¡Descarga DESCRIPCION DEL CASO y más Ejercicios en PDF de Idioma Inglés solo en Docsity! UNIVERSIDAD DEL VALLE DE MÉXICO CAMPUS COYOACAN ESCUELA DE CIENCIAS DE LA SALUD LICENCIATURA EN MEDICINA ASIGNATURA: Ingles de la practica Actividad: DVD U3. Taking a mmedical history & Virtual Interactive Case Docente: Denisse Ubaldo Suarez Alumno: Luna Rodriguez Maria Nasheli
CASO CLÍNICO 1
AN
A E
IS / Review of System DS
EM_Abdominal_Pain_Case1
Welcome to the Virtual Interactive Case (VIC) Player. Please
begin by reading the presenting complaint to your right. When
you are finished, you may begin your examination by clicking
on the options in the patient examination menu above.
Take a focused history and review of systems, and conduct a
physical exam in the most efficient and cost-effective way to
reach a diagnosis. Each action you take will add to the time and
cost of arriving at the diagnosis. The essential actions to
discover the pertinent findings will contribute to a score which
reflects your success in assessing all the pertinent findings.
Points will be deducted for essential actions that you miss.
When you feel confident that you have reached a diagnosis,
finish the case by clicking on Diagnosis 8: Management above.
DASS STA ER ST
A 44-year-old male presents to the Emergency Department with a chief
complaint of abdominal pain.
DES ysical Examination OS O]
Gastrointestinal
Do you ever have any pale, fattystools?
Have you taken any antibiotics recently?
Are your stools foul-smelling?
Have you ever vomited blood? »
Have you ever had a colonoscopy?
Have you ever had a upper or lower Gl endoscopy?
E SS
Have you noticed any yellowing of the eyes or skin?
TS
Time: 00:06:00 Cost: $18
Review triage vital signs (pulse, respiratory rate, BP, temp,
pulse ox)
Glasgow Coma Scale
Repeat temperature by mouth.
Repeat temperature rectally.
Patient is uncomfortable and holding their stomach
Repeat blood pressure and pulse.
Repeat Pulse Ox
Time: — 00:06:40 Cost: $20
EM_Abdominal Pain Casel Licensed for use by the Michigan State University College of Human Medicine,
Michigan, USA.
Palieni Hist Physical Fxaminal
¡General Inspoction and Vital Signs
¡General Aopearence
Glasgow Come Scale
Repeat temperature by mouth,
Repeat temperature rectally
Repara! blend pressure am quese.
Repeat Pulsa Ox
Time: 000700 Cost $71 Jultation
Abdominal examination
Inspection from the side, eyes at becside level:
Palpation: Superficial
AS lender tc paipation across the upper abdomen wth guarding. No
rigidity - No hepatosplenomegaly. - No masses. - No renal angle
tendemess kidneys not ballottable. - No rebound teaderness. - No
Special maneuvers » abnormal masses present
-No renal angle tenderness, kidneys not ballottable.
-No rehound tenderness.
- No abnormal masses present
Time: 00:07:40 Cost $23
EM_Abdeminul Pain_Cusel Licensed for use by Ue Michigun Stute University College uf Hurur Medicine,
Michigan, USA.
Vir Ieu Cas Poe coi 2011-2013 Unverty Hao Neon Al rs Devepes y Perperais nera Etucton PI - ep /pe muro.
TAL Verón 2.5 Version 102
al Examination
Renal Function
Calcium
Liver enzymes
Bilirubin Na: — 140 mmol/L (135to 145)
K 41mmo/L G2t050)
Ch 106 mmol/L (100 to 110)
Albumin HCO3: 26mmol/L (21to 29)
Lipase
Time: 00:11:00 Cost: $40
Diagnosis: Score: 100%.
Correct Diagnosis Selected: Acute Pancreatitis due to choledocholithiasis
Feedback: The history, exam findings, lab work (elevated lipase and LFTs), and US imaging (dilated common duct) all confirm
this diagnosis. Choledocholithiasis (also called bile duct stones or gallstones in the bile duct) is a common cause of acute
pancreatitis.
History of Presenting lllness
Has the pain changed since it began?
Is it continuous or does it come and go?
What were you doing when the pain started?
Did the paín come on suddenly or gradually?
Have you ever seen a health care provider for this
before?
'What medications, including non-prescription.
medication, have you used for this problem?
there anythinc ing you?
Heel hot and cold. | have also been feeling fatigued and weak in the
past few days.
e
LAGO SEUS Ad]
Past Medical History
What medical conditions have you been diagnosed with?
Have you had any surgeries or other procedures?
What prescription medications do you take?
Do you take any over-the-counter medications?
Are you allergic to any medications?
Do you thave any problems taking all of your medications as
prescribed?
have Type 2 diabetes.
TS ; IEA ET
General
How are your energy levels?
Do you have any difficulty sleeping?
you experienced any fevers or chills?
Have you experienced any drenching night sweats?
Yes
Patient History Review of Systems A] ISS A ere] E]
Respiratory
Have you had a cough? »
What color is the sputum?
Have you coughed up any blood?
Have you had any shortness of breath? »
Does ithurtio ikea breath? Yes. | cough up green stuff with some blood streaks.
Patient History
General Inspection and Vital Signs
General Appearance
Review triage vital signs (pulse, respiratory rate, BP, temp,
pulse ox)
Glasgow Coma Scale
Repeat temperature by mouth.
Repeat temperature rectally.
Repeat blood pressure.
Patient History SITAS
Respiratory
Inspection
Palpation
Percussion
Ausculation
Speech Pattern
air.
Physical Examina: Ad
Decreased breath sounds in both lung bases.
Rhonchi heard in right lower lung field.
