Physical Diagnosis, Case Study Example

Case Scenario: Ms. Smith is a 28-year old woman who presents to the Emergency Department complaining of abdominal pain.

Vital signs: BP 118/75 mmHg; HR 90 bpm, regular; RR 16 rpm; Temp 100.2°F

Differential Diagnoses: List at least 4 differential diagnoses that should be included for the above chief complaint.

• Appendicitis, which is due to inflammation of the appendix organ
• Gastroenteritis, which is due to inflammation of the intestinal lining
• Food poisoning, which would be caused by eating poorly cooked or uncooked food, which raises the risk of bacterial intake
• Diverticulitis, which is an inflammation of diverticula, pouches present on the large intestine

History: Use the space below to list the questions you would ask to obtain a full history of present illness (HPI).

In order to obtain a full history regarding the patient’s present illness, the following questions are required to obtain a more accurate depiction of her condition:

• Where is the pain in your abdomen? Is it on the left side? Right side? In the middle? All over the abdominal area?
• What is the level of pain on a scale of 1-10, with 1 being mild and 10 being very severe?
• What type of pain are you experiencing? Dull, sharp, throbbing, aching, burning?
• How long have you felt this pain? Has it been a period of hours? Days?
• Are you experiencing any tingling or numbness in your abdominal area or anywhere else in your body? If so, how often does this occur?
• Does anything cause the pain to flare up and get worse?
• Does anything help the pain get better?
• When did the pain begin? Is it worse at any point during the day?
• Have you experienced any vomiting or diarrhea? Any swelling in the abdominal area?
• Are you more tired than usual?
• Have you had any periods of cold sweats?
• What else might you want to share about your condition?

Physical Exam: Use the space below to document your physical findings. Use creativity to describe findings that you would expect with one of the diagnoses you listed above. Indicate the diagnosis you chose at the end of your physical exam. Include all appropriate exams you have learned to date. (i.e. you would likely examine the cardiac and pulmonary systems in a patient with a complaint of chest pain)

Upon examining the patient, I determined that she had been experiencing abdominal pain for approximately 48 hours, with periods of both mild and severe pain. The pain was generally constant and ranked 6-8 on a scale of 1-10. Her pain was in the right lower quadrant and was accompanied by two different vomiting events over the past 36 hours. There was tenderness in her right lower quadrant and mild swelling. Her temperature was elevated and she was visibly uncomfortable when laying down on the exam table. She also presented with Dunphy’s sign, which is identified by increased pain in the abdominal area upon coughing. The patient was also visibly fatigued and uncomfortable. She had no appetite and had eaten very little all day. She drank several glasses of water throughout the day and her urine output was normal.

Management: List below the lab tests and one imaging study you would order for this patient.  Give a brief indication/justification for each test. (i.e. Chest x-ray – to determine if the patient has an infiltrate. Avoid use of “rule out” – aka “to rule out pneumonia”).

The most likely tests that are necessary to determine a diagnosis for this patient include the following:

• A CBC should be conducted to determine if WBC are elevated
• A urine test is required because the patient is of childbearing age and is currently sexually active; the urine test will eliminate the possibility of ectopic pregnancy
• If WBC and the urine test are inconclusive, an x-ray is required to identify the presence of fecolith in the appendix lumen
• An ultrasound will determine if there is fluid buildup in the right iliac fossa.