremities , DTR 2 + in bilateral lower extremities

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 : Diabetes mellitus

History finding(s)
. Polyuria
. Polydipsia and polyphagia
. Family history of diabetes in father and mother
. Weight loss

Physical examination finding(s)
. None

Diagnosis #2 : Diabetes insipidus

History finding(s)
. History of bipolar disorder
. Lithium use
. Polyuria

Physical examination finding(s)
. None

Diagnosis #3 : Psychogenic polydipsia

History finding(s)
. history of bipolar disorder
. Polyuria
. Polydipsia

Physical examination finding(s)
. None

Diagnostic studies
. Fasting blood glucose
. Hemoglobin A1c
. Urinalysis
. Serum electrolytes , lithium level
. Urine and serum osmolality


-- 作者: JuanFe
-- 發表時間: 2018/08/15 03:34pm

17 Case 17 scenario (jaundice)

Doorway information about patient

The patient is a 35-year-old woman who comes to the office due to jaundice

Vital signs

. Temperature : 38.5’C (101.3F)
. Blood pressure : 120/75 mmHg
. pulse : 98/min
. Respirations : 22/min

Basic differential diagnosis

. Infectious hepatitis
. Hemolytic jaundice
. Alcoholic hepatitis
. Drug-induced hepatitis
. Primary biliary cirrhosis
. Wilson disease
. Hemochromatosis
. Malignancy

—————

Case 17 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 comes to the clinic due to jaundice

History of present illness

. Onset of jaundice 2 days ago
. Fever beginning 5 days ago
. Dark urine and pale stools ,then yellowing of the eyes
. Associated symptoms :
- Mild abdomen discomfort
- 2-3 episodes non bilious , non bloody vomiting
- No sore throat , headache , neck stiffness , itching , diarrhea , or constipation
. Recent return form a trip to india (ate local food and drank bottled water)
. No vaccination for hepatitis in the past

Past medical history

. Motor vehicle accident 2 years ago requiring hospitalization and blood transfusion
. No surgires
. No medications
. No medication allergies
. Immediate family members 9parents and 3 siblings ) are all healthy
. Occupation: homemaker
. Married , live with husband
. 2 pregnancies with uncomplicated delivers
. Tobacco : no
. Alcohol  : 2-3 beers a day for 15 years
. recreational drugs : No

Physical examination

HEENT
. PERRLA, EOMI
. Scleral icterus present
. Oropharynx clear

Neck :
. No lymphadenopathy

Abdomen :
. Non-tender , non-distended
. No hepatosplenomegaly
. Normative bowel sounds

—————

Case 17 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 and duration of jaundice
. Asked about the color of stool and urine
. Asked about itching /pruritis
. Asked about abdominal pain
. Asked about fever and chills
. Asked about appetite and changes in weight
. Asked about sore throat
. Asked about any bleeding tendencies
. Asked about enlarged glands
. Asked about travel history

Past medical /family/social history

. Asked about similar episodes before
. Asked about past medical issue (especially hepatitis ,liver disease , blood transfusion , high blood pressure , diabetes ) , hospitalizations , and surgeries
. Asked about current medications
. Asked about family health
. Asked bout tobacco , alcohol , and drug use
. Asked bout sexual and reproductive history
. Asked bout occupation

Examination

. Washed heads before examination
. Examined without gown , not through gown
. Auscultation abdomen
. Palpated abdomen (superficial abandon deep) , including liver and spleen
. Checked rebound tenderness
. Examined for enlarged nodes

Counseling

. Explained physical findings and possible diagnosis
. Explained further workup
. Explained the importance of lifestyle modifications (especially reducing alcohol intake)

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

. infectious hepatitis
. Alcohol hepatitis
. Drug-induced hepatitis
. Primary biliary cirrhosis
. Malignancy

Diagnostic study/studies

. CBC with differential
. Liver function tests (AST,ALT, alkaline phosphatase , bilirubin)
. Coagulation studies (PT,PTT)
. Viral hepatitis serologies ( HBs antigen , HBc antibody , hepatitis A antibody , hepatitis C antibody)
. Urine for bile salts
. Anti-mitochondrial antibodies
. Liver ultrasound

—————

Case 17 clinical summary

Clinical Skills Evaluation
Case 17 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 2 days of jaundice associated with fever
. Returned 3 weeks ago form trip to india
. Dark urine endplate stools
. Mild diffuse abdominal discomfort , nausea ,vomiting.

ROS : No sore throat , headache , stiff neck , dysuria , weight loss , itching , diarrhea , or constipation
PMHx: Car accident 2 years ago  requiring hospitalization and blood transfusion
PSHx: None
Meds: None
Allergies : None
FHx: Father , mother and siblings are healthy
SHx: No history of tobacco use , 2-3 beers / day for the past 15 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 sign: temperature , 38.5’C (101.3F) ; blood pressure , 120/75 mmHg; pulse , 98/min; respirations , 22/min
. HEENT : PERRLA , EOMI , icterus present , oropharynx clear
. Neck : No lymphadenopathy
. Abdomen : Non-tender and non-distended , no hepatosplenomegaly , normative 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 : infectious hepatitis

History finding(s)
. Travel to India
. Jaundice
. Nausea , vomiting , abdomen discomfort
. Dark urine , pale stools

Physical examination finding(s)
. Fever
. Jaundice

Diagnosis #2 : Alcoholic hepatitis

History finding(s)
. Alcohol use
. Nausea , vomiting , abdominal discomfort

Physical examination finding(s)
. Fever
. Jaundice

Diagnostic studies
. Hepatitis serologies : A,B, and C
. CBC with differential
. Liver function tests
. Urinalysis


-- 作者: JuanFe
-- 發表時間: 2018/08/15 03:35pm

18 Case 18 scenario (chest pain)

Doorway information about patient

The Patient is a 35-yea-old woman who comes to the emergency department due to chest pain

Vital signs

. Temperature ; 36.8’C (98.3F)
. Blood pressure : 120/75 mmHg
. Pulse : 98/min
. Respirations : 12 /min

Basic differential diagnosis
. Pneumonia
. Gastroesphageal reflux disease
. Pain disorder/ hyperventilation syndrome
. hyperthyroidism
. Angina
. Costochondritis

—————

Case 18 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 with chest pain

History of present illness

. Onset of this episode 1 days ago
. Squeezing sensation over the entire chest
. 4-5/10 severity
. No aggravating or relieving factors ( no relief form antacids)
. Intermittent chest discomfort for the last year; episodes usually last 20 minutes ; initially about once a month but now every week; usually triggered buy going out in public
. Associated symptoms:
- Fasting breathing
- Sweating
- Headache
- Palpations
. Hospitalized over might 6 months ago for the same problem; all tests came back normal

Review of systems

. No nausea , vomiting , diarrhea , or abdominal pain
. No dysuria
. Headache
. Palpitations

Past medical history

. Hospitalized following a motor vehicle accident 32 years ago (required blood transfusion)
. No surgeries
. Medications : None
. Medication allergies : None
. After os healthy ; mother has “hypochondriasis” ; sister has hyperthyroidism
. Occupation : Secretary at a law firm
. Single, live a lone
. Tobacco : 1 pack a day for 15 years
. Alcohol : None
. Recreational drugs ; None

Physical examination

Neck :
. No lymphadenopathy
. No thyromegaly

Lungs :
. Clear to auscultation bilaterally

Heart :
. Regular rate and rhythm
. No murmurs, gallops , or rubs

Ask this question : “Do you think that this is a heart attack ? I feel like I am going to die “

—————

Case 18 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 location of pain
. Asked about the intensity of pain
. Asked about the quality of pain
. Asked about the duration and frequency of pain
. Asked about the course of the painter time
. Asked about any radiation of pain
. Asked about any aggravating or relieving factors
. Asked about any precipitating factors
. Asked about associated symptoms
- Nausea and vomiting
- Sweating
- hyperventilation or trouble breathing
- Cough
- Palpitations or rapid heart beat
- Fear of dying or sense of tremor
- Syncope or dizziness
- Headache
- changes in appetite or weight

Past medical /family/social history

. Asked about similar episodes in the past
. Asked about past medical issues (especially high blood pressure , heart problems , diabetes , thyroid problems)
. Asked about previous hospitalizations and surgeries
. Asked about current medications
. Asked about medication allergies
. Asked about family health
. Asked about tobacco , alcohol , and drug use
. Asked about sexual and reproductive history
. Asked bout occupation and stress in life

Examination

. Washed heads before examination
. Examined without gown , not through gown
. Examined neck and thyroid
. Listened to heart and lungs
. Check reflexes

Counseling

. Explained physical findings and possible diagnosis
. Discussed result of chest x-ray
. Explained further workup
. Discussed quitting smoking

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

. Panic disorder
. Hyperthyroidism
. Hyperventilation syndrome
, Angina

Diagnostic study/studies

. CBC with differential
. Electrolytes and blood glucose
. ECG
. TSH

—————

Case 18 clinical summary

Clinical Skills Evaluation
Case 18 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 year of worsening episodes of chest pain
. Diffuse chest tightness associated with headache , palpations , diaphoresis , hyperventilation ,a dn sense of impending doom
. Previous hospitalization with normal testing
. Episodes occur more often when out in public and are not relieved with antacids.

ROS : No nausea , vomiting , dysuria , constipation , flushing , sleep disturbance , or abdominal pain
PMHx: None
PSHx: None
Meds: None
Allergies : None
FHx : Fater os healthy , mother has hypochondriasis , and sister has hyperthyroidism
SHx : 1 PPD smoker for 15 years , no use of alcohol or illicit drugs

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 , 36.8’C (98.3F); blood pressure , 120/75mmHg; pulse , 98/min; and respirations, 12/min
. Neck : No lymphadenopathy por thyromegaly
. Lungs ; Clear to auscultation bilaterally
. heart : RRR without murmurs, gallops, or rubs

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 : Panic disorder

History finding(s)
. Episodes of chest pain
. Worse when in public
. Normal investigation in the past

Physical examination finding(s)
. Normal vital signs
. Normla cardiac examination

Diagnosis #2 : Hyperthyroidism

History finding(s)
. Family history
. Palpitations

Physical examination finding(s)
.None

Diagnosis #3 : Cardiac arrthemia

History finding(s)
. Episodic palpations
. Chest pain and diaphoresis

Physical examination finding(s)
. None

Diagnostic studies
. ECG
. TSH
. Chest x-ray shows only mild hyperinflation


-- 作者: JuanFe
-- 發表時間: 2018/08/15 03:36pm

19 Case 19 scenario (abdominal pain RLQ)

Doorway information about patient

The patient is a 45-year-old man who comes to the emergency department due to right lower abdominal pain

Vital signs

. Temperature : 37.1’C (89.7F)
. Blood pressure : 130/80 mmHg
. Pulse : 100/min
. Respirations : 20/min

Basic differential diagnosis

. Appendicitis
. Mickel diverticulitis
. Perforation viscus
. Intestinal obstruction
. Yersinia enterocolitica
. Pancreatitis
. Urolithiasis
. Acute cholecystitis
. Herpis zoster (shingle)

—————

Case 19 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-year-old man who comes to the emergency department with abdominal pain

History of present illness

. The pain stated suddenly 2 hours ago
. Pain started behind the belly button , than radiated to the right lower abdomen
. Pain is sharp. 8-9/10 severity , and has increased over time
. The symptoms started after a large meal and are worse with movement ; nothing relives the pain
. Associated symptoms
-  Nausea
- 2 episodes of non bilious , non bloody vomiting
. Last bowel movement was 20 hours ago , and you are passing gas normally

Review of systems

. No fever or chill
. No dysuria
. No diarrhea or constipation
. No back pain

Past medical/family/social history

. Peptic ulcer disease ; treated 10 years ago with omeprazole
. No current medications
. No surgeries
. Immediate family members are all healthy
. Occupation : Bus driver
. Single ,live alone
. Tobacco : 1 pack a day for 20 years
. Alcohol : 3 beer a day for past 15 years
. Recreational drugs : No

Physical examination

Abdomen :
. Right lower quadrant tenderness to superficial and deep palpation
. Rebound tenderness noted
. Normative bowel sounds throughout
. No hepatosplenomegaly
. No CVA tenderness
. Posts and obturator signs : Negative

—————

Case 19 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 location and radiation of pain
. Asked about the intensity of pain
. Asked about the quality of pain
. Asked about the origin and duration of pain
. Asked about the course of pain over time
. Asked about any aggravating or relieving factors
. Asked about any vomiting
. Asked about fever
. Asked bout urinary problems
. Asked about bowel problems , constipation , and last bowel movement
. Asked about appetite and change in weight

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 ,medical allergies
. Asked about family health
. Asked about tobacco , alcohol ,and recreational drug use
. Asked about sexual history
. Asked occupation

Examination

. Washed heads before examination
. Examined without gown , not through gown
. Auscultated abdomen(before palpation)
. Palpated abdomen(superficial and deep)
. Checked rebound tenderness
. Check for costovertebral angle tenderness
. Percussed for liver span
. Performed psoas sign and obturator sign

Counseling

. Explained physical findings and possible diagnosis
. Explained further workup
. Discussed lifestyle modifications , including quitting smoking and reducing alcohol

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

. Appendicitis
. Meckel diverticulitis
. Perforated peptic ulcer
. Intestinal obstruction
. Pancreatitis
. Urolithiasis

Diagnostic study/studies

. CBC with differential
. Serum chemistries(glucose, electrolytes , liver enzymes , creatinine)
. Serum lipas
. Abdomen x-ray
. Abdomen ultrasound
. Lipase, amylase
. Upper GI endoscopy

—————

Case 19 clinical summary

Clinical Skills Evaluation
Case 19 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 2 hors of worsening poplin form mid-epigastric region to RLQ
. Pain worse with movement but not relieved buy anything
. Nausea and vomiting (non-bloody , non-bilious)
. Last bowel movement 20 hours ago with passage flatus.

