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Diarrhea Possible

The document provides instructions and guidance for conducting a patient encounter during a medical school simulation. It includes templates for gathering a history, conducting a physical exam, educating the patient, developing a treatment plan, and establishing follow-up care. Sample questions are provided to guide discussions around prenatal history, delivery, neonatal period, nutrition, development, and social factors. Differential diagnoses, potential investigations, and initial management steps are also outlined.

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79 views5 pages

Diarrhea Possible

The document provides instructions and guidance for conducting a patient encounter during a medical school simulation. It includes templates for gathering a history, conducting a physical exam, educating the patient, developing a treatment plan, and establishing follow-up care. Sample questions are provided to guide discussions around prenatal history, delivery, neonatal period, nutrition, development, and social factors. Differential diagnoses, potential investigations, and initial management steps are also outlined.

Uploaded by

crcesp
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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STATION #

J.D.

PLEASE CONDUCT FOCUSED HISTORY AND COUNSEL AS YOU WOULD IN PRACTICE.

INSTRUCTIONS

1 - YOU HAVE 8 MINUTES TO COMPLETE THE STATION 2 - WARNING WILL NOT BE GIVEN 3 - THERE WILL BE POST ENCOUNTER QUESTIONS

MY ACTUAL 2 MINUTES NOTES:

ACTUAL ENCOUNTER: Patient cues: POST ENCOUNTER QUESTIONS: FEEDBACK COMMENTS:

POSSIBLE APPROACH:
Possible Differentials I should think about while waiting for 2 minutes: Vascular: Infectious: Trauma: Autoimmune: Metabolic: Idiopathic/Iatrogenic: Neoplastic: Substance abuse and psychiatric: Congenital:

INTRODUCTION: Hello. (First Name) (Last Name)? I am First of all, (how may I call you?) (may I call you (First Name)? Thank you, (First Name). I would like to begin by asking you some questions (and later on do a physical exam) so I could determine what needs to be done. STANDARD Qs: (Now, I would like to ask questions that I usually ask all my other patients/parents) (Determine if age/case appropriate) PRENATAL: Did you have prenatal care? Any difficulties during the pregnancy?

Any complications during it? High blood pressure, Anemia, diabetes, infection? Explore: What? How was it treated? Did you use alcohol or recreational drugs during the pregnancy? Did you smoke during the pregnancy? Was it a single pregnancy or multiple? NATAL: When was your delivery? Was it a term pregnancy? What was the method of delivery? (If, induced) Why? How long did it take? Any complications during labor like prolonged labor, ruptured water bag, fever? NEONATAL: How was he/she at birth? (APGAR SCORE) How much was his/her weight? Any abnormalities or complications like being yellow or blue, feverish, or didnt cry immediately? Explore: What/ When/ How long? (Empathy for healthy/ unhealthy pregnancy.) Any problems as a baby? Any hospital admissions? IMMUNIZATION HX: What needles has been done so far? Does he/she have? (age appropriate immunization) NUTRITION/ OUTPUT: Tell me about his/her feeding/eating habits? Is he/she on breast or bottle feeding? How much do you give him/her each time? How many times in a day? Any solids, vitamins, iron, supplements? What? When did you start? Is it balanced diet? Any junk food? Any difficulty sucking/ swallowing? Is he/she a picky eater? Tell me about the feeding setting & facilitation? OUTPUT (BLADDER/ BOWEL MOTIONS): How many times a day dose he/she pass water? How much each time? (Or How many wet diapers day?) Smelly urine? Red urine? How many times a day does he/she have a bowel motion?

How much each time? Is it formed or loose? Smelling stool? Blood? Mucus? What color is it? Green/ yellow/ white cheesy? Explore. Does he/she control his/her bladder & bowel? (for >4 years old) DEVELOPMENT: Any delay in speech, language, or motor development? Physical: What is his/her height and weight now? Milestones Is he/she able to.. ? (Gross motor, Fine motor, Speech, Social)Age appropriate now only, no need for previous. Social/ School performance: How is his temper? Is he irritable, crying frequently? What about sleep? Does he/she attend school? What grade? Any problems at school? Any failures or suspensions? What is his/her daily routine? ENVIRONMENT: Are there similar problems with relatives, at daycare, at school? Who is usually taking care of him/her? How are the family relationships? How has this been affecting the family? Do you feel your mood low? Any lost workdays? How are you managing with the expenses? COUNSEL: (First Name) or Mr./Ms (Last Name), let me give you some information about the .(Subject). Then EDUCATE the patient about: SRS AI OEM 1- Subject: In small chunks asking him in between: Am I making sense? or Is that clear? 2- Risk factors/ Seriousness: of not acting on the subject. (e.g Keep smoking) As you may realize, ..(Subject) causes 3- Side effects and complications of acting on the subject, emotionally and physically, and how to avoid them. There is a chance to have . as a side effect. If that happens, you can ./ call me/ go to emergency. 4- Alternatives: of acting on the subject. To deal with this, there are other options. .. 5- Investigations: Im going to send you for some (blood work and X-Ray/Ultrasound), which will help us to rule out any contraindications. 6- Outcome/ Prognosis: Clearly & truly: If treatable/successful - Assure. If severe/ chronic/ bad - Discuss family and community support. 7- Effect on patient: Now, how do you feel about that? 8- Mode of Usage: Pills, puffs, patches, injections, instruments, ..etc

WRAP UP: 1- Okay (First Name) or Mr/Ms (Last Name) is there anything else youd like to tell me or ask me? 2- Negotiate with him/her an agreed upon PLAN OF ACTION. A CONTRACT. Clarify his/her and your responsibilities: Okay, so Ill send you for the investigations, you will take the medication/change your life style and report progress . 3- Follow up: I want to see you next week / in a month. 4- Last word in the interview is for the patient: Is there anything else youd like to tell me or ask me? 5- It was nice to meet you, have a nice day. DIFFERENTIAL DIAGNOSIS: Infectious diarrhea 2 to Viral infection Infectious diarrhea 2 to Bacterial infection Infectious diarrhea 2 to Parasitic infection (CF, Lactose intolerance) INVESTIGATIONS: CBC D Stool exam Urinalysis MANAGEMENT: Hydration Treat underlying cause

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