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Medical simulation scenario

Clinical case: "Diagnosis of acute appendicitis" Situational task: You

are a doctor in the surgical emergency department. 17-year-old patient N. was brought to you by ambulance.
delivered. ÿ Collect anamnesis and examine the patient ÿ Interpret laboratory data ÿ Formulate the diagnosis ÿ
Determine treatment tactics.

Outcomes: ÿ Conducting a
survey and physical examination of a patient with acute appendicitis.

Assessment sheet (check-list)

"Diagnosis of acute appendicitis" Date of
Examiner Code Examiner _________________________ examination __________________________
__________________________________________________________________________

Scoring
did
didn't
do
He
it
comments
With

Steps evaluation criteria right

did
He
it

1 Clarification of complaints, medical history, life in detail. Correctly designed 1.0 0.5 0
questions Physical examination: general examination. Assessment of the
general condition of the patient. Examination of the cardiovascular system: 1.0 0.5
2 0
auscultation of the heart, measurement of blood pressure, heart rate, pulse
3 measurement in both arms. Examination of the pulmonary system: 1.0 0.5 0
auscultation of the lungs, measurement of respiratory rate. Made and justified
the preliminary diagnosis 10 Prescribed the research plan 11 Interpreted 1.0 0.5
4 0
laboratory data 12 Conducted differential diagnosis Justified and correct
further surgical tactics 1.0 0.5 0

1.0 0.5 0

1.0 0.5 0

1.0 0.5 0

1.0 0.5 0

1.0 0.5 0

1.0 0.5 0

1.0 0.5 0

1.0 0.5
13 0
determined
14 Specify the type of operation, select the type of creation 1.0 0.5 0

15 He established a trusting relationship with the patient, reassured 1.0 0.5 0

the patient, and obtained written consent to the operation
1.0 0.5 0
16 State the complications of surgical intervention
1.0 0.5 0
17 List of medical equipment and consumables

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18 Wear personal protective equipment 1.0 0.5 0

19 Sterile glove wearing technique 1.0 0.5 0

20 Control of treatment effectiveness 1.0 0.5 0

TOTAL SCORE -
Full name and signature of the examiner Maximum
score - 20

Script text for a standardized actor (patient) and his role

Description:

Man, 17 years old, height 162 cm, weight 46 kg. Complaints: abdominal pain, pain in the right iliac
region, constant nausea, fever. The pain doesn't go anywhere. There was vomiting once. It is on the
right side.

The essence of the question Formulation of the question Answer

for the actor What
bothers you? Abdominal pain, mainly on the right
Determination body side, increased
of the temperature, vomiting Pain gradually
patient's complaints ofIspain
the pain sharp or gradual? Is the began in the area. Yes, constant No,
stomach
character i pain constant or not? Does the pain at first it was in the stomach area,
specifying the intensity stay in the stomach area or is it and now I have pain on the right side
displaced? What caused the pain? I don't know, the last meal was in the
evening, 10 hours ago
Relationship
of pain with non-
compliance with
diet and other
factors
determine
the frequency of the nature When was the vomiting, what was the There was 1 vomiting, with regurgitated food
i of vomiting vomiting and how many times?
determine
the anamnesis How long have you had stomach about 8 hours
of the disease aches? Tell me how you got sick?
determine: At night I woke up with pain in the
stomach area, in the morning the
pain gradually decreased to the right
side, it has been there all this time, it
does not get better and even gets
worse No No, it didn't happen. This
Have you taken any medication is the first time
yourself? Have you ever had this
before? Have you ever had Botkin's
Determination of life disease? Are you registered in the No
anamnesis clinic with a chronic disease? What No, I am not registered
bad habits do you have? Do you
have any drug or food allergies? No, I don't have
No

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In the anamnesis: acute illness, pain in the epigastric region was noticed 8 hours ago, it began gradually, then the pain moved
to the right iliac region. There was vomiting once. Nothing hurts. There was no Botkin disease. He is not allergic to drugs.
Objective: Normal colored skin. He has a clear mind and answers questions adequately. The patient tries to turn to the right.
Blood pressure is 120/80, pulse is 78, respiratory rate is 16. Abdominal pain is severe in the right iliac region, tension of the
anterior abdominal wall is detected during palpation in that region, when the left iliac region is tapped with the palm of the hand,
the pain shifts to the right iliac region, the patient is on the left side of the body. pain increases when turning in half and palpating
the right iliac region while lying on the left side. Pain in the right hip region increases when pulling the shirt and making the
movement from top to bottom.