ROS : No fever , chills , diarrhea , constipation , or back pain
PMHx : Peptic ulcer disease
PSHx: None
Meds : None
Allergies : None
FHx : Father ,mother , and siblings are healthy
SHx : 1 PPD smoker for past 20 years , 3 beers .day for past 15 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, 37.1’C(98.8F) ; blood pressure , 130/80mmHg ; pulse ,100/min ; and respirations , 20/min
. Abdomen ; RLQ tenderness to superficial and deep palpation , rebound tenderness present , normative bowel sounds throughout , no hepatosplenomegaly, no CVA tenderness ,negative psoas and obstructor signs

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 : Appendicitis

History finding(s)
. Sudden onset RLQ pain
. Nausea and vomiting

Physical examination finding(s)
. RLQ tenderness
. Rebound tenderness in abdomen

Diagnosis #2 : Perforated peptic ulcer

History finding(s)
. History of peptic ulcer
. Abdomen pain
. Alcohol use

Physical examination finding(s)
. Rebound tenderness in abdomen

Diagnosis #3 : Intestinal obstruction

History finding(s)
. Abdomen pain
. Last bowel movement 20 hors ago

Physical examination finding(s)
. Rebound tenderness in abdomen

Diagnostic studies
. CBC with differential
. Abdominal x-ray
. CT of the abdomen


-- 作者: JuanFe
-- 發表時間: 2018/08/15 03:37pm

20 Case 20 scenario (leg pain bilateral)

Doorway information about patient

The patient is a 50-year-old man who comes to the office due to bilateral leg pain

Vital signs

. Temperature : 36.7”C(98F)
. Blood pressure : 140/80 mmHg
. Pulse : 78/min
. Respirations : 20 /min

Basic differential diagnosis

Bilateral pain
. Atherosclerotic vascular disease
. Lumber spinal stenosis
. Diabetic polyneuropathy
. Radiculopathy due to spinal disease
. Medications , such as statin
. Trauma
. Thromboangiitis obliterans

Unilateral pain
. Cellulitis / myofasciitis
. Deep vein thrombosis
. Rupture of baker cyst
. Osteomyelitis
. Radiculopathy /sciatica
. Pathological fracture of the bone

—————

Case 20 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 50 year-old-man with bilateral leg pain

History of present illness

. Onset 2 months ago
. Pain stated gradually and has become progressively worse
. Throbbing pain with 5-6 /10 severity
. Located in the calf muscles , no radiation
. Worse with walking , running , and prolonged standing
. Better while sitting and at rest
. No history of trauma

Review of systems

. No fever
. No back pain
. No weakness , numbness , or tingling in the leg
. No sexual or bladder symptoms

Past medical / Family / social history

. Diabetes for the past 3 years , controlled by diet
. High cholesterol
. No surgires
. Medications : Simvastain 40 mg  daily at bedtime
. Allergies : No
. Father died at age 65 of a stroke ; mother and 2 sibling are healthy
. Occupation: Postal worker
. Married , live with wife
. Tobacco : 2 pack a day for past 30 years
. Alcohol : Occasional beer
. Recreational drugs : No

Physical examination

Abdomen:
. No bruits

Extremities
. Pulse 2+ and symmetrical in bilateral lower extremities

Musculoskeletal
. Negative Homans sign
. ,No calf tenderness to palpation bilaterally

Neurologic
. Motor strength 5/5 in both lower extremities
. Grossly intact sensation
. Deep tendon reflexes 2+ symmetrically

—————

Case 20 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 location and radiation of the pain
. Asked about the onset of pain
. Asked about whether it is continuous or intermittent pain
. Asked about the intensity of pain
. Asked about the quality of pain
. Asked about the course of pain over time
. Asked about any aggravating or relieving factors
. Asked about rest pain
. Asked about swelling of the legs
. Asked about sensory changes ( such as numbness ) and paresthesia
. Asked boy any weakness of the legs
. Asked about any history of back pain
. Asked about fever
. Asked about trauma to the legs
. Asked about other joint pain
. Asked about recent surgeries or prolonged immobilization
. Asked about impotence

Past medical /family/social history

. Asked about similar episodes in the past
. Asked about past medical issues (especially high blood pressure , diabetes , high cholesterol, disc prolapse)
. Asked about current medications
. Asked about family health (especially history of blood clots)
. Asked about tobacco , alcohol , and recreational drug use
. asked bout occupation

Examination

. Washed heads before examination
. Examined without gown , not through gown
. Examined calf tenderness
. Elicited Homans sign
. Checked pulses in both legs and  arms
. Listened for bruits at the distal aorta , iliac , or femoral arteries
. Checked sensation in both legs
. Checked reflexes in bother legs
. Checked for vibration sense in both legs

Counseling

. Explained physical findings and possible diagnosis
. Explained further workup
. Discussed lifestyle modifications, including quitting smoking

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
. 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

. Thromboangiitis obliterans
. Atherosclerotic vascular disease
. Drug induced (statins)
. Diabetic polyneuropathy

Diagnostic study/studies

. Creatinine kinase
. Blood sugar and hemoglobin A1c
. Lipid profile
. Arterial doppler study coif the lower extremities
. Duplex venous ultrasound of power limbs
. CBC with differential
. Spine MRI

—————

Case 20 clinical summary

Clinical Skills Evaluation
Case 20 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).

. 50-yo man with 2 months of worsening bilateral leg pain
. Trolling pain mainly over the calf muscle made worse with walking , running, and prolonged standing.
. Symptom improvement with rest and sitting

ROS : No pain at rest , fever , trauma , swelling , back pain, weakness , sexual difficulties , numbness , or tingling in legs
PMHx : Diabetes for 3 years under diet control , hypercholesterolemia
PSHx : None
Meds: Simvasatin 40 mg daily at bedtime
Allergies : None
FHx : Father died at age 65 of stroke ; mother and 2 siblings are healthy
SHx : 2 PPD smoker for past 30 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 , 36.7’C (98.1F); Blood pressure , 140/80 mmHg; pulse , 78/min; and respirations ,20/min
. Abdomen : No bruits
. Extremities : Pulse 2+ and symmetrical in bilateral lower extremities
. Musculoskeletal : Negative Homans sign , no calf tenderness to palpation bilaterally
. Neurologic : bilateral lower extremities with 5/5 motor strength , intact vibratory sensation and proprioception, and DTR 2+

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 : Drug-induced (statin) myopathy

History finding(s)
. Proximal muscle pain
. History of statin use

Physical examination finding(s)
. Normal motor strength in legs
. No sensory deficits in legs

Diagnosis #2 : Atherosclerotic peripheral vascular disease

History finding(s)
. History of diabetes and high cholesterol
. History of smoking
. Family history of stroke

Physical examination finding(s)
. None

Diagnosis #3 : Diabetic polyneuropathy

History finding(s)
. Diet-controlled diabetes
. History of high cholesterol

Physical examination finding(s)
. None

Diagnostic studies
. Creatinine kinase
. Fasting blood sugar and hemoglobin A1c
. Lower-extremity arterial Doppler


-- 作者: JuanFe
-- 發表時間: 2018/08/15 03:38pm

21 Case 21 scenario (vomiting)

Doorway information about patient

The patient is a 56-year-old woman who comes to the emergency department due to vomiting

Vital signs

. Temperature : 36.7’C (98F)
. Blood pressure : 90/60 mmHg
. Pulse : 98/min
. Respirations : 20/min

Clinical Images

The paint has vomited into a pan of water at the bedside , as shown in the image : frank-blood or coffee-ground vomiting

Basic differential diagnosis

. Peptic ulcer disease
. Gastric erosion
. Esophageal varices
. Mallory-Weiss tears
. Esophagitis
. Duodenitis
. Malignancy (esophageal and gastric)

—————

Case 21 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 56-year-old woman who is vomiting up blood

History of present illness

. Felt lightheaded while climbing stairs at home and passed out (2 hours ago)
. Sharp mid-epigastric pain starting 1 day ago (4-5/10 severity , no radiation)
. Nausea that is worse today
. Threw up a teaspoon of blood twice at home ; threw up more blood in the emergency department
. Back stools for 1 week

Review of systems

. No changes in appetite or weight
. No fever or chills
. No shortness of breath
. No otters dizziness or chest pain

Past medical history / family / social history

. GERD for past 2 years relieved with antacids as needed
. Chronic back pain
. No surgeries
. Medications : Ibuprofen as needed
. No allergies
. Father died of heart attack at age 60; mother and 2 siblings are healthy
. Single ,live with roommate
. Tobacco : 1 pack a day for past 25 years
. Alcohol : 4-5 beers a day for past 20 years
. Recreational drugs : No

Do not volunteer this information unless asked about problems with drinking: You were admitted to an alcohol; treatment facility 1 years ago and left after 1 week

Physical examination

HEENT :
. Oropharynx clear

CV :
. Regular rate and rhythm
. No murmurs

Abdomen :
. Non-tender , non-distended
. Normative bowel sounds
. No hepatosplenomegaly

—————

Case 21 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 vomiting
. Asked about the frequency of vomiting
. Asked about any blood in the vomit (frank-blood or coffee-ground vomiting) and quantity of blood
. Asked about any abdomen pain associated with the vomiting
. Asked about prior history abdomen pain ( or heartburn ) especially in relation to food
. Asked specifically about melena (black stools)
. Asked about recent change in appetite and weight loss

Past medical /family/social history

. Asked about similar episodes in the past
. Asked about other medical issues (peptic ulcer disease , reflux disease , liver problems),hospitalizations , and surgeries
. Asked about current medications
. Asked about medication allergies
. Asked about family health (including bleeding problems)
. Asked about tobacco , alcohol , and recreational drug use (including detailed discussion of alcohol abuse and treatment)
. Asked about occupation

Examination

. Washed heads before examination
. Examined without gown , not through gown
. Performed orthostatic vital signs
. Examined oropharynx
. Auscultated abdomen (prior to palpation)
. Palpated abdomen (superficial and deep)
. Checked for rigidity and rebound
. Percussed for liver span
. Performed neurologic examination
. Performed cardiovascular examination

Counseling

. Explained physical findings and possible diagnosis
. Explained further workup (blood test,endoscopy)
. Explained the importance of lifestyle modifications , including quitting smoking and alcohol

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

. Variceal hemorrhage
. Peptic ulcer decease
. Gastric erosions
. Esophagitis
. Duodenitis

Diagnostic study/studies

. CBC with differential count
. PT/PTT/INR
. BUN, serum creatinine , electrolytes
. Upper GI endoscopy
. Liver function test (albumin, AST,ALT, alkaline phosphatase , total and direct bilirubin)
. ECG

—————

Case 21 clinical summary

Clinical Skills Evaluation
Case 21 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).

. 56-yo woman with syncope while climbing stairs
. Followed by recurrent hematemesis over the last 2 hours
. History of GERD  relieved with as-needed antacids.
. 1 day of mid-epigastric abdomen pain without radiation , associated with nausea
. 1 week of melena

ROS : No changes in appetite , weight loss , fever , chills , shortness of breath , or chest pain
PMHx: GERD , chronic back pain , alcohol abuse
PSHx: None
Meds : ibuprofen , as needed
Allergies : None
FHx: Father died at age 60 of heart attack ; motor and 2 siblings are healthy
SHx: 1 PPD smoker for past 20 years , 4-5 beers /day for past 20 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 , 90/60 mmHg; pulse , 98/min ; and respirations , 20/min
. HEENT : Oropharynx clear
. Heart : RRR with no M,G,R. Abdomen : non-tender , non-distended , normative bowel sounds , no hepatosplenomegaly

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 esophageal varices

History finding(s)
. History of ibuprofen and excessive alcohol use
. Mid-epigastric pain
. Hematemesis and melena

Physical examination finding(s)
. None

Diagnosis #2 : Bleeding peptic ulcer

History finding(s)
. History of GERD and excessive alcohol use
. Mid-epigastric pain and hematemesis
. Melena

Physical examination finding(s)
. None

Diagnosis #3 : Gastritis

History finding(s)
. History of ibuprofen and excessive alcohol use
. Mid-epigastric pain
. Melena

Physical examination finding(s)
. None

Diagnostic studies

. Orthostatic BP and HR measurement
. CBC with differential
. Basic metabolic panel
. Liver function test
. PT/PTT/INR
. Upper GI endoscopy


-- 作者: JuanFe
-- 發表時間: 2018/09/13 07:49am

22 Case 22 scenario (chest pain)

Doorway information about patient

The patient is a 55-year-old man who comes to the emergency department due to chest pain

Vital signs

. Temperature : 37.1 C (98.7F)
. Blood pressure : 130/80 mmHg
. Pulse : 78 /min
. Respirations : 20/min

Clinical images

ECG is shown in the image : S-T segment lowered

Basic differential diagnosis

. Miocardio infarction
. Unstable angina
. Pulmonary embolism
. Costochrondritis
. Pleuritis
. Pericarditis
. Aortic dissection
. Gastroesophageal reflux
. Esophageal; perforation

—————

Case 22 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 55-year-old man who comes to the emergency department with chest pain.

History of present illness

. The pain came on suddenly and has progressively worsened
. Pain located in substernal area with no radiation
. “Tight , squeezing “ sensation with 8-9/10 severity
. Pain is worse when walking and moving around
. Associated symptoms:
- Nausea
- 1episode of vomiting
- Sweating
- Mild shortness of breath

Review of systems

. No fever , cough , headache . abdominal pain , diarrhea , constipation , recent trauma, appetite changes   weight loss , or urinary problems

Past medical history

. High blood pressure for 20 years
. Diabetes for 5 years
. Cholesterol tested a year ago was 280 ( you are trying to control your cholesterol who diet but not eat a lot of fast food)
. No surgires
. Medications : lisinopril , metformin
. No allergies
. Father died at age 60 of heat attack ; mother tis living and ad stroke at age 65 ; brother had a heart attack at age 58
. Occupation : lawyer
. Married , live with wife
. Tobacco : 1 pack a day for the past 30 years
. Alcohol : 1 glass of wine a day for past 20 years
. Recreational drugs : No

Physical examination

Physical examination

Neck :
. supple without JVD or lymphadenopathy
. No thyromgaly

Lungs :
. Clear to auscultation bilaterally
. No reproducible chest pain with palpation

Heart :
. Regular rate and rhythm
. No murmurs , gallops , or rubs

Review of system

You have non of the following:
. Fever
. Cough
. Headache
. Abdominal pain
. Diarrhea
. Constipation
. Recent trauma
. Appetite changes
. Weight loss
. Urinary problems

—————

Case 22 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 location and radiation of pain
. Asked about the intensity of pain
. Asked about the quality of pain
. Asked about the origin and duration of pain
. Asked about the course of pain over time
. Asked about any aggravating or relieving factors
. Asked about associated symptoms , especially :
- Nausea and vomiting
- Sweating
- Fever
- Coughing
- Shortness of breath
- Palpitations
- Syncope and dizziness

Past medical /family/social history

. Asked about similar episodes in the past
. Asked about past ,medical issue (especially high blood pressure , heart problems , diabetes , heart burn/reflux), hospitalizations , and surgeries
. Asked about current medications and medication allergies
. Asked about family health
. Asked about tobacco , alcohol , and recreational drug use
. Asked about occupation and stress in life
. Asked about cholesterol level (if known)

Examination

. Washed heads before examination
. Examined without gown , not through gown
. Examined carotid artery and jugular viens
. Examined heart (inspection , palpation , auscultation)
. Auscultated the lungs
. Examined peripheral pulse and edema
. Examined abdomen

Counseling

. Explained the physical findings and possible diagnosis
. Discussed ECG result
. Explained further workup
. Discussed lifestyle modifications ( especially quitting smoking and moderate alcohol intake).

