Felisha is a 34-year-old female with PMH of asthma, Hypertension, and dysmenorrhea, who presents to the clinic for evaluation of “abdominal pain.” She states it started 3 days ago. She denies any injury to her abdomen. She says it started by her belly button, then slowly moved to the RLQ and flank. Her partner Sally, said that on the way to the office, every pothole they drove over, she complained of pain. She took OTC Ibuprofen 600mg two days ago, but it just dulled the pain. She rates the pain currently 8/10 on the pain scale. She reports a low-grade fever of 37.8 Celsius yesterday but none today. She has intermittent nausea and admits to vomiting twice over the past 3 days. She works as a marine biologist, and it has been very hard for her to swim at work, so she had to call in today to get to the clinic. She has had decreased PO intake at home. She admits to smoking 3 cigarettes/day x 10 years. She drinks white wine socially. She has a mother (58yo HTN, CAD), father (62yo AFIB, CAD, CVA), Brother 26 (healthy). She takes amlodipine 5mg daily and uses albuterol inhaler as needed for her asthma control. She has had a PAP smear at age 32, and a LEEP procedure following with her gynecologist. She denies any urinary frequency, or blood in her urine. Her last BM was yesterday.
Vitals 36.8 oral, HR 98, BP 140/45, RR 18, SPO2 99% room air, Weight 157lbs, 5ft 9in
She is alert and oriented x 3. PERRLA, EOMI. Appropriate appearance. Oral mucosa dry, pink. Dentition in good repair. Neck supple, trachea midline, no lymphadenopathy, no JVD. Chest clear to auscultation. No pain to palpation of chest wall. Cardiovascular with normal s1, s2. No murmur or gallops appreciated. Abdomen is soft, BS X 4 quadrants. Pain with palpation of the right lower quadrant. No suprapubic tenderness. On GU exam, normal vaginal mucosa, cervical OS closed. LMP 2 weeks ago. Skin no rashes, no joint tenderness. No pedal edema is noted. ROM is intact in all joints bilaterally. Able to heel and toe walk. DTR’s 2+ BUE, BLE. Normal rectal tone, no hemorrhoids, Fecal occult blood negative.
CBC: WBC 21.6, HGB 13.5, HCT 29.0, PLTS 250
Chemistry: Na 135, K 3.5, Mag 2.0, BUN 27, Crea 0.9, glucose 114
Urine HCG: negative
Instructions: Reformat the above data as follows from Bates:
You must include a full ROS and Physical Exam for full Credit
1). CC:
HPI
PMH (include surgeries and traumatic injuries)
Current medications
Allergies
Psychosocial
Family History – genogram (you can draw it and place on last page, or create in word document)
ROS – complete information
Physical Exam – complete information
2). List 3 Differential Diagnoses in descending order of suspicion
(Number these as #1, #2, #3, your #1 should be your primary working DX)
3). List the pertinent positives/negatives to support your differentials. (at least 3 of each)
4). List additional history data that would support your primary differential diagnosis and why? (At least 10 history questions listed)
5). List any additional physical components that would support your primary differential diagnosis and why? (At least 5 PE findings that would better help you diagnose your primary differential)
6). Select your primary differential diagnosis as #1 and include 2 other differentials:
a) Give a brief pathophysiologic description of each disorder (< 10 sentences) b) Etiology (primary dx) c) Usual clinical findings or features (primary dx) d) Diagnostic criteria (if any) for making the diagnosis (primary dx) e) Treatment Plan – include specific treatments like pharmacotherapy (be specific with doses, amounts, etc) (for your PRIMARY DX) The Basic 7 Questions 1. Where is it located? Where does it hurt the worst?2. 2. Quality: What do you bring up when you cough? How would you describe the pain? What does it feel like? 3. Severity: How bad is it? 4.Context: How did it happen? When do you notice it?5. 5. Timing: When did it start? or how long have you had it? How frequently does it happen?6. Modifying factors: 6. What makes it better? or What have you done about it? What makes it worse?7. 7. Associated symptoms: What other symptoms are you having