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2/5/12 12:00 AM

case1 Scenario

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30 Yr. O/F Complaining of Abdominal Pain Vitals Pulse--98/min B.P--120/75 mm of Hg Temp-101.3 R.rate--22/min Make a mental checklist of Differential Diagnosis Pelvic inflammatory disease Pelvic abscess Endometriosis Urinary tract infection Appendicitis Rupture/torsion of ovarian cyst Acute cholecystitis Renal colic Ectopic pregnancy Abortion Acute gastroenteritis Inflammatory bowel disease
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2/5/12 12:01 AM

case1 SP

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If the doctor asks you anything other than these just say 'no' (or) say things that are normal in daily routine life. You are Mrs. Mary, age: 30yrs Have abdominal pain since 12 hrs Started slowly, progressively increasing 6-7/10 in severity Right below the umbilicus It's a type of sharp pain All over your lower abdomen Began after eating a large meal Moving around makes it worse No alleviating factors Associated with nausea and vomiting Passing urine more number of times and have burning urination No bowel problems Last menstrual period was 3 weeks ago No discharge from vagina/no bleeding from vagina Have fever since yesterday associated with chills and rigors Have one episode of urinary tract infections (UTI) in the past No allergies Once hospitalized for evaluation of UTI Have multiple sexual partners Using oral contraceptive pills Familie's health is normal Smoking - No Alcohol - No Recreational drugs- No Occupation: Working as a receptionist Appetite and wt is normal No illicit drug intake Ask this qt - Doc is it an appendicitis?
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1/28/12 3:53 PM

case1 checklist

History Taking (General Proforma) Asked about the location 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 progression of pain Asked about any radiation of pain Asked about the aggravating factors. Asked about the relieving factors Asked about any vomiting Asked about fever Asked about urinary problems Asked about bowel problems. Asked about last menstrual period Asked about vaginal discharge Asked about vaginal bleeding Past History Asked about similar episodes in the past Asked about history of allergies Asked about past medical problems (high blood pressure, diabetes, kidney problems, urinary tract infections) Asked about previous hospitalizations (surgery) Asked about family health. Asked about appetite and changes in weight Asked about smoking Asked about alcohol

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Asked about Obg/gyn history (in detail) Asked about sexual history (in detail including contraception) Asked about medications Asked about occupation Examination Examinee washed hands Auscultated abdomen Palpated abdomen superficially Palpated abdomen deeply Checked rebound tenderness Looked for CVA tenderness Performed Psoas sign and obturator sign Examined without gown not through the gown Counseling Explained the physical findings and diagnosis Explained further work up (Blood tests, urinalysis, ultrasound, abdomen x ray) Explained the importance of safe sexual practices and use of condoms. Asked to perform rectal and vaginal examination Communication Skills Knocked before entering the room Introduced himself and greeted warmly Used my name to address me Paid attention to what I said and maintained good eye contact Asked few open ended questions Asked non leading questions
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Asked one question at a time Listened to what ever I said with out interrupting me in between Used lay man's language Used appropriate transition sentences Used appropriate draping techniques Summarized the history and explained physical findings Expressed empathy, made appropriate reassurances Asked whether I have any concerns/ questions. D.D for this Case Pelvic inflammatory disease Pelvic abscess Urinary tract infection Appendicitis Rupture/torsion of ovarian cyst Investigations Rectal and vaginal examination CBC with differential count Urinalysis Pregnancy test Abdomen x ray Ultrasound abdomen

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2/5/12 12:01 AM

case1 Pt Notes

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C.C: A 30 Y/O WF with abdominal pain. HPI: A 30 Y/O WF who has a H/O UTI, pyelonephrtis who is in her usual state of health until yesterday started to have abdominal pain right below the umbilicus. The pain started after having a heavy meal; She describes the pain as sharp, 6-7/10 in severity, gradual in onset and progressively increasing. Later on, the pain moved to the lower abdomen. Moving around makes the pain worse; denies any alleviating factors. The pain is associated with nausea and 2 episodes of non-bloody vomitings. She is also C/O having frequent burning urination, which started at more or less same time. She also has fever associated with chills and rigors. ROS: She has regular bowel movements; no diarrhea/constipation. She denies recent change in appetite and weight. Rest is unremarkable. PMH: UTI one episode. Hospitalized once for evaluation of possible pyelonephritis. All: NKA SH: Working as a receptionist. She never smoked nor had alcohol. SxH: Multiple sexual partners, her partner doesn't use condoms, uses oral contraceptive pills. Never been tested for STDs. FH: Both parents are alive and healthy Ob & Gyn: LMP 3 weeks ago. No priors STD's. No H/o vaginal discharge PE: Vitals: Gen: Heart: Pulse 98/min, B.P -120/75 mm of Hg, R.R - 22/min, Temp 101.30F AAOx3 (Alert, Awake and oriented to time place and person), in mild to moderate pain. S1, S2 heard. No thrills/murmurs /gallops/rubs.

Lungs: CTA B/L (Clear to auscultation bilateral) Abdomen: Flat, no scars and pigmentations. BS are + in all 4 quadrants. Tenderness is present in periumbilical, RLQ and LLQ regions. Not distended. No rebound/guarding/organomegaly. CVA tenderness is negative. Psoas and obturator signs are D/D: Pelvic Inflammatory disease Pelvic abscess Urinary tract Infection Appendicitis Rupture or Torsion of ovarian cyst Investigations: Rectal and pelvic examination CBC with differential Urinalysis including C/S Pregnancy test Ultrasound Abdomen

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