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

. Myocardial infarction
. Unstable angina
. Pulmonary embolism
. Aortic dissection
. Gastroesphageal reflux

Diagnostic study/studies

. Complete blood count
. Cardiac markers (eg, troponin)
. Electrolytes . blood urea nitrogen, creating , glucose
. Chest x-ray
. Echocardiogram

—————

Case 22 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).

. 55-yo man with 2 hours of chest pain described as substernal tightness and pressure and increased  with movement and walking ; pain of 8-9 lb on a scale of 10 , no radiation.
. Associated nausea , vomiting , sweating , and shortness of breath

ROS : No fever , cough , headache , abdominal pain , diarrhea , constipation , recent trauma, appetite change , weight loss , or urinary problems
PMHx : HTN , diabetes , hight cholesterol
PSHx : None
Meds : lisinpril, metformin
Allergies : None
FHx: Fateghr died at age 60 of heat attack , motor had a stroke at age 65 , and mother had a heart attack at age 58
SHx: 1 PPF smoker for past 30 years , 1 glass of wine/day for past 20 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 ,. 37.1”C (98.8F) : blood pressure , 130/80 mmHg; pulse , 78/min; and respirations , 20/min
. Neck ; Supple without JVD or lymphadenopathy , no thyromegaly
. Lungs ; Clear to auscultation bilaterally , no reproducible chest pain to palpation
. Heart : RRR without murmurs , gallops , or rubs

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 : Acute contrary syndrome

History finding(s)
. Substernal chest pain
. History of multiple cardiac risk factors
. Nausea , vomiting , diaphoreses

Physical examination finding(s)
. No reproducible chest pain to palpation

Diagnosis #2 : Aortic dissection

History finding(s)
. History of hypertension
. substernal pain
. Sudden-onset symptoms

Physical examination finding(s)
. No reproducible chest pain to palpation

Diagnosis #3 : Pulmonary embolism

History finding(s)
. Sudden -onset chest pain
. Shortness of breath

Physical examination finding(s)
. No reproducible chest pain to palpation

Diagnostic studies
. ECG shows ST depressions in V2-V5
. Chest x-ray
. Cardiac enzymes
. Echocardiogram


-- 作者: JuanFe
-- 發表時間: 2018/09/13 07:50am

23 Case 23 scenario ( frequent falls )

Doorway information about patient

The patient is a 70-year-old man who comes to the office due to frequent falls.

Vital signs
. Temperature : 37.1’C (98.7F)
. Blood pressure : 130/80 mmHg
. Pulse : 78/min
. Respirations : 20/min

Basic differential diagnosis

Neurologic
. Cerebellar disease (alcohol, tumor , stroke)
. Parkinson disease
. Brain tumor
. Seizure
. Depressed vision

Metabolic
. Diabetic neuropathy
. Hypoglycemia
. Thyroid disease

Cardiovascular
. Valvular disease

Miscellaneous
. Medication side effect
. Vitamin B12 deficiency
. Vertigo

—————

Case 23 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 70-year-old man who comes to the clinic due to frequent falls.

History of present illness

. Several falls over he last 2 months
. Initially once a week , now twice a week
. Decreased balance while standing
. No major injury/fracture but you are concerned that you may develop one
. Also have tremor that makes it difficult to hold things ; worse when reaching for an object
. Headache in the morning
. Friend said you speech is different

Review of systems

. No weakness , numbness , or tingling in arms or legs
. No dizziness/vertigo
. No fever
. No chest pain
. No nausea , vomiting , diarrhea , constipation , or abdominal pain
. No urinary symptoms
. No sin or hear changes

Past medical history

. Diabetes for last 10 years (under good control)
. No surgires
. Medications : Metformin 500mg twice a day
. No allergies
. Father and mother both died of”old age”; no siblings
. Retired machinist
. Widower (wife passed away 5 years ago), live alone
. Tobacco : No
. Alcohol : 2 beers a day for 40 years
. Recreational drugs : No

Physical examination

HEENT:
. Visual acuity and visual fields normal

Neck :
. Supple without IVD or lymphadenopathy
. No thyromegaly
. No bruits

Lungs :
. Clear to auscultation bilaterally

Heart :
. Regular rate and rhythm
. No murmurs , gallops , or rubs

Neurologic :
. Motor 5/5 bilaterally
. Sensory grossly intact bilaterally
. Resting tremor
. Mild dysmetria (finger to nose ) present
. Mild dysdiadochokinesia (alternating movements)
. DTR2+ bilaterally

—————

Case 23 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 and frequent of falls
. Asked about any injury associated with falls
. Asked about loss of consciousness
. Asked about any difficult in initiating , controlling , stopping movements
. Asked about progression of the problem
. Asked about associated symptoms:
- Tremors
- Headache
- Nausea /vomiting, bowel problem
- Fever
- Palpations and syncope
- Thyroid symptoms(eg, temperature intolerance , skin or hear changes)
- Changes in appetite or weight
- Problems with speech or memory
- Problems wit attention or calculation
- urinary problem
. Asked abort living conditions and support systems

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 occupation

Examination

. Washed heads before examination
. Examined without gown , not through gown
. Checked orthostatic vital signs
. Examined eyes
. Examined heart and lungs
. Performed mini-mental status exam
. Examined touch , pain , and temperature sensations in legs add hands
. Tested muscle power in limbs
. Tested for muscle tone/rigidity
. Asked you to get up and walk and turn around and sit again (“ Get up and go “ test)
. Performed finger nose test
. Performed alternating movements test
. Performed Romberg test
. Checked reflexes

Counseling

. Explained the 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

. Cerebellar disease
. Parkinson disease
. Diabetic neuropathy
. Brain tumor
. Thyroid disease
. Vitamin B12 deficiency

Diagnostic study/studies

. CBC with differential
. CT or MRI of brain
. Serum electrolytes, glucose, creatinine
. Hemoglobin A1c
. ECG
. TSH

—————

Case 23 clinical summary

Clinical Skills Evaluation
Case 23 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).

. 70-yo man with 2 months of frequent fall
. Balanced problems while standing up ; no syncope
. Tremor in hands worse when reaching for objects.
. Change in speech , occasional morning headache.
. No sensory symptoms (numbness , tingling) in legs.
. No dizziness or vertigo

ROS : No fever , nausea , hair loss, chest pin , abdominal , pain , recent trauma, diarrhea , constipation , or urinary problems
PMHx : Diabetes
PSHx : None
Meds : Metformin 500 mg BID
Allergies : None
FHx : Father and mother both fiddled of old age
SHx : No smoking , 2 beers daily for past 40 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 , 37.1’C (98.8F) ; blood pressure , 130/80 mmHg ; pulse , 78/min ; and respirations , 20 /min
. HEENT : PERRLA , EOMI , normla visual acuity
. Neck : Supple without JVD or lymphadenopathy , no thyromegaly , no bruits
. Lungs : Clear to auscultation bilaterally
. Heart : RRR without murmurs, gallops , and rubs
. Neurologic ; Motor 5/5 bilaterally , sensory grossly intact bilaterally , resting tremor , mild dysmetria (finger to nose) , mild dysdiadochokinesia (alternating movements) , DTR 2+ bilaterally


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 : Cerebellar disease due to alcohol use

History finding(s)
. History of chronic alcohol use
. Difficulty with balance

Physical examination finding(s)
. Dysmetria
. Disdiadochokineasia

Diagnosis #2 : Parkinson disease

History finding(s)
. Tremor
. Balance problems

Physical examination finding(s)
. Resting tremor

Diagnosis #3 : Brain tumor

History finding(s)
. Speech difficulties, headache
. Balance problems
. 2 months of symptoms

Physical examination finding(s)
. None

Diagnostic studies

. Orthostatic vitals
. Brain imaging (CT scan or MRI)
. Basic metabolic panel
. Thyroid function tests; vitamin B 12 levels
. Complete blood count


-- 作者: JuanFe
-- 發表時間: 2018/09/13 07:51am

24 Case 24 scenario ( cough and chest pain )

Doorway information about patient

The patient is a 35-year-old man who comes to the office due to cough and chest pain.

Vital signs

. Temperature L 38.7’C (101.7F)
. Blood pressure : 130/80 mmHg
. Pulse ; 94/min
. Respirations : 24/min

Basic differential diagnosis

. Pneumonia
. Pleuretic pain
. Pleural effusion
. Pulmonary edema
. Tuberculosis
. Pulmonary embolism
. Lung cancer
. Infective endocarditis
. GERD

—————

Case 24 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 man who comes to the clinic due to a cough

History of present illness

. Onset 2 days ago
. Started with “ feeling tired and sick”
. Productive cough with yellow sputum and blood streaks
. Sharp pain 5-6/10 severity at left chest ; worse with moving and any deep breath and better with exhalation
. Associated symptoms :
- Fever
- Chills
- Sweating
- Mild shortness of breath
. Exposure to “ pneumonia “ form a colleague at work

Ask the doctor : “ Do I have pneumonia too?”

Review of systems

. No changes in appetite
. No weight loss
. No abdominal pain
. No recent trauma
. No diarrhea or constipation
. No urinary symptoms

Past medical / family / social history

. Hospitalized once for chest pain 5 years ago with negative testing
. No surgieres
. No medications
. Allergies : Penicillin (rash)
. Father and mother are both healthy ; no siblings
. Occupations ; Investment advisor
. Tobacco : 1 pack a day for 15 years
. Alcohol : often go out with friends on weekends and drink average of 2 shot of liquor
. Recreational drugs : No

Physical examination

HEENT :
. Oropharynx clear

Neck :
. Supple without JVD and lymphadenopathy
. No thyromegaly
. No bruits
. No accessory muscle use

Lungs :
. Clear to auscultation bilaterally
. Fremitus symmetrical bilaterally
. Resonant to percussion bilaterally
. No bronchophony or egophony

Heart :
. Regular rate and rhythm
. No murmurs ,  gallops,  or rubs

Abdomen :
. Non-Tender, non-distended
. No hepatosplenomegaly
. Normative bowel sounds

—————

Case 24 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 location and radiation of pain
. Asked about the intensity of pain
. Asked about the quality of pain
. Asked about the onset and duration of pain
. Asked about the course of pain one time
. Asked about any aggravating or relieving factors
. Asked about associated symptoms , especially :
- Vomiting
- Fever
- Coughing( and details of expectoration)
- Shortness of breath
- Hemoptysis
- Change in appetite

Past medical /family/social history

. Asked about similar episodes in the past
. Asked about past medical issues ( especially lung problems) , 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’
. Inspected neck , accessory muscles of respiration , and jugular views
. Examined heart : inspection , palpation , auscultation
. Examined lungs including:
- Inspection of lung inflation
- Anterior and posterior auscultation
- Percussion
- Tests for consolidation (tactile fremitus ,, egophony)
. Palpated abdomen for splenomegaly and hepatomegaly

Counseling

. Explained the physical findings and possible diagnosis
. Explained further workup
. Discussed quitting smoking

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

. Pneumonia
. Pleuritic pain
. Pleural effusion
. Pericarditis
. Lung cancer

Diagnostic study/studies

. CBC with differential count
. Sputum Gram stain, C/S
. ECG
. Chest x-ray
. Blood culture

—————

Case 24 clinical summary

Clinical Skills Evaluation
Case 24 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 man with 2 days go product cough of yellow , blood-tinged sputum
. 2 dash pf sharp . left-sided chest pain worse with inspiration and improved with expiration.
. Fever . chills , sweating , and mild shortness of breath
. Sick contact in office

ROS : No changes in appetite our weight , abdominal pain, recent trauma , diarrhea , constipation , or urinary problems
PMHx : None
PSHx : None
Meds : None
Allergies ; Penicillin (rash)
FHx : Father and mother are healthy
SHx : 1 PPD smoker for past 15 tears , 2 shots a week for past 10 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 , 38.7’C(101.7F) ; blood pressure , 130/80 mmHg ; pulse , 94/min ; and respirations , 24/min
. HEENT ; Oropharynx clear
. Neck : Supple without JVD or lymphadenopathy , no thyromegaly, no bruits , no accessory muscle use
. Lungs ; clear to auscultation bilaterally , fremitus symmetrical bilaterally , resonant to percussion bilaterally , no brochophony or egophony
. Heart : RRR without murmurs, gallops, our rubs
. Abdomen : Non-tender , non-distended , no hepatopslenomegaly , normative 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 : Acute bronchitis

History finding(s)
. Smoking history
. Fever
. Cough productive of yellow , blood-tinged sputum

Physical examination finding(s)
. Fever

Diagnosis #2 : Pneumonia

History finding(s)
. Fever and chills
. Cough productive of yellow, blood-tinged sputum
. Pleuritic chest pain
. Sick contact at office

Physical examination finding(s)
. Fever
. Respirations , 24/min

Diagnosis #3 : Lung cancer

History finding(s)
. Smoking history
. Cough productive of blood-tinged sputum

Physical examination finding(s)
. None

Diagnostic studies
. Chest x-ray
. Sputum Gram stain and culture
. CBC with differential


-- 作者: JuanFe
-- 發表時間: 2018/09/13 07:52am

25 Case 25 scenario ( lower abdominal pain )

Doorway information about patient

The parents is 60-year-old man who comes to the emergency department due to lower abdominal pain

Vital signs
. Temperature : 38.3’C (101F)
. Blood pressure : 130/84 mmHg
. Pulse : 98/min
. Respirations : 22/min

Basic differential diagnosis

. Diverticulitis
. Renal colic
. Appendicitis
. Ischemic colitis
. Infectious colitis
. Abdominal aortic aneurysm
. Intestinal obstruction

—————

Case 25 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 60-year-old man who comes to the emergency department with lower abdominal pain

History of present illness

. The pain onset was 1 day ago after eating at a restaurant with family
. Pain is located at lower abdomen with no radiation
. 6/10 severity , progressively with no radiation
. Episodic (10-15 minute episodes ) . crampy pain
. No aggravated or alleviating factors
. Associated symptoms
- 1 episode non bilious , non bloody vomiting
- You did not check temperature but feel “ a little feverish’
- 2-3 episodes of diarrhea with visible blood (no black stools)
. No family members with symptoms
. No recent travel or sick contact

