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 (98.1 F)
Blood pressure: 110/65 mm Hg
Pulse: 100/min
Respirations: 18/min
Basic differential diagnosis
Viral gastroenteritis
Bacterial gastroenteritis & food-borne pathogens
Medication induced
Giardiasis
Clostridium difficle colitis
Inflammatory bowel disease
Irritable bowel disease
Malabsorption
HIV

Question

Quizplus · Accepted Answer

The Answer is 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 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 stools 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 systems
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 (other than amoxicillin)
No medication allergies
Both 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:
Nontender, nondistended
Normoactive bowel sounds throughout
Tympanic to percussion
No hepatosplenomegaly
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 onset and duration of diarrhea
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 other 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 other medical issues
Asked about medications (especially antibiotics) and medication allergies
Asked about recent and previous hospitalizations
Asked about any abdominal surgeries
Asked about occupation
Asked about tobacco, alcohol, and drug use
Asked about family history (especially gastrointestinal diseases)
Examination
Examinee washed hands
Examined without gown, not through 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 other 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 what you said and maintained good eye contact
Asked open-ended questions
Asked nonleading 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
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 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 (pertinent 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 a 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 other friends who ate at the restaurant have the same symptoms.
ROS: No fever, chills, chest pain, shortness of breath, burning with urination, recent 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.
Vital signs: Temperature, 36.7 C (98 F); blood pressure, 110/65 mm Hg; 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: Nontender, nondistended, normoactive bowel sounds throughout; tympanic on percussion; no hepatosplenomegaly
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 complaint(s). List your diagnoses from most to least likely. For some cases, fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from 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: Viral gastroenteritis

Instructions: <strong>If the doctor asks you about anything other than these, just say no, or provide an answer that a normal patient might give.</strong> You are a 35-year-old man who has diarrhea. <strong>History of present illness</strong> Onset 1 day ago, 6-8 hours after meal Ate salad and shrimp at a local seafood restaurant Loose, watery stools 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 <strong>Review of systems</strong> 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 <strong>Past medical/family/social history</strong> No significant past medical problems or surgeries No other medications (other than amoxicillin) No medication allergies Both parents and siblings (2 brothers) are healthy Single, live alone Occupation: Software engineer Smoking: No Alcohol: No Recreational drugs: No <strong>Physical examination</strong> 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: Nontender, nondistended Normoactive bowel sounds throughout Tympanic to percussion No hepatosplenomegaly Checklist: Following the encounter, check which of the following items were performed by the examinee. <strong>History of present illness/review of systems</strong> Asked to clarify characteristics of diarrhea: Increased frequency? Increased volume? Altered consistency? Asked about the onset and duration of diarrhea 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 other family members or other contacts are sick Asked about exposure to suspicious foods (eg, unpasteurized/undercooked food, unusual foods, dairy products, seafood) <strong>Past medical/family/social history</strong> Asked about prior episodes of diarrhea and gastrointestinal illness Asked about other medical issues Asked about medications (especially antibiotics) and medication allergies Asked about recent and previous hospitalizations Asked about any abdominal surgeries Asked about occupation Asked about tobacco, alcohol, and drug use Asked about family history (especially gastrointestinal diseases) <strong>Examination</strong> Examinee washed hands Examined without gown, not through gown Auscultated abdomen Palpated abdomen superficially Palpated abdomen deeply Examination of skin for any rashes Examination of oral cavity Respiratory examination Cardiac auscultation <strong>Counseling</strong> Explained the physical findings and possible diagnosis Explained further workup Discussed need for rectal examination Discussed fluids and other basic interventions <strong>Communication skills and professional conduct</strong> 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 nonleading 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 <strong>Differential diagnosis</strong> Viral gastroenteritis Bacterial gastroenteritis Clostridium difficile diarrhea <strong>Diagnostic study/studies</strong> 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 <strong>Case 7 Patient Note</strong> <strong>The following represents a typical note for this patient encounter. The details may vary depending on the information given by the simulated patient.</strong> <strong>History:</strong> Describe the history you just obtained from this patient. Include only information (pertinent 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 a 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 other friends who ate at the restaurant have the same symptoms. ROS: No fever, chills, chest pain, shortness of breath, burning with urination, recent travel, or back pain PMHx: None PSHx: None Meds: None Allergies: None FHx: Noncontributory SHx: Denies tobacco and alcohol use <strong>Physical examination:</strong> 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 F); blood pressure, 110/65 mm Hg; 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: Nontender, nondistended, normoactive bowel sounds throughout; tympanic on percussion; no hepatosplenomegaly <strong>Data interpretation:</strong> Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patient's complaint(s). List your diagnoses from most to least likely. For some cases, fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from 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.). <strong>Diagnosis #1: Viral gastroenteritis</strong> <strong>Diagnosis #2: Bacterial gastroenteritis</strong> <strong>Diagnosis #3: Clostridium difficile colitis</strong>

Diagnosis #2: Bacterial gastroenteritis

Diagnosis #3: Clostridium difficile colitis

Doorway Information About Patient