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Expert problem list

Progressive, intermittent RUQ abdominal pain x two


weeks; now increasing in severity x three to four days -
Most Significant Active Problem Occasional radiation of
RUQ pain to right shoulder - Related Nausea, vomiting
(nonbilious; nonbloody) and poor appetite x two days -
Related Prior self-resolving episodes over the last one
year - Related Pain initially provoked by fast foods; now
occurring with all food intake - Related Pain
nonresponsive to antacids and NSAIDs - Related
Temperature 100.0 F (oral) - Related Tachycardia -
Related Mild scleral icterus - Related RUQ abdominal
tenderness with voluntary guarding - Related Positive
Murphys sign - Related FH of biliary disease Related.
Expert problem statement

This 48-year old female presents to the urgent-care


clinic with a two-week history of intermittent, colicky
RUQ pain that has now increased over the past three to
four days. She reports associated nausea and emesis
(nonbilious; nonbloody) x two days, with associated
anorexia. Family history is positive for biliary disease
(mother). The patient is found to have low-grade
temperature elevation, mild scleral icterus, RUQ
abdominal tenderness with guarding, and a positive
Murphys sign.
**Add S.O.A.P.Probable Diagnosis, Differental Diagnoses, Plan of Care at the End***
Abdominal Assessment

You should have asked the following in the first five questions
1. Why are you seeking help today?
2. Any other symptoms?
3. Where more precisely is the pain in your abdomen?
4. What does the pain in your abdomen feel like?
5. Does the pain in your abdomen radiate someplace else? Where?

Q UES TI O N S TO ASK
6. When did the pain in your abdomen start?
7. Does anything make the pain in your abdomen better or worse?
8. How severe (1-10 scale) is the pain in your abdomen?
9. Have you had the pain in your abdomen before?
10. How quickly does the pain in your abdomen come on?
11. Any change in your abdominal pain since it began?
12. Is there a pattern to your abdominal pain?
13. Do you or have you had any stomach, intestinal or bowel problems?
14. What are the events surrounding the start of your abdominal pain?
15. What treatments have you had for the pain in your abdomen?
16. Do you have diarrhea?
17. Have you had any yellowing of the skin or eyes (jaundice)?
18. Do you have pain when you urinate?
19. Do you have any pain in your flanks?
20. Is there any blood in your stools or with your bowel movement?
21. Do you have black tar-like or foul smelling stools?
22. Are your stools unusually light in color?
23. Do you have any pelvic pain
24. How is your overall health?
25. Are you taking any prescription medications
26. Are you taking any over-the-counter or herbal medications?
27. Any previous medical, surgical or dental procedures?
28. Tell me about the health of your parents and children.
29. Tell me about your diet, what you normally eat.
30. Do you drink alcohol? If so, what do you drink and how many drinks per day?
31. Do you now or have you ever smoked or chewed tobacco?
32. Is the amount you urinate more or less than usual?
33. When did your last period begin?
34. Have you had vaginal bleeding or discharge?
35. Have you had any more stress in your life lately?
36. What is the color of your urine and has it changed recently
37. Is your pain affected by what, when or how much you eat
38. Do you have shaking chills?
39. Do you have heartburn, a food or acid taste in your mouth
40. Have you lost weight?
Review of Systems
Good, you performed 14 key exams for this case
Skin, Hair, Nails: inspect skin overall
HEENT: inspect eyes
Abdomen: visual inspection abdomen Abdomen: palpate abdomen
Abdomen: auscultate abdomen Abdomen: percuss abdomen
Genitourinary: genitourinary female exam
Vitals: Respiration Vitals: BP Vitals: Pulse Vitals: Skin Vitals: Temperature
Chest Wall & Lungs: auscultate lungs
Heart: auscultate heart

MISSING
1) Vitals: orthostatic blood pressure
Orthostatic hypotension is defined as a decrease in systolic blood pressure of 20 mm Hg or a decrease in
diastolic blood pressure of 10 mm Hg within three minutes of standing when compared with blood pressure
in the sitting or supine position.
2) HEENT: inspect mouth/throat
- Examination of the oral cavity is a simplistic way to evaluate for signs of systemic processes:
- Dehydration: dry oral mucosa
- Hepatic disease: sublingual mucosal jaundice (seen earlier than skin jaundice)
- Nutritional deficiencies: e.g., angular stomatitis
- Immunodeficiencies: oral candida
3) Neck: palpate neck
The presence of regional lymphadenopathy (LAD) can be a critical clue to underlying disease states, both
local and distant. The anatomical relationship to distant sites reflects lymphatic drainage patterns.
Specific sites of LAD have a high correlation with underlying malignancy:
- Right supraclavicular: mediastinal, pulmonary or esophageal malignancies
- Left supraclavicular: testicular, ovarian, renal, pancreatic, prostatic, gastric, or biliary malignancies.
Problem List

Progressive, intermittent RUQ abdominal pain x two weeks; now increasing in severity x Most Significant
three to four days Active Problem

Occasional radiation of RUQ pain to right shoulder Related


Nausea, vomiting (nonbilious; nonbloody) and poor appetite x two days Related
Prior self-resolving episodes over the last one year Related
Pain initially provoked by fast foods; now occurring with all food intake Related
Pain nonresponsive to antacids and NSAIDs Related
Temperature 100.0 F (oral) Related
Tachycardia Related
Mild scleral icterus Related
RUQ abdominal tenderness with voluntary guarding Related
Positive Murphys sign Related
FH of biliary disease Related

Progressive intermittent RUQ abdominal pain x two weeks, now increasing in severity x three to four days,
represents Lt Col James most significant active problem (MSAP). The remainder of the key findings per history
and physical exam (here listed as problems) can be provisionally categorized in the following manner:

Further symptom characterization:


Occasional radiation of RUQ to right shoulder
Pain initially provoked by fast food; now occurring with all food intake
Symptoms nonresponsive to antacids or NSAIDs

Associated clinical findings and potential indicators of severity:


Nausea and vomiting (nonbilious; nonbloody)
Poor appetite
Temperature elevation: 100.0 F (oral)
Tachycardia
Mild scleral icterus
RUQ tenderness to palpation with voluntary guarding
Positive Murphys sign

Risk factors:
Prior self-resolving occurrences x one year
Overweight status
Female; G3P3
FH of biliary disease
-