Do not volunteer this information unless asked :

Review of systems

. No chills
. No urinary symptoms

Past medical / family / social history

. Hospitalized once 10 years ago for kidney stone that passed spontaneously
. Hypertension
. No surgeries
. Medications : Hydrochlorothiazide 25 mg daily
. No allergies
. Father died at 65 of colon cancer ; mother died at 70 of breath cancer ; no siblings
. Occupation : Financial planner
. Married , live with wife
. Tobacco : No
. Alcohol : 1 beer a day for past 30 years
. Recreational drugs : No

Physical examination

Heart :
. Regular rate and rhythm
. No murmurs , gallops , or rubs

Abdomen :
. LLQ tenderness to deep palpation , no rebound tenderness
. Non-distended
. No hepatosplenomegaly
. Normative bowel sounds
. No CVA tenderness

—————

Case 25 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 location and radiation of pain
. Asked about the intensity of pain
. Asked about the quality of pain
. Asked about the onset and duration of pain
. Asked about the progression of pain
. Asked about any aggravating or relieving factors
. Asked about associated symptoms , especially :
- Nausea and vomiting
- Fever and chills
- Changes in appetite and weight
- Bowel problems (constipation and diarrhea)
- Blood in the stool or black stood
- Urinary symptoms
. Asked bout recent travel and contaminated food ingestion
. Asked about recent antibiotic use

Past medical /family/social history

. Asked about similar episodes in the past
. Asked about past medical issues , hospitalizations ,ad surgeries (especially abdominal surgeries)
. Asked about current medications
. Asked about medication allergies
. Asked about family health
. Asked about tobacco , alcohol , and recreational drug use

Examination

. Washed heads before examination
. Examined without gown , not through gown
. Auscultated abdomen
. Palpated abdomen
. Checked rebound tenderness
. Checked for costovertebral angel tenderness
. Examined the heart

Counseling

. Explained physical findings and possible diagnosis
. Explained further workup
. Discussed need to perform 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

. Diverticulitis
. Renal colic
. Intestinal obstruction
. Infectious colitis
. Ischemic colitis

Diagnostic study/studies

. Rectal examination , genital examination
. CBC with differential count
. Electrolytes , glucose , BUN , creatinine
. Urinalysis
. ECG
. Abdomen x-ray
. CT scan of the abdomen and pelvis

—————

Case 25 clinical summary

Clinical Skills Evaluation
Case 25 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).

. 60-yo man with 1 day of episodic , crapmy LLQ abdominal pain lasting 10-15 minutes each time ; no radiation.
. Pian is 6/10
. Ate at a local restaurant with family , but no one else is sick
. Nausea ,  1 episode of vomiting , 2-3 episodes of diarrhea with blood , subjective fever

ROS :  no recent travel , sick contact , chills , or urinary problems
PMHx : HTN , kidney stone in past
PSHx : None
Meds : Hydrochlorothiazide 25 mg daily
Allergies ; None
FHx : Father died at age 65 of colon cancer ; mother died at age 70 of breast cancer
SHx : No smoking , 1 beer daily for past 30 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 , 38.3’C (100.9F) ; blood pressure , 130/84 mmHg; pulse , 98/min; and respirations , 22/min
. Heart : RRR without murmurs , gallops , or rubs
. Abdomen : LLQ tenderness to deep palpation , no rebound tenderness , non distended , no hepatosplenomegaly , 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 : Acute diverticulitis

History finding(s)
. Abdominal pain
. Fever
. Diarrhea with blood

Physical examination finding(s)
. Fever
. LLQ abdomen tender to palpation

Diagnosis #2 : Infectious colitis

History finding(s)
. Fever
. Ate at local restaurant before symptom onset
. Diarrhea with blood

Physical examination finding(s)
. Fever
. Abdomen tender to palpation

Diagnosis #3 : Ischemic colitis

History finding(s)
. History of hypertension
. Fever
. Abdominal pain

Physical examination finding(s)
. Fever

Diagnostic studies
. Rectal examination with stool guaiac
. Abdominal imaging (x-ray, CT scan)
. CBC with differential
. Urinalysis


-- 作者: JuanFe
-- 發表時間: 2018/09/13 07:52am

26 Case 26 scenario ( fatigue )

Doorway information about patient

The patient is a 35-year-old man who comes to the office due to fatigue

Vital signs

. Temperature : 37’C (98.6F)
. Blood pressure : 120/80 mmHg
. Pulse : 82/min
. Respirations : 16/min

Basic differential diagnosis

. Depression
. Anemia
. Thyroid disorder
. Chronic fatigue syndrome

—————

Case 26 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 man who comes to the office due to fatigue

History of present illness

. Onset 2 months ago
. Previously well until victim of robbery
. Tired during the day with constant anxiety and impaired concentration
. Difficulty falling asleep at night with frequent nightmare
. You have cut back on daily activities and feel emotionally distant and lonely
. No other significant stress at work or home

Do not volunteer this information unless asked :

Review of systems

. No shortness of breath
. No palpations
. No seating , fever , or chills
. No weight loss
. No change in appetite

Past medical / family / social history

. No significant illness , surgeries , or hospitalizations
. No medications
. No allergies
. Immediate family members are all healthy
. Live with girlfriend
. Occupation : Florist
. Tobacco : 1 pack a day for last 15 years
. Alcohol : Social occasions only
. Recreational drugs : No

Physical examination

HEENT
. No pallor
. Oropharynx clear

Neck
. Supple without lymphadenopathy
. No thyromegaly

Heart
. Regular rate and rhythm
. No murmurs, gallops, or rubs

Lungs :
. Clear to auscultation

Abdomen :
. No masses or tenderness

Psychiatric
. Alert and oriented to person , place , and time

—————

Case 26 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 onset of symptoms
. Asked about severity and change over time
. Asked if you are having difficulty falling or staying asleep
. Asked nightmares
. Asked if you had any traumatic events recently
. Asked about feeling of guilt
. Asked about suicidal intentions
. Asked if you have been feeling lonely
. Asked about anxiety
. Asked about associated symptoms , especially
- Palpitations
- Dizziness
- Sweating
- Tremors
- Changes in appetite or weight
- Shortness of breath
- Swelling /limps in neck
- Changes in bowel or bladder habits
. Asked about stress at work or home

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 occupation
. Asked bout tobacco , alcohol , and recreational; drug use
. Asked about sexual history

Examination

. Washed heads before examination
. Examined without gown , not through gown
. Examined oral mucous membranes for pallor
. Palpated neck for masses or swelling
. Checked memory , orientation , and judgement

Counseling

. Explained physical findings and possible diagnosis
. Explained further workup
. Offered to help and support while getting treated
. Discussed the importance of quitting smoking and offered help

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

. Post-Traumatic stress disorder/anxiety disorder
. Depression
. Hypothyroidism
. Occult medical disease

Diagnostic study/studies

. CBC with differential
. TSH
. Electrolytes , glucose , BUN , Creatinine
. HIV test

—————

Case 26 clinical summary

Clinical Skills Evaluation
Case 26 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 man with 2 months of fatigue after robbery
. Insomnia increased daytime fatigue , nightmares every night , generalized anxiety throughout the day , and inability to concentrate at work
. Feels emotionally alone and distant , no increased stress at work or home
. No hallucinations or delusions.
. Constipation for 3-4 months

ROS : No shortness of breath , chest pain , palpations , sweating, fever , chills , weight loss, or change in appetite
PMHx : None
PSHx : None
Meds : None
Allergies : None
FHx : Father , mother , and 3 siblings 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 , 36’C (98.6F) ; blood pressure , 120/80 mmHg;pulse , 82/min; and respirations , 16/min
. HEENT : No pallor , oropharynx car
. Neck : Supple without lymphadenopathy or thyromegaly
. Heart : RRR without murmurs, gallops, or rubs
. Lungs ; Clear to auscultation
. Abdomen ; no masses or tenderness
. Psychiatric : Alert and oriented to person , place,and time

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 : Post-traumatic stress disorder

History finding(s)
. Symptom onset after robbery 2 months ago
. Insomnia
. Difficulty concentrating , nightmares

Physical examination finding(s)
. None

Diagnosis #2 : Depression

History finding(s)
. Fatigue
. Insomnia
. Feels alone and distant

Physical examination finding(s)
. None

Diagnosis #3 : Hypothyroidism

History finding(s)
. Constipation for 3-4 months
. Fatigue
. Inability to concentrate at work and home

Physical examination finding(s)
. None

Diagnostic studies

. TSH
. CBC with differential
. Electrolytes, glucose, BUN , creatinine
. HIV test


-- 作者: JuanFe
-- 發表時間: 2018/09/13 07:53am

27 Case 27 scenario ( loss of hearing )

Doorway information about patient

The patient is a 65-year-old woman who comes to the office due to loss of hearing

Vital signs

. Temperature ; 36.7’C (98.1F)
. Blood pressure : 130/86 mmhm
. Pulse ; 80 /min
. Respirations : 16/min

Basic differential diagnosis

conductive hearing loss
. Cerumen impaction
. Otitis media with effusion
. Tympanic membrane perforation
. Otosclerosis
. Foreign body in ear canal
. cholseteatoma
. Tympanosclerosis
. Tumor of the ear canal or middle ear

Sensorineural hearing loss
. Prescycusis (age-0related hearing loss)
. Ototoxicity
. Noise-induced hearing loss
. Meniere disease
. Diabetes
. Acoustic neuroma

—————

Case 27 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 65-year-old woman who comes to the clinic due to hearing loss

History of present illness

. 3 months of reduced hearing in the left
. Hearing loss was initially mild but is progressively worsening
. Has been difficult to hear people with high-pitched voice
. No associated pain , ringing in the ear , or discharge from the ear
. Admitted to the hospital 4 months ago for a kidney infection and treated with IV antibiotics (you do not recall the name of the drug)

Review of systems

. No dizziness
. No facial muscle weakness
. No weakness or numbness i other parts of the body

Past medical / family / social history

. Hypertension for the last 30 years
. No surgires
. Medications : Hydrochlorothiazide 50 mg daily
. No drug allergies
. Father and mother both died of ‘ old age” ; 2 siblings , both healthy
. Occupations ; Supervisor at a steel factory (If the examinee specifically asks about the noise exposure , say “ there is a lot of noise every day at work.”)
. Married , live with husband
. Tobacco : No
. Alcohol : Occasional beer or wine
. Recreational drugs : No

Physical examination

HEENT :
. PERRLA , EOMI
. Oropharynx clear
. Tympanic membrane clear bilaterally
. Rinne test : Air conduction > bone conduction bilaterally
. Weber test ; localizes to the right ear

Neck:
. Supple
. No lymphadenopathy
. Thyroid normal

Neurologic:
. Alert and oriental to person , place , and time
. Cranial nerves 2-12 intact , except for decreased hearing in the left ear

—————

Case 27 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 which ear is affected (right , left , bilateral)
. Asked about the onset of symptoms
. Asked about the course of symptoms over time
. Asked about the subjective severity of hearing loss(mild , moderate , severe , profound)
. Asked about the possible initiating events
. Asked about associated symptoms , especially:
- Earache
- Tinnitus
- Vertigo
- Aural fullness
- Drainage from the ear
. Asked about any occupational exposure to noise
. Asked about trauma to the ear
. Asked about the social impact that it was had

Past medical /family/social history

. Asked about any similar episodes in the past
. Asked about past medical issues (especially ear. nose. throat and neurologic disorders ) ,hospitalizations , and surgeries
. Asked about current (and recent0 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 eye movements and pupillary reflexes
. Examined facial sensation and motor function (eg , show teeth , puff out cheeks , stick out tongue)
. Examined external ear and ear canal ( with otoscope)
. Tested hearing , including Rinne and Weber tests

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

. Presbycusis
. Occupational exposure
. Ceremony impaction
. Drug induced

Diagnostic study/studies


. Serum electrolytes and blood sugar
. Audiometry
. MRI of the brain
—————

Case 27 clinical summary

Clinical Skills Evaluation
Case 27 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).

. 65-yo woman with 3 moths of heigh-frequency hearing loss
. Hospitalized for pyelonephritis 4 months ago and treated with unknown antibiotic.
. Exposure to loud noises at work in steel factory.

ROS : No discharge from ear , ringing in ear , dizziness , facial muscle weakness , weakness or numbness in other parts of the body , or earache
PMHx : HTN
PSHx : None
Meds : Hydrochlorothiazide 50 mg daily
Allergies : None
FHx : Father and mother died of old age , healthy siblings
SHx : No smoking , 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 , 36.7’C (98.1F) ; blood pressure , 130/86 mmHg; pulse , 80/min; and respirations , 16/min
. HEENT : PERRLA , EOMI , oropharynx clear , TMs clear bilaterally , Rinne test with AC>BC , Weber test localization to the right ear , oropharynx clear
. Neck l Supple without lymphadenopathy or thyromegaly
. Neurologic : Alert and oriented to person , place , and time ; cranial nerves II-XII intact except for decreased hearing in left ear

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 : Presbycusis (age-related hearing loss)

History finding(s)
. Decreased hearing for 2-3 months
. High-Frequency hearing loss

Physical examination finding(s)
. Weber test localization to right ear

Diagnosis #2 : Noise-induced hearing loss

History finding(s)
. Decreased hearing
. Work at still factory with loud noise

Physical examination finding(s)
. Weber test localization to right ear

Diagnosis #3 : Drug-induced hearing loss

History finding(s)
. History of recent antibiotic use

Physical examination finding(s)
. Weber test localization to right ear

Diagnostic studies
. Audiometric testing
. Electrolytes and blood sugar
. MRI of brain


-- 作者: JuanFe
-- 發表時間: 2018/09/13 07:53am

Case 28 scenario ( knee pain )

Doorway information about patient

The patient is a 53-year-old man who comes to the emergency department due to right knee pain and swelling.