Per rectum: There is no protrusion of the back wall of the rectum, without pain on examination. Feces in normal colored gloves.

The results of the study:

1. HCV: hemoglobin - 124 g/l, erythrocytes - 4.8*1012/l, Ht - 42%, leukocytes - 10.5x109/l, ESR - 16 mm/h. 2. UTI: light yellow,
transparent, specific gravity - 1022, protein - negative, urine diastase - 32 units. 3. Temperature - 37.6oC

Abdominal CT with intravenous (A) and oral contrast administration

Sample response to the clinical situation

"Diagnosis of acute appendicitis" Evaluation
No of steps Response sample criteria Clarify complaints, medical life
history,
in detail.

Identification of complaints, nature of pain, transfer of pain to the right iliac

region, identification of other symptoms of the disease (nausea, vomiting)

1
Life history? Morbi et vitea history, allergic history and family history
anamnesis

Have all the questions been asked? The questions were clear, correct and well formulated. The

Physical examination: general situation was evaluated as satisfactory. Assessed the color of the
2 examination. Assessment of the skin, determined its moisture or dryness to the touch, the color of the
general condition of the patient skin is normal. Temperature - 37.6ÿC

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Examination of the
cardiovascular system:
auscultation of the heart,
3
measurement of blood pressure,
heart rate, pulse measurement
in both arms Examination of
the pulmonary system:
4 auscultation of the lungs,
measurement of respiratory rate
He performed auscultation, percussion and palpation of the heart, counted
pulse, measured blood pressure. Pulse data - 78 beats per minute, blood
pressure - 120/80
He performed auscultation of the lungs, counted the frequency of breathing.
There is no vesicular breath or wheezing in the lungs. The respiratory rate was
16 times/min. Palpation and percussion of the abdomen was performed. The

abdomen is soft, tense in the right hip area. The following symptoms were
Abdominal palpation and identified: Kocher, Bartomier-Michelson, Voskresensky, Sitkovsky, Shchetkin-
5
percussion Blumberg. Abdominal auscultation was performed. Bowel sounds are heard. There
is no protrusion of the back wall of the rectum, without pain on examination. Normal-
6 Abdominal auscultation colored gloved stool Acute appendicitis

8. Conducted a rectal examination

Prediagnosed and justified

9.
Prescribed study plan Interpreted
laboratory data CT scan of the abdominal cavity
10

CKD - moderate leukocytosis, elevated ESR CKD - no

11.
pathology Intravenous and oral contrast CT images of the
pelvis (A and B) show inflammatory appendicitis and a thickened appendix
CT of the abdomen was with surrounding fluid (arrow) Differentiate with perforated ulcer, pancreatitis,
12
interpreted acute cholecystitis , explained the need for an urgent operation, received a
written consent to the operation. He gave forms to fill out
Carried out differential
13
diagnosis, justified and
correctly determined further
14 surgical tactics, indicated the
type of operation, chose the type
of operation Volkovich-Dyakonov method, local anesthesia with 0.25% novocaine
15
solution, appendectomy Early - suture event, bleeding into the
abdominal cavity, disruption of the process stem, abscess Late -
suppuration (usually earlier) and wound divergence, keloid scars,
16 List the complications of surgery
neuromas, ligature fistulas, postoperative hernia, acute intestinal obstruction.
Training technique, the correct list of tools, the algorithm of using tools

List of medical supplies and

17 consumables Wear personal
protective equipment Wear sterile
gloves Listed and demonstrated the technique of wearing personal protective equipment
18

19 The technique of wearing sterile gloves according to the rules of asepsis and
technique
antisepsis can relieve abdominal pain, endogenous intoxication phenomena,
fever, leukocytosis;
20 Control of treatment effectiveness

Simulation equipment: 1.
Task sheet, scenario for a volunteer (patient), criteria for evaluating steps 2. Analyzes: LV, LV 3. Tonometer, phonendoscope
4. Artificial doll for rectal examination

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5. Gloves, petroleum jelly.

1. Actor - patient
Situation: study room - doctor's office 1. Couch-1

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