Vital signs

. Temperature ; 38.3’C (101F)
. Blood pressure : 130/60/mmHg
. Pulse : 80/min
. aspirations : 18/min

Basic differential diagnosis

. Osteoarthritis
. Septic arthritis and bursitis
. Pseudogout and gout
. Reactive arthritis
. Traumatic knee injury
. Lyme disease
. Monoarticular rheumatoid arthritis
. Psoriatic arthritis

—————

Case 28 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 with right knee pain

History of present illness

. 2 days of worsening right knee pain
. Throbbing pain , 7/10 severity
. No radiation of pain
. no relief with ibuprofen
. No recent trauma
. Chronic bilateral knee pain starting a year ago that is worse with walking and thought to be due to being overweight
. Stiffness in multiple joints every morning for 10-15 minute that resolves spontaneously
. No other aggravating or relieving factors

Do not volunteer this information unless asked :

Review of systems

. No fever or chills
. No nausea , vomiting , diarrhea , or constipation
. No rash
. No recent travel or sick contacts
. No inset bite
. No urinary symptoms

Past medical / family / social history

. Hypertension for the past 10 years
. No surgeries or hospitalizations
. Medications ; Hydrochlorothiazide 25 mg daily ; ibuprofen 600 mg up to 3 times a day as needed
. Medication allergies : None
. Father as hypertension and mother has pseudo gout ; no siblings
. Occupation : Librarian
. Married , live with wife
. Tobacco : none
. Alcohol ; 1 or 2 beers on social occasions
. Recreational drugs ; None

Physical examination

HEENT :
. PERRLA , EOMI
. No conjunctival abnormalities

Heart :
. Regular rate and rhythm
. No murmurs , gallops , or rubs

Musculoskeletal :
. Right knee is tender to palpation with decreased range of motion but no redness or warmth
. no other joint abnormalities

Skin :
. No rates or lesions

—————

Case 28 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 bout the course of pain over time
. Asked about the intensity of pain
. Asked about the quality of pain
. Asked about the location of pain
. Asked about any radiation of pain
. Asked about any aggravating or relieving factors
. Asked about associated symptoms , especially :
- Fever
- Joint swelling
- Joint redness
- Rash
. Asked about history of trauma to the joint
. Asked about morning stiffness
. Asked about history of travel (especially areas with endemic Lyme disease)
. Asked about any rennet ticks bites
. Asked about any pain and swelling in the other joints
. Asked about nay recent history of febrile illness
. Asked about any eye symptoms

Past medical /family/social history

. Asked about similar episodes in the past or other joint problems
. Asked about past medical issue , surgeries , and hospitalizations
. Asked about current medications
. Asked about medication allergies
. Asked about family health (especially joint disorders)
. Asked bout tobacco , alcohol , and recreational drug use
. Asked about occupation
. Asked about living situation and sexual contacts

Examination

. Washed heads before examination
. Examined without gown , not through gown
. Checked knee for range of motion
. Checked other joints for swelling and redness
. Auscultated heart
. Examined eyes
. Examined skin for washed or painful nodules

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

. Osteoarthritis
. Septic arthritis or bursitis
. Pseudo gout , gout
. Inflammatory (eg, rheumatoid ) arhritis

Diagnostic study/studies

. CBC with differential
. Joint aspiration
. X-ray of knee
. Sedimentation rate or C-reactive protein , antinuclear antibody, rheumatoid factor or cyclic citrullinated peptide antibodies
. MRI of joint
. Lyme serology (if travel to endemic area)

The following points should be addressed for traumatic knee pain:

. Asked what you were doing at the time of injury
. Asked about mechanism of injury
. Asked bout any noise or popping sensations at the time of injury
. Asked whether you can bear weight and whether the knee is unstable with walking
. Asked about locking of joint
. Performed Lachman maneuver or drawer test
. Performed McMurray maneuver

—————

Case 28 clinical summary

Clinical Skills Evaluation
Case 28 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 1 year of bilateral knee pain , now with 2 days of worsening right knee pain described as throbbing and constant
. Pain is 7/10 , no relief with ibuprofen
. 15-20 minute of morning stiffness in multiple joints each day that resolves spontaneously.
. No H/O trauma

ROS : No fever , chills , nausea , vomiting , diarrhea , constipation , rashes , travel history , sick contacts , insect bites , or urinary issue
PMHx : HTN for 10 years
PSHx : None
Meds : Hydrochlorothiazide 25mg  daily , ibuprofen 600mg as needed
Allergies : None
FHx : Father has hypertension ; mother has pseudogout
SHx : No smoking , 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(100.9F); blood pressure , 130/60 mmHg; pulse , 80/min; and respirations , 18/min
. HEENT : PERRLA , EOMI , no conjunctival hemorrhage
. Heart : RRR without murmurs , gallops , or rubs
. Musculoskeletal : Tender right knee , decreased ROM , no swelling or warmth , no other joint deformities
. Skin ; No rashes or lesions

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 : Osteoarthritis flare

History finding(s)
. History of chronic knee pain
. Acute worsening of right knee pain

Physical examination finding(s)
. Decreased ROM in right knee

Diagnosis #2 : Septic joints

History finding(s)
. Acute-onset right knee pain

Physical examination finding(s)
. Fever
. Decreased ROM in right knee

Diagnosis #3 : Acute crystal arthritis (Gout or pseudogout )

History finding(s)
. History of diuretic use
. Acute-onset right knee pain
. Family history of pseudogout

Physical examination finding(s)
. Fever
. Decreased ROM in right knee

Diagnostic studies

. Right knee arthrocentesis
. Right knee x-ray
. ESR
. CBC with differential


-- 作者: JuanFe
-- 發表時間: 2018/09/13 07:54am

29 Case 29 scenario ( blurred vision )

Doorway information about patient

The patient is a 50-year-old man who comes to the office due to blurred vision

Vital signs

. Temperature : 36.7’C (98.1F)
. Blood pressure : 160/90 mmHg
. Pulse : 70/min
. Respirations : 22/min

Basic differential diagnosis

. Diabetes mellitus
. Cataract
. Hypertensive retinopathy
. Glaucoma
. Macular degeneration
. Brain lesion
. Hyperviscosity syndorme (eg, polycythemia)
. Illicit drugs
. Temporal arthritis (usually starts unilaterally)
. Trauma to or infections of the eye (if unilateral)

—————

Case 29 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 50-year-old man who comes to the office due to blurry vision

History of present illness

. Onset 2 month ago
. Objects are becoming increasingly blurry with no halos around them
. No headache , eye pain , or eye discharge
. Over-the -counter reading glasses have made only minimal improvement
. Last physician visit was 10 years ago

Do not volunteer this information unless asked :

Review of systems

. 10-lb weight loss
. Increased appetite , thirst , and urination
. No nausea or vomiting
. No muscle weakness
. No dizziness or loss pf consciousness
. No numbness or tingling in the extremities

Past medical / family / social history

. No prior ,medical issue , surgeries , or hospitalizations
. Medications : None
. No medication allergies
. Father has hypertension and motor has diabetes(you have no siblings)
. Married;live with wife
. Occupation ;Truck driver
. Tobacco ; 1 pack a day for the last 30 years
. Alcohol : Occasional beer
. Recreational drugs : None

Physical examination

HEENT :
. PERRLA , EOMI
. Funds show no hemorrhage or AV nicking

Neck :
. Supple
. No lymphadenopathy or thyromegaly
. No bruits

Heart :
. Regular rate and rhythm without murmurs , gallops, or rubs

Extremities :
. Pulse 2+ in bilateral lower extremities

Neurologic :
. Motor strength 5/5 bilaterally
. Sensation grossly intact bilaterally

—————

Case 29 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 symptoms
. Asked whether symptoms were in 1 or both eyes
. Asked about the severity and course over time
, Asked about the eye discharge
. Asked about halos around the light
. Asked about eye pain
. Asked about any headache
. Asked about nausea and vomiting
. Asked bout any weakness or sensory changes in the areas and legs
. Asked about excessive thirst and urination
. Asked about changes in the appetite and weight

Past medical /family/social history

. Asked about similar episodes in the past
. Asked about past medical issues (especially diabetes and hypertension)
. Asked about current medications
. Asked about medication allergies
. Asked about family health
. Asked bout tobacco , alcohol , and recreational drug use
. Asked bout occupation

Examination

. Washed heads before examination
. Examined without gown , not through gown
. Examined eyes , including extra ocular movements , pupillary reflexes , and ophthalmoscope examination
. Did a neurological examination with emphasis on sensory examination
. Auscultated heart and carotid arteries
. Examined peripheral pulses

Counseling

. Explained physical findings and possible diagnosis (especially diabetes)
. Discussed dietary changes and weight reduction
. Explained further evaluation

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

. Diabetic retinopathy and /or diabetes osmotic changes in the lens
. Hypertensive retinopathy
. Cataracts
. Glaucoma
. Macular degeneration

Diagnostic study/studies

. Fasting blood glucose and /or hemoglobin A1c
. Urinalysis for microscopic proteinuria
. Lipid profile
. Carotid ultrasound

—————

Case 29 clinical summary

Clinical Skills Evaluation
Case 29 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).

. 50-yo man with 2 months of blurry vision , polyuria , polydipsia , polyphagia , and 4.5-kg (10-lb ) weight loss
. Has not seen a doctor in 10 years
. Objects blurry without complete loss of vision or halos around it

ROS : No nausea , vomiting , headache , arm/leg weakness , eye discharge , eye pain , dizziness , loss of consciousness, or numbness or tingling in the extremities
PMHx : None
PSHx : None
Meds : none
Allergies : None
FHx : Father has hypertension , mother has diabetes
SHx : 1 PPD smoker for past 30 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 , 36.7”C(98.1F) ; blood pressure , 160/90 mmHg; pulse , 70/min; and respirations , 16/min
. HEENT : PERRLA , EOMI < funds without hemorrhages or AV nicking
. Neck : Supple without lymphadenopathy , thyromegaly, or bruits
. Extremities : Pulses 2+ in bilateral lower extremities
. Neurologic : Motor 5/5 bilaterally , sensory grossly intact bilaterally

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 : Diabetic retinopoathy

History finding(s)
. Polyuria , polydipsia , polyphagia
. Weight loss
. Blurry vision

Physical examination finding(s)
. None

Diagnosis #2 : Hypertension retinopathy

History finding(s)
. Blurry vision

Physical examination finding(s)
. BP 160/90 mmHg

Diagnosis #3 : Glaucoma

History finding(s)
. Decreased vision

Physical examination finding(s)
. None

Diagnostic studies

. Fasting blood glucose and hemoglobin A1c
. Eye examination to mesure pressure
. Lipid profile
. CBC with differential


-- 作者: JuanFe
-- 發表時間: 2018/09/13 07:55am

30 Case 30 scenario ( multiple bruises )

Doorway information about patient

The patient is a 32-year-old woman who comes to the emergency department due to multiple bruises

Vital signs

. Temperature : 37.4’C(99.3F)
. Blood pressure : 120/80 mmHg
. Pulse : 90/min
. Respiration : 16/min

Basic differential diagnosis

. Accident
. Physical assault
. Spousal abuse
. Bleeding disorders
. Collagen vascular disorders

—————

Case 30 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 32-year-old woman who is brought to the emergency department by your husband due to bruises

History of present illness

. Bruises on the right are between the shoulder and elbow
. When asked how you sustained the injury , say , “ My husband told me that I fell down the stairs”
. If the examinee asks for further clarification, say that you have been hit by your husband
. Husband hits you whenever he has a “ rage episode “ - usually once a week
. He dose not hit your children , although they are afraid to go near him wen he has a rage episode
. Husband is an alcoholic , and he almost always has a bottle of bourbon by his side
. Both of your parents live in the same town as you do but they are not aware of the abuse
. You feel that your husband loves you; you love your husband , but are always on edge when he is around and you do not feel safe
. There have been 2 episodes when you thought height kill you (there is a shotgun in the house and you are afraid he might use it)
. You feel that it would be very difficult for you to leave him
. You have never reported the matter to any government of social agency and of not with to do so
. You have a satisfying sexual relationship with him , and you are monogamous
. If the examinee explains that you need not endure such a relationship in which you are always in mortal fear, say that you will think about reporting it to the social welfare agencies and ask for an emergency contact number for the emergency department

Past medical / family / social history

. No prior medical problems
. No medications
. No drug allergies
. Mother and father are healthy
. Married 7 years , live with spouse
. 2 children , bout age 6 and girl age 5
. Tobacco: No
. Alcohol : No
. Recreational drugs : No

Physical examination

Multiple bruises at right upper arm in various stages f healing . Examination is otherwise normal.

—————

Case 30 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 how the injuries occurred
. Asked an open-ended question regarding the abuse
. Asked this happens regularly
. Asked how you feel about your husband
. Asked how your husband feels about you
. Asked if you feel safe at home
. Asked if there are nay weapons at home
. Asked about your sexual relationship with your husband
. Asked if you had emergency plan to leave the house if the need were to arise
. Asked bout any other injuries that you had
. Asked if your daily is aware that you are being abused
. Asked about your husband’s alcoholism
. Asked about child abuse at home

Past medical /family/social history

. Asked about past medical issues , hospitalizations , and surgeries
. Asked about current medications
. Asked about allergies
. Asked about tobacco , alcohol , and recreational drug use
. Asked about sexual history
. Asked about occupation
. Asked about personal supports (eg, friends, family)

Examination

. Washed heads before examination
. Examined without gown , not through gown
. Examined shoulder and elbow on affected side
. Check for the injuries

Counseling

. Explained physical findings
. Explained further workup(eg,x-ray)
. Discussed the need for an emergency action plan
. Discussed finding additional support groups in the community
. Gave you emergency contact number and offered ongoing support

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
. If husband is present , discussed the need to ask additional questions privately
. Did not pressure you to leave your husband , report abuse to authorities , or take additional actions you did not want to take
. Listened to what you said without interrupting me
. Used plain English rather than technical jargon
. Used appropriate transition sentences
. Used appropriate draping techniques
. Expressed empathy and gave appropriate reassurances
. Asked whether you have any concerns/questions

Differential diagnosis

. Spousal abuse

Diagnostic study/studies

. X-ray in involved area(s)

—————

Case 30 clinical summary

Clinical Skills Evaluation
Case 30 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).

. 32-yo woman with bruises on the right upper extremity
. caused by multiple incidence of altercation/ abuse by her husband
. Husband has frequent “ rage episodes : associated with alcohol abuse
. Patient has not reported abuse to civil authorities of family member

ROS : Negative
PMHx : Noncontributory
PSHx : None
Meds : None
Allergies : None
FHx : Mother and father are healthy
SHx : Married 7 years , lives with spouse and 2 children ; no tobacco , alcohol , or illicit 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 , 37.4’C (99.3F) ; blood pressure ,120/80 mmHg; pulse , 90/min; and respirations , 16/min
. HEENT : PERRLA , EOMI , normal ENT examination , no head trauma
. Neck : No visible injuries
. Musculoskeletal ; Multiple bruises in various stages of hearing on right upper arm
. Neurologic L CN II-XII grossly intact , UE and LE motor strength and reflexes normla and symmetric
. Psychologic : Awake and alert , affected apprehensive but with appropriate range , clear speech

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 : Intimate partner abuse

History finding(s)
. Recurrent spouse assault
. Spouse with history of alcohol abuse

Physical examination finding(s)
. Multiple bruises in various stages of healing

Diagnostic studies

. x-rays of shoulder, humerus , and elbow
. CBC
. PT/PTT/INR


-- 作者: JuanFe
-- 發表時間: 2018/09/13 07:56am

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


-- 作者: JuanFe
-- 發表時間: 2018/09/13 07:57am

32 Case 32 scenario ( difficulty swallowing )

Doorway information about patient

The patient is a 50-year-old man who comes to the office due to difficulty swallowing

Vital signs
. Temperature : 36.7’C (98.1F)
. Blood pressure ; 130/90 mmHg
. Pulse : 85/min
. Respirations : 16/min

Basic differential diagnosis

. Oropharynx dysphagia
- Neuromuscular (stroke , parkinsonism , multiple sclerosis)
- Mechanical obstruction (Zener diverticulum , thyromegaly)
- Skeletal muscle disorders ( myasthenia gravis , muscle dystrophies ,polymyositis)
- Miscellaneous (medication ,radiation)

. Esophageal dysphagia
- Mechanical obstruction (esophageal carcinoma, benign strictures ,webs and rings [Schazki])
- Abnormal motility (achalasia , scleroderma)
- Gastroesphageal reflux disease
- Miscellaneous (diabetes , alcoholism)

—————

Case 32 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 50-year-old man who comes to the clinic due to difficulty swallowing

History of present illness

. Onset 3 months ago
. Initially had difficulty swallowing soils (food would get stuck in the middle of the chest before slowly going down)
. Symptoms progressed slowly and now you have had difficulty swallowing liquids for the past 3 weeks
. Food regurgitates into the chest 2-3 hours after eating
. No problem chewing of transferring food out of the mouth into the throat
. 10-lb (4.5kg) weight loss in the past 3 months ; decreased appetite for the past 3 weeks

Review of systems

. No weakness in the arm or legs
. No shortness of breath or chest pain
. No nausea , vomiting , diarrhea , or constipation

Past medical / family / social history

. Gastroseophageal reflux (symptoms 2-3times a week for the past 25 years ; relieved with antacids)
. No surgires
. No other medications
. No drug allergies
. Father, mother , and 2 siblings are healthy
. Married , live with wife
. Occupation : Stockbroker
. Tobacco : 1 pack a day for last 30 years
. Alcohol : Occasional wine

Physical examination

—————

Case 32 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 an open-ended question about describing the dysphagia
. Asked about the onset and progression over time
. Asked bout exact location where food gets stuck
. Asked whether the dysphagia is for solid , liquid , or both
. Asked which started first( sold or liquids)
. Asked whether there is any associated pain
. Asked about any aggravating or relieving factors
. Asked about episodes of chocking or regurgitation/ aspiration
. Asked about any nausea and vomiting
. Asked about heartburn / gastroesophageal reflux
. Asked about history of ingestion of corrosive materials
. Asked about appetite and changes in weight

Past medical /family/social history

. Asked about similar episodes in the past
. Asked about past medical issues
. Asked bout medications
. Asked about 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
. Palpated neck for swelling
. Examined mouth and throat
. Gave you water and asked you to swallow
. Palpated lymph nodes in neck , axilla , and about the clavicles
. Auscultated abdomen
. Palpated abdomen(superficial and deep)
. Examined heart and lungs

Counseling

. Explained physical findings and possible diagnosis
. Explained further workup
. Discussed smoking cessation

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

. Carcinoma of the esophagus
. Achalasia
. Reflux esophagitis
. Stricture

Diagnostic study/studies

. CBC
. Esophagram
. Esophagogastroduodenoscopy
. Chest x-ray

—————

Case 32 clinical summary

Clinical Skills Evaluation
Case 32 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).

. 50-yo man with 3 months of dysphagia , initially with solids and now with liquids for the past 3 weeks.
. No problem with chewing and transferring food to throat , but feels food getting struck in the middle of the chest
. Decreased appetite and 4.-kg (10-lb) weight loss
. Food regurgitation 2-3 hours after eating

ROS : No weakness in the arms or legs , shortness of  breath , nausea , vomiting , chest pain ,diarrhea , constipation , or urinary problems
PMHx : GERD for 25 years ,relieved with OTC antacids
PSHx : None
Meds : OTC antacids
Allergies : None
FHx : Father , mother ,  and 2 sibling are healthy
SHx ; 1 PPD smoker for 30 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 : 36.7’C(98.1F) ; blood pressure , 130/90 mmHg; pulse, 80/min; respirations , 16/min
. HEENT : Oropharynx clear , difficulty swallowing water
. Neck : supple with no lymphadenopathy
. Lymph nodes: No axillary or supraclavicular adenopathy
. Lungs : Clear to auscultation bilaterally
. Heart : RRR with no murmurs , gallops, or rubs
. Abdomen : Non-tender , non-distended , normative bowel sounds , no hepatopslenomeagly, 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 : Esophageal cancer

History finding(s)
. Dysphagia with solids and then liquids
. Weight loss with decreased appetite
. Smoking history

Physical examination finding(s)
. None

Diagnosis #2 : Achalasia

History finding(s)
. Dysphagia with solids and liquids
. Weight loss

Physical examination finding(s)
. None
Diagnosis #3 : Reflux esophagitis / stricture

History finding(s)
. History of GERD
. Food regurgitation 2-3 hours after eating
. OTC antacid use

Physical examination finding(s)
. None

Diagnostic studies

. Chest-x-ray
. Barium swallow
. Upper GI endoscopy


-- 作者: JuanFe
-- 發表時間: 2018/09/13 07:57am

33 Case 33 scenario ( refill medication for HIV )

Doorway information about patient

The patient is a 30-year0-old man who comes to the office to refill medications for HIV

Vital signs

. Temperature : 37.1’C (98.8F)
. Blodpressure : 120/75 mmHg
. Pulse : 78/min
. Respirations : 16/min

Basic differential diagnosis

. HIV

—————

Case 33 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 30-year-old man requesting a refill for your HIV medications

History of present illness

. Diagnosed with HIV 1 year ago
. Your partner at the time terminated the relationship , and you were sad initially but have slowly recovered and currently have a positive outlook
. You have been compliant with your medications for the past 6 months
. Your CD4 count 3 months ago was 480 with an undetectable viral load

Do not volunteer this information unless asked :

Review of systems

. Normal appetite with no recent change in weight
. No fever , chills , or night sweats
. No  weakness , numbness , or tingling in the extremities
. No chest pain , cough , or shortness of breath
. No abdominal pain , diarrhea , or constipation
. No genital lesion , urethral discharge , or ruining with urination
. No skin lesion or rashes

Past medical / family / social history

. HIV decided on screening 1 year ago
. No prior medical problems
. Medications : HARRT medications
. Allergies : None
. Surgeries : None
. Immediate family members (after , mother , sister ) are all healthy
. Occupation : Truck driver
. Single ; male partners in the past but none in the last year
. Tobacco : No
. Alcohol : No
. Recreational drugs : No

Physical examination

HEENT :
. Oropharynx clear
. Fund without papilledema or lesion

Neck :
. Supple without lymphadenopathy

Lungs :
. Clear to auscultation bilaterally

Heart :
. Regular rate and rhythm
. No murmurs , gallops , or rubs

Abdomen :
. Non-tender , non-distended
. Normative bowel sounds
. No hepatosplenomegaly
. No CVA tenderness

Extremities :
. No edema
. No skin rashes

—————

Case 33 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 current medication regimen and compliance
. Asked about side effects of drugs
. Asked about symptoms of possible HIV-related illness
- Systemic symptoms (eg , fever , changes in weight )
- Breathing problems (eg, cough , shortness of breath)
- Headaches
- Eye problems (eg , pain , redness , blurred vision)
- Oral ulcers or white patches
- Pain of difficulty with swallowing
- Skin lesion or rashes
- Weakness and sensory symptoms
- Abdominal /bowel problems (eg , pain , cause , vomiting , diarrhea)
- Urogenital problems (dysuria, lesion)
. Asked about  symptoms of depression

Past medical /family/social history

. Asked about past medical issues
. Asked about concurrent medications
. Asked about medical allergies
. Asked about past hospitalizations and surgeries
. Asked about family health
. Asked about tobacco , alcohol , and recreational drug use
. Asked about sexual history
. Asked bout occupation

Examination

. Washed heads before examination
. Examined without gown , not through gown
. Examined eyes, ears, nose , and throat
. Examined lymph nodes
. Examined lungs and heart
. Examined sensation in hands and legs
. Examined abdomen

Counseling

. Explained physical findings and possible additional diagnosis(if any)
. Explained further workup
. Discussed safe sexual practices and use of condoms
. Discussed potential complications and how to deal with them
. Discussed recommended vaccinations

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

. HIV
.(if the simulated patient is instructed to report additional symptoms or signs , consider also: Pneumocytis infection , Candida infection, cytomegalovirus retinitis , esophagitis)

Diagnostic study/studies

. CBC with differential count
. Serum chemistry (including hepatic function markers)
. CD4 cell count
. Viral load (HIV , RNA , PCR)
. Chest x-ray

—————

Case 33 clinical summary

Clinical Skills Evaluation
Case 33 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).

. 30-yo man needing refill of HIV medications
. Diagnosed a year ago
. Initially felt sad but now has positive outlook
. Compliant with medications
. No weight loss , normal appetite

ROS : No numbness or tingling in the extremities , weakness , chest pain , shortness of breath , abdominal pain . rashes , cough , diarrhea , constipation , genital lesions , fever, chills , or night sweats
PMHx : HIV diagnosis a year ago ; 3 months ago , CD4 count was 480/mm3 with undectetable viral load
PSHx : None
Meds : HAART therapy
Allergis : None
FHx : Father , mother , and sister are healthy
SHx : No tobacco or 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 , 37.1’C (98.8F) ; blood pressure , 120/75mmHg; pulse , 78/min; and respirations, 16/min
. HEENT : Oropharynx clear , fund without papilledema or lesions
. Necks ; Supple without lymphadenopathy
. Lungs ; Clear to auscultation bilaterally
. Heart : Regular rate and rhythm without murmurs , gallops, or rubs
. Abdomen ; Non-tender, non-distended , normative bowel sounds , no hepatosplenomegaly, no CVA tenderness
. Extremities ; No rash or edema

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 : Chronic HIV

History finding(s)
. HIV diagnosis a year ago
. Recent stable CD4 count and viral load
. Complaints with medications

Physical examination finding(s)
. Normal examination findings

Diagnostic studies

. CD4 count and viral load
. CBC with differential
. Liver function tests


-- 作者: JuanFe
-- 發表時間: 2018/09/13 07:58am

34 Case 34 scenario ( amenorrhea )

Doorway information about patient

The patient is a 16-year-old girl who comes to the office due to amenorrhea

Vital signs
. Temperature : 36.7’C(98.1F)
. Blood pressure ; 120/70 mmHg
. Pulse : 76/min
. Respirations : 16/min

Basic differential diagnosis

. Pregnancy
. Primary amenorrhea
- Chromosomal disorders
- Abnormal mullerian development
- Androgen insensitive

. Secondary amenorrhea
- Eating disorder
- Hyperprolactinemia
- Thyroid disfunction
- Polycystic ovarian syndorme
- Functional hypothalamic amenorrhea
- Postpill amenorrhea
- Hypothalamic / pituitary mass

—————

Case 34 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 16-year-old girl who has not had a menstrual period for 2 months

History of present illness

. Menses began at age 13 and were regular with no missed periods until 2 months ago
. The cycle usually last 28-30 days with moderate bleeding for 3-4 days (3-4 full soaked pads a day)
. Increased stress at school for the past 4 months , and you are currently studying for mid-term examinations in 2 weeks
. 10-lb (4.5kg) weight loss over the last 4 months despite normal appetite

Do not volunteer this information unless asked :

. No palpations
. No diarrhea or constipation
. No hair or skin changes
. No breast tenderness or nipple discharge
. No vaginal discharge or otters genitourinary symptoms

During the interview , ask the examinee : “Do you think I’m pregnant ? I can’t be pregnant right now . My parents will not be happy .”

Past medical / family / social history

. No history of pregnancy (G0P0)
. No surgeries
. No medications
. No drug allergies
. Immediate family members ( father , mother , sister ) are healthy
. Single , live with parents
. Junior in high school ; during well in school and participate in multiple extracurricular activities
. Sexually active with boyfriend for last 6 months ; do not always use a condom
. Tobacco : No
. Alcohol : No
. Recreational drugs : No

Physical examination

HEENT :
. PERRLA , EOMI
. Oropharynx clear

Neck :
. Supple without lymphadenopathy or thyromegaly

Abdomen :
. Non-tender , non-distended
. Normative bowel sounds
. No hepatosplenomegaly

Psychiatric :
. Alert and oriented
. Anxious affect

—————

Case 34 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 and duration of amenorrhea (i.e., last menstrual period)
. Asked about menarche and previous menses (frequency , duration , quantify of blood loss)
. Asked bout associated symptoms:
- Abdominal pain
- Vaginal discharge
- Change I’m appetite or weight
- Cold or heat intolerance
- Changes in skin or hair
- Breast changes or nipple discharges
- Headache
. Asked about sexual activity (and use of contraception )
. Asked about life stressors

Past medical /family/social history

. Asked about similar episodes in the past
. Asked about other medical problems
. Asked about surgeries and gynecologic procedures (eg , dilation and curretage )
. Asked about current and recent medications
. Asked about medication allergies
. Asked about family  health
. Asked about tobacco , alcohol , and recreational drug use

Examination

. Washed heads before examination
. Examined without gown , not through gown
. Examined eyes (including visual fields)
. Examined neck ( including thyroid )
. Examined abdomen

Counseling

. Explained physical findings and possible diagnosis
. Explained further workup
. Discussed the need for pelvic and breadth examinations

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

. Pregnancy
. Eating disorder
. Thyroid dysfunction
. hyperprolactinemia
. Functional hypothalamic amenorrhea

Diagnostic study/studies

. Pelvic and breast examination
. Pregnancy test
. TSH
. Serum prolactin level
. Pelvic ultrasound
. Brain MRI
. LH and FSH levels

—————

Case 34 clinical summary

Clinical Skills Evaluation
Case 34 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).

. 16-yo girl with 2 month of amenorrhea
. Menarche at age 13 with regular and no missed periods until 2 months ago.
. Sexually active with boyfriend and dose not always use condoms.
. Increased stress at school
. Unintentional 4.52-kg (10-lb ) weight loss in past 4 months with good appetite.

ROS : No palpation , diarrhea , constipation , hair loss  skin changes , breath tenderness , nipple discharge , vaginal discharge , or urinary problems
PMHx : G0P0
PSH : None
Meds : None
Allergies : None
FHx : Father , mother and sister are healthy
SHx : No tobacco or 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 ,36.7’C (98.1F); blood pressure 120/70 mmHg; pulse : 76/min; and respiration , 16/min
. HEENT : PERRLA , EOMI , oropharynx clear
. Neck : Supple without lymphadenopathy or thyromegaly
. Abdomen ; Non-tender, non-distended , normative bowel sounds ,. no hepatosplenomegaly

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 : Pregnancy

History finding(s)
. Amenorrhea
. Sexually active, sometimes not using condoms

Physical examination finding(s)
. None

Diagnosis #2 : Hyperthyroidism

History finding(s)
. Amenorrhea
. Increased anxiety
. Weight loss with good appetite

Physical examination finding(s)
. None

Diagnosis #3 :Hyperprolactinemia

History finding(s)
. Amenorrhea

Physical examination finding(s)
. None

Diagnostic studies
. Pregnancy test
. TSH and T4
. Pelvic and breath examination
. Prolactin level


-- 作者: JuanFe
-- 發表時間: 2018/09/13 07:59am

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


-- 作者: JuanFe
-- 發表時間: 2018/09/13 08:00am

36 Case 36 scenario ( insomnia )

Doorway information about patient

The patient is a 70-year-old man wth insomnia

Vital signs

. Temperature ; 36.7’C(98.1F)
. Blood pressure : 130/90 mmHg
. Pulse ; 58/min
. Respirations : 16/min

Basic differential diagnosis

. Depression
. Post-Traumatic stress disorder
. Anxiety disorder
. Chronic pan syndormes
. Adverse effect of medication
. Age-related sleep change
. Thyroid problems
. Sleep apnea
. Restless legs syndorme

—————

Case 36 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 70-year-old man who has insomnia

History of present illness

. Admitted to the hospital 3 months ago with chest pain and diagnosed with coronary artery disease . Coronary angioplasty was performed and several new medications were initiated . you were very anxious throughout the hospitalization and were given lorazepam for anxiety . A few weeks after discharge , you began having difficulty falling asleep and are able to stay asleep for only 2-3 hours before getting up and pacing.
. No unusual dreams or nightmares
. You do not wake refreshed and feel tired in the morning and throughout the day
. You do not drink alcohol or caffeine in the evening before you go to bed
. Decreased appetite an a 2.27-kg (5-lb) weight loss since the hospitalization
. Your son loves nearby and says that you have become more isolated and not interested in normal activities

Review of systems

. No chest pain
. No shortness of breath or swelling in the ankles /feet
. No tremors or change in strength or sensation
. No changes in hair or skin
. No nausea , vomiting , diarrhea , constipation , or abdominal pain
. No palpitations or dizziness

Past medical / family / social history

. Coronary artery disease
. no surgires
. Medications ; Aspiri , clopidogrel , metoprolol, atovastatin , lisinpril , nitroglycerin, sublingual as needed (have not used)
. No drug allergies
. After died at age 75 of heart attack , motor died at age 68 of breath cancer , 1 sister (healthy)
. Widowed for last 2 years , live alone
. Retired accountant
. Tobacco : 1 pack a day for last 50 years
. Alcohol : Occasional beer
. Recreational; drugs : No

Physical examination

General :
. Awake and alert but appear fatigued
. Grooming and hygiene normal
. No distress

HEENT :
. Oropharynx clear

Neck :
. Supple without lymphadenopathy

Lungs :
. Clear to auscultation bilaterally

Heart :
. Regular rate and rhythm
. no murmurs , gallops ,or rubs

Abdomen :
. Non-tender, non-distended
. Normative bowel sounds
. No hepatosplenomegaly

Neurologic :
. Oriented to person , place, and time
. Motor 5/5 throughout
. Reflexes 2+ throughout

—————

Case 36 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 symptoms
. Asked bout the average duration and quality of sleep
. Asked if having difficulty falling asleep ,staying asleep , or both
. Asked about bedtime habits
. Asked if having nightmares
. Asked if having anxiety or depressive symptoms
. Asked if having any associated palpitations , sweating , or dizziness
. Asked if having any pain
. Asked about snoring / breathing problems
. Asked about daytime sleepiness and morning headaches
. Asked about appetite and changes in weight
. Asked about constipation and diarrhea
. Asked bout impact on personal relationship and daily activities

Past medical /family/social history

. Asked about similar episodes in the past
. Asked about past medical issues , hospitalizations ,and surgeries
. Asked about curent medications
. Asked about medication allergies
. Asked about family health
. Asked bout current living situation and family support
. Asked about occupation

Examination

. Washed heads before examination
. Examined without gown , not through gown
. Examined pharynx
. Examined neck/thyroid
. Performed neurologic examination including cranial nerves , motor strength , and reflexes
. Examined heart and lungs

Counseling

. Explained physical findings and possible diagnosis
. Explained further workup
. Discussed sleep habits/ sleep hygiene
. Discussed smoking cessation and readiness to quit

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

. Anxiety disorder
. Drug-induced insomnia
. Depression
. Sleep apnea

Diagnostic study/studies

. CBC
. Basic metabolic panal (Na, K , BUN , Cr, CO2 , Cl)
. TSH
. Nocturnal polysomnography

—————

Case 36 clinical summary

Clinical Skills Evaluation
Case 36 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).

. 70yo man with 2 months of insomnia after hospitalization for CAD with angioplasty
. Difficulty falling and staying asleep
. Decreased appetite and 2.27-kg (5-lb ) weight loss.
. Family thinks the patient feels isolated and has loss interest in activities

ROS : Fatigue , no chest pain , shortness of breath , tremor , hair loss diarrhea , constipation, palpitations , dizziness , or recent trauma
PMHx : CAD
PSHx : None
Meds : Aspirin , clopidogrel , metoprolol, lisinpril, atovastatin, nitroglycerin as needed
Allergies : None
FHx : Father died of MI ; mother died of breast cancer
SHx: 1 PPD smoker for 50 years , occasional alcohol use

. Vital signs : Temperature ,36.7’C(98.1F); blood pressure , 130/90 mmHg; pulse , 58/min; respirations , 16/min
. HEENT : Oropharynx clear
. Neck : Supple without lymphadenopathy
. Heart : RRR without murmurs , gallops , or rubs
. Abdomen ; Non-tender, non-distended, normative bowel sounds , no hepatosplenomegaly
. Neurologic : Motor 5/5 bilaterally ; alert and oriented to person , place , and time ; DTR 2+ bilaterally

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.

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 : Anxiety disorder

History finding(s)
. Recent hospitalization
. Difficulty falling and staying asleep
. Previous anxiety requiring medications

Physical examination finding(s)
. None

Diagnosis #2 : Depression

History finding(s)
. Decreased appetite and weight loss
. Decreased interest in activities
. Insomnia , fatigue

Physical examination finding(s)
. None

Diagnosis #3 : Drug induced insomnia

History finding(s)
. Recently started metoprolol
. Insomnia

Physical examination finding(s)
. Bradycardia

Diagnostic studies

. Basic metabolic panel
. CBC with differential
. TSH


-- 作者: JuanFe
-- 發表時間: 2018/09/13 08:01am

37 Case 37 scenario ( difficulty urination)

Doorway information about patient

. The patient is a 65-year-old man who comes to the office due to difficulty with urination

Vital signs
. Temperature : 37.2’C(99F)
. Blood pressure ; 130/80 mmHg
. Pulse ; 92/min
. Respirations : 16/min

Basic differential diagnosis

. Benign prostate hyperplasia
. Prostatitis
. UTI / cystitis
. Carcinoma of the prostate
. Stone in the urinary tract (obstructive)
. Carcinoma of the bladder
. Neurologic dysfunction
. Drug-induced bladder dysfunction

—————

Case 37 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.

History of present illness

. Onset of symptoms 2 months ago
. Difficulty initiating urine stream with decreased flow , straining with urination , sensation of incomplete emptying , and increased urinary frequency
. Mild burning on urination and 1 episode of blood in the urine
. Getting up 5-6 times a night to urinate
. Asked doctor :” Do you think I have prostate cancer?”

Review of systems

. Decreased appetite with 4.5-kg (10-lb) weight loss over the last year
. No fever or chills
. No  abdominal pain , diarrhea , or constipation
. No muscle weakness
. No recent trauma

Past medical / family / social history

. Diabetes mellitus for the past 10 years
. No surgeries or hospitalizations
. Medications : Metformin 500mg twice daily
. No drug allergies
. Father died of prostate cancer at age 75 , mother died of “kidney problems” at age 78 , sister is healthy
. Occupation : Accountant
. Married , lived with wife
. Tobacco : No
. Alcohol : 2 beers /day for last 35 years
. Recreational drugs : No

Physical examination

Abdomen :
. Non-tender, non-distended
. Normative bowel sounds
. No hepatosplenomegaly
. No CVA or suprapubic tenderness

Neurologic :
. Motor 5/5 throughout
. DTR 2+bilaterally

—————

Case 37 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 symptoms and course over time
. Asked about difficulty initiating or maintaining urinary flow
. Asked bout the strength of flow
. Asked about intermittency (stopping and starting again while urinating), straining, and sensation of incomplete emptying
. Asked about the frequency or urination
. Asked about urgency
. Asked about nocturia
. Asked bout any burning sensations with urination
. Asked if any blood in the urine
. Asked about associated symptoms , especially :
- Abdominal pain
- Fever
- Weakness in legs
- Change in bowel movements
- Change in appetite or weight
- Back pain or trauma

Past medical /family/social history

. Asked about similar episode sin the past
. Asked about past medical issues(especially urinary or sexually transmitted infections), Surgeries , and hospitalizations
. 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 abdomen  (auscultation ,palpation)
. Examined back , including palpation/ percussion for ocstovertebral angle tenderness
. Tested lower extremity strength and reflexes

Counseling

. Explained physical findings and possible diagnosis
. Explained further  workup
. Explained the need for rectal / prostate 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

. Benign prostate hyperplasia
. Urinary tract infection
. Prostatitis
. Prostatic carcinoma
. Bladder carcinoma
. Overflow incontinence

Diagnostic study/studies

. Rectal examination
. urinalysis andurine culture
. Serum BUN , Creatinine , glucose
. Hemoglobin A1c
. CBC with differential
. Prostate-specific antigen

—————

Case 37 clinical summary

Clinical Skills Evaluation
Case 37 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).

. 95-yo man with 2 months of difficulty initiating urination , decreased urinary flow , nocturia , increase urinary frequency , and incomplete emptying of bladder
. 1 episode of hematuria
. Decreased appetite and 4.53kg(10-lb) weight loss over the past year.

ROS : No increased urinary urgency , abdominal pain, flank pain , fever , chills , diarrhea , constipation, leg weakness , or trauma
PMHx : Diarrhea for past 10 years
PSHx : None
Meds : Mptformin 500 mg twice a day
Allergies : None
FHx : Father died of prostate cancer ; motor died of kidney problems
SHx : No tobacco use l 2 beers daily for 35 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 ,37.2;C(99F); blood pressure , 130/80 mmHg; pulse, 92/min; and respirations, 16/min
. Abdomen : Non-tender, non-distended , normative bowel sounds , no hepatosplenomegaly, no CVA tenderness
. Neurologic : Motor 5/5 bilaterally , DTR 2+ bilaterally

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 : Benign prostate hyperplasia

History finding(s)
. Difficulty with urination
. Incomplete emptying of bladder
. Nocturia, decreased urinary flow

Physical examination finding(s)
. None

Diagnosis #2 : Prostate cancer

History finding(s)
. Family history of prostate cancer
.Decreased urinary flow, nocturia
. Weight loss

Physical examination finding(s)
. None

Diagnosis #3 : Bladder cancer

History finding(s)
. Gross hematuria
. Incomplete emptying of bladder
. Weight loss

Physical examination finding(s)
. None

Diagnostic studies

. Rectal examination
. Urinalysis with curse culture
. PSA
. Basic metabolic panel


-- 作者: JuanFe
-- 發表時間: 2018/09/13 08:02am

38 Case 38 scenario ( anxiety )

Doorway information about patient

The patient is a 35-year-old woman who comes to the emergency department due to breathlessness and anxiety.

Vital signs

. Temperature : 36.1’C(97F)
. Blood pressure : 130/80 mmHg
. Pulse ; 94/min
. Respirations : 22/min

Basic differential diagnosis

. Anxiety secondary to medical condition (eg, hyperthyroidism, arrhythmias)
. Substance abuse
. Panic disorder
. Generalized anxiety disorder
. Adjustment disorder with anxious mood
. Acute stress disorder or post-traumatic stress disorder
. Hypochondriasis

—————

Case 38 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 experiencing shortness of breath

History of present illness

. Episodic shortness of breath for 3 months ; slight problems previously but never this severe
. Episodes last 30 minutes and are associated with palpitations , sweating ,and feeling that you are going to die
. Episodes occur about 2 or 3 times a week at any time but are worse in crowded places outside the house , and you have stopped going to outdoor activities to avoid triggering symptoms
. Symptoms seem to improve with sloe breathing and relaxation
. Multiple emergency department evaluations for the same symptoms ; all test have been normal/nondiagnostic
. Ask the doctor : “ Do you think that this is anxiety like my mother has?”

Review of systems

. No chest pain
. No headaches or tremors
. Occasional diarrhea alternating with constipation
. No nausea , vomiting , or abdominal pain

Past medical / family / social history

. No prior medical issues , surgeries , or hospitalizations
. No medications
. Allergies : Penicillin causes a rash
. Father is healthy , mother has generalized anxiety disorder, sister is healthy
. Married , live with husband and 2 children
. Occupation : Homemaker
. Tobacco : No
. Alcohol : Wine on social occasions only
. Recreational drugs : Used marijuana occasionally in college but non since then
. Caffeine : 1 cup of coffee daily

Physical examination

Neck:
. Supple without thyromegaly or lymphadenopathy

Lungs :
. Clear to auscultation

Heart :
. Regular rhythm
. No nurtures, rubs, or gallops

Neurologic :
. No treor in extremities

Psychological :
. Alert and oriented
. Affect mildly anxious but otherwise appropriate
. Speech clear

—————

Case 38 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 initial onset of symptoms and course over time
. Asked about the frequency and duration of attacks
. Asked about associated symptoms . especially :
- Chest pain
- Swelling in neck
- Fear/apprehension, sense of impending doom
- Palpitations
- Dizziness
- Tremor
- Sweating
. Asked about aggravating and relieving factors
. Asked about impact of symptoms on relationship and normal activities

Past medical /family/social history

. Asked about similar episodes in the past
. Asked about past medical issues (especially thyroid and psychological disorders)
. Asked about previous hospitalizations and surgeries
. Asked about current medications
. Asked about medication allergies
. Asked about family health
. Asked about occupation
. Asked bout tobacco , alcohol , and recreational drugs

Examination

. Washed heads before examination
. Examined without gown , not through gown
. Palpated neck for swelling
. Examined hands for tremor
. Examined heart and lungs
. Examined cranial nerves , motor strength , and reflexes

Counseling

. Explained the physical findings and possible diagnosis
. Explained further workup (if any)

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

. Panic disorder/ agoraphobia
. Generalized anxiety disorder
. Hyperthyroidism
. Substance abuse

Diagnostic study/studies

. ECG
. Electrolytes and glucose
. TSH
. Urine drug screen

—————

Case 38 clinical summary

Clinical Skills Evaluation
Case 38 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 3 months of episodic shortness of breath , palpitations , diaphoresis, and feeling of impending death
. Episodes lasting 30 minutes and occurring more frequently outside of house in crowded places
. Symptom improvement with slow breathing and relaxation
. Multiple ED trips with normal investigations and no definitive diagnosis

ROS : Occasional diarrhea alternating with constipation ; no chest pain, headache nausea , vomiting , tremors , neck swelling , or abdominal pain
PMHx : None
PSHx : None
Meds : None
Allergies : Penicillin (rash)
FHx : Father is healthy ; mother has generalized anxiety disorder
SHx ; No tobacco use , occasional glass of wine

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 ,36.1’C(97F); blood pressure , 130/80/mmHg; pulse ,94/min; and respirations , 22/min
. Neck : Supple without thyromegaly or lymphadenopathy
. Lung : Clear to auscultation
. Heart : Regular rhythm without murmurs , rubs, gallops
. Neurologic ; No tremor in extremities

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 : Panic disorder

History finding(s)
. Episodes of palpitations with dyspnea
. Family history of anxiety
. Symptoms worse in crowded places
. Symptoms relieved wth slow breathing

Physical examination finding(s)
. None

Diagnosis #2 : Hyperthyroidism

History finding(s)
. Episodes of palpitations
. Shortness of breath and diaphoresis

Physical examination finding(s)
. None

Diagnosis #3 : Cardiac arrhythmia

History finding(s)
. Palpitations
. Shortness of breath and diaphoresis

Physical examination finding(s)
. None

Diagnostic studies

. ECG
. TSH
. Serum electrolytes and glucose


-- 作者: JuanFe
-- 發表時間: 2018/09/13 08:02am

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

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


-- 作者: JuanFe
-- 發表時間: 2018/09/13 08:04am

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


-- 作者: JuanFe
-- 發表時間: 2018/09/13 08:04am

41 Case 41 scenario ( dizziness )

Doorway information about patient

The patient is a 60-year-old man who comes to the office due to dizziness

Vital signs

. Temperature : 36.1’C (97F)
. Blood pressure : 140/90 mmHg
. Pulse ; 80 /min
. Respirations : 16 /min

Basic differential diagnosis

. Vertigo (benign paroxysmal positional vertigo , labyrinthitis , Meziere disease , posterior circulation stroke )
. Lightheartedness (hypotension ,postural hypotension , arrhythmia , anemia, congestive heart failure)
. Disequilibrium (anxiety , autonomic  dysfunction)
. TIA or stroke
. Medication affect
. Hypoglycemia

—————

Case 41 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 60-year-old man who has dizziness

History of present illness

. Onset 4 days ago
. Intermittent espies latina 2-5 minutes
. Worse when standing up form a seated position ; better when lying down
. Sometimes associated with palpitations and sweating
. No associated loss of consciousness
. During an espies earlier today , you noticed weakness in the right lower leg that lasted 10 minutes and resolved spontaneously

. Asked this questions: “ Doc , did I have a stroke? “
. If the examinee asked you to clarify the quality of dizziness , say: “ If feels alike I might fall over or pass out.”

Review of systems

. No headaches
. No changes in hearing or ringing in the ear
. No nausea , vomiting , or diarrhea
. No chest pain
. No incontinence of bowel or bladder
. Decreased force of urine stream with nocturia 1 or 2 times a night

Past medical / family / social history

. Type 2 diabetes : Diagnosed 15 years ago and treated with glyburide twice daily and atovastatin ; finger -stick blood glucose has recently been 120-160 mg/dl’
. Hypertension : Diagnosed 10 years ago ; changed 1week ago form atenolol (which you had taken for many years ) to terazosin due to increasing symptoms of benign prostatic hyperplasia
. No history of heart dies or stroke
. No other medications
. No drug allergies
. No surgeries or hospitalizations
. Father and motor died in their 80s due to chronic obstructive pulmonary disease
. Married , live with wife
. Occupation : Supermarket cashier
. Tobacco : 2 packs a day for last 30 years
. Alcohol : No
. Recreational drugs : No

Physical examination

HEENT :
. Cerumen accumulation in both ears
. Normal nares , mouth ,and pharynx

Neck :
. No goiter or palpable lymph modes

Cardiovascular :
. Regular rate and rhythm
. No murmur
. No carotid bruits
. Pedal pulses faint but palpable

Neurologic :
. Gait slow and hesitant
. Cranial nerves normal
. Normal balance and coordination
. Normal strength and reflexes

If the examinee performs the Dix-Hallpike maneuver (lie back quickly with head turned 45 degrees ), there are no eye movements elicited but say :” I feel kind of dizzy.”

—————

Case 41 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 to clarify the quality of dizziness ( eg, spinning/vertigo , lightheaded)
. Asked about the onset and duration of symptoms
. Asked about the relation to posture and otters triggering factors ; asked about any relieving factors
. Asked whether dizziness is continuous or intermittent
. Asked about associated symptoms (eg, visual changes, headaches , tingling /numbness, weakness , loss of consciousness)
. Asked about ear problems (eg , loss of hearing , ringing in ears)
. Asked about nausea and vomiting

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 bout tobacco , alcohol , and recreational drug use
. Asked about current living situation and family support
. Asked about occupation

Examination

. Washed heads before examination
. Examined without gown , not through gown
. Checked BP on both arms in sitting , standing , and lying positions
. Examined ears , nose , and throat
. Checked motor power and sensation in all limbs
. Checked reflexes
. Examined cranial nerves
. Performed Romberg test and coordination / cerebellar function tests (eg, finger-to-nose)
. Checked gate
. Performed Dix-Hallpike maneuver (patient lies down quickly with head turned 45 degrees to each side)
. Examined heart , carotid arteries , and distal circulation

Counseling

. Explained physical findings and possible diagnosis
. Explained further workup
. Discussed smoking cessation and readiness to quit

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

. Drug-induced postural hypotension
. Benign paroxysmal positional vertigo
. Autonomic dysfunction from disease
. Hypoglycemia
. Arrhythmia
. Transient ischemic attack

Diagnostic study/studies

. CBC
. Doppler carotid study
. Blood glucose and hemoglobin A1c
. Serum electrolytes (Na, K, Cl, BUN, creatinine)
. ECG
. Head CT

—————

Case 41 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).

. 60-yo man with 4 days of intermittent dizziness
. Brief episodes of nonspecific  dizziness triggered by positional changes
. Associated with palpitations and 1 episode of leg weakness (resolved spontaneously) but no loss of consciousness

ROS : No headache , hearing symptoms , nausea , chest pain , or incontinence ; positive for lower urinary tract symptoms
PMHx : HTN, diabetes , BPH
PSHx : None
Meds ; Glyburide , atovastatin , terazosin (chenaged from atenolol a week ago)
Allergies : None
FHx : Father and mother died of COPD
SHx : Married , works as casher , 2 PPD smoker for 30 years , no alcohol 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 , 36.1’C(97F) ; blood pressure , 140/90 mmHg ; pulse , 80/min; and respirations , 16/min
. HEENT : Cerumen accumulation bilaterally ; ears , nose , and throat otherwise normal
. Neck : No lymphadenopathy or thyromegaly
. Heart : RRR with no murmurs , no carotid bouts , pedal pulses palpable but diminished
. Neurologic : Slow gait , CN II-XII normal , normal motor strength and reflexes , Romberg and finger-to-nose tests normal , Dix-Hallpike test subjectively positive

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 : Benign paroxysmal positional vertigo

History finding(s)
. Intermittent / episodic dizziness
. Symptoms provoked by position change

Physical examination finding(s)
. Subjectively positive Dix-Hallpike test

Diagnosis #2 : Medication -induced postural hypotension

History finding(s)
. Symptoms trigged by position changes
. Recent initiation of alpha blocker

Physical examination finding(s)
. None

Diagnosis #3 : Transient ischemic attack

History finding(s)
. Chronic diabetes and hypertension
. Unilateral lower extremity weakness that resolved spontaneously

Physical examination finding(s)
. None

Diagnostic studies

. ECG
. Electrolytes and blood glucose
. CT scan of brain


-- 作者: JuanFe
-- 發表時間: 2018/09/13 08:06am

42 Case 42 scenario ( new-onset seizure )

Doorway information about patient

The patient is a 30-year-old man who comes to the emergency department due to new-onset seizure

Vital signs

. Temperature : 37.2’C (99F)
. Blood pressure : 120/80 mmHg
. Pulse ; 82/min, regular
. Respirations : 18/min

Basic differential diagnosis

. Seizes (secondary to head trauma , infections , drugs , metabolic disorders)
. Hypoglycemia
. Syncope
. Migraine
. Stroke
. Psychogenic seizure
. Space-occupying lesion
. Alcohol or drug withdrawal

—————

Case 42 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 30-year-old man who is brought to the emergency department with a new seizure

History of present illness

. Seizure occurred a few hours ago
. Witnesses (coworkers) noted shaking lasting about 3 minutes , followed by 20 minutes of loss of consciousness
. Symptoms preceded by nausea
. Bit tongue but did not pass urine  or feces during the episode
. Have noticed some weakness in the right hand for the past 3 months
. Chronic, occasional mild headaches , but recently the headaches are constant and more severe
. No history of head trauma

Review of systems

. Mild fever ; cold and flu-like symptoms for the past couple of days
. No ear discharge or sinus pain
. No neck pain

Past medical / family / social history

. Type 1 diabetes diagnosis 15 years ago and treated with insulin pump (If the examinee asks you if you think this could be due to hypoglycemia , say: “ I don’t think so because I know what that looks like.’ )
. No other medical issues , hospitalizations , or surgeries
. No otters medications
. No drug allergies
. Father , mother , and sister are healthy ( No family history of seizures)
. Single , not sexually active
. Occupation : Postal clerk
. Smoking : No
. Alcohol : Social occasions only ; last drink was 2 days ago
. Recreational drugs : No

Physical examination

HEENT :
. Normal , no injuries

Neck :
. Supple with no goiter or lymphadenopathy

Heart :
. regular rate and rhythm
. No murmurs

Chest / lungs :
. Clear to auscultation and percussion

Neurologic :
. Awake and alert
. Cranial nerve examination normal
. Motor strength and reflexes normal

—————

Case 42 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 bout a description of the seizure
- Duration
- Shaking
- Automatisms (eg, lip smaking)
- Fecal/urinary incontinence
- Biting of tongue or other injuries
- Post-seizure confusion /loss of consciousness
. Asked about aura (prodromal symptoms) and activities at the onset of seizures
. Asked about any recent head trauma
. Asked about associated symptoms:
- Palpitations , chest pain
- Headaches
- Nausea / vomiting
- Fever
- Muscle weakness
. Asked about any past seizures of loss of consciousness

Past medical /family/social history

. Asked about other medical issues(especially diabetes , meningitis /encephalitis, neurologic disorders)
. Asked about prior hospitalizations and surgeries
. Asked about current medications
. Asked bout medication allergies
. Asked about family health
. Asked about tobacco , alcohol , and recreational drug use ( including most recent alcohol use and any history of alcohol withdrawal)
. Asked about occupation

Examination

. Washed heads before examination
. Examined without gown , not through gown
. Examined for head injury and neck stiffness
. Checked motor power , reflexes, and sensation in all limbs
. Examined the cranial nerves
. Examined eyes with ophthalmoscope
. Examined ears with otoscope
. Examined heart and lungs
. Examined abdomen

Counseling

. Explained physical findings and possible diagnosis
. Explained further workup
. Discussed family support

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

. Intracranial mass
. Hypoglycemia
. Alcohol withdraw
. Meningitis / encephalitis

Diagnostic study/studies

. CBC with differential
. Serum electrolytes (Na,K, Cl, CO2, BUN, Cr, Ca, Mg) and glucose
. LFTs
. Urinalysis and urine toxicology screen
. Head CT scan
. Lumber puncture
. EEG

—————

Case 42 clinical summary

Clinical Skills Evaluation
Case 42 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).

. 30-yo man with new-onset seizure
. Onset a few hours ago
. Single episode of shaking (3 min) followed by loss of consciousness (20min)
. Proceeded by nausea and associated with biting of tongue
. Recent history of right hand weakness and increasing headaches

ROS : Mild fever and flu-like illness last few days
PMHx : Type 1 diabetes for 15 years
PSHx : None
Meds : Insulin via pump
Allergies : None
FHx : Father , mother , and sister are healthy
SHx : Single , works as postal clerk ; social alcohol , 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 , 37.2’C (99F); blood pressure , 120/80mmHg; pulse , 82/min; and respirations , 18/min
. HEENT : PERRLA , EOMI, no papilledema
. Neck ; Supple without thyromegaly or lymphadenopathy
. Heart : RRR with no murmurs
. Lungs : Clear to auscultation and percussion
. Neurologic ; Awake and cranial nerves II-XII intact , motor strength and reflexes normal

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 : Intracranial mass

History finding(s)
. New seizure
. Increasing headaches
. Recent subjective weakness

Physical examination finding(s)
. None

Diagnosis #2 : Hypoglycemia

History finding(s)
. Type 1 diabetes
. Use of insulin pump

Physical examination finding(s)
. None

Diagnosis #3 : Alcohol withdraw

History finding(s)
. New Seizure
. Last alcohol intake 2 days ago

Physical examination finding(s)
. None

Diagnostic studies

. CT scan of the head
. CBC with differential
. Serum electrolytes and glucose
. Urine toxicology screen
. Lumbar puncture
. EEG


-- 作者: JuanFe
-- 發表時間: 2018/09/13 08:06am

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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