Comprehensive Patient History: Exploring Abdominal Pain Symptoms
School
San Jacinto Community College**We aren't endorsed by this school
Course
MDCA ALL COURSE
Subject
Nursing
Date
Dec 12, 2024
Pages
3
Uploaded by Educator26148
Sample Conversation converted to patient history and physical examUse the elements in a patient’s history and physical exam to convert the conversation to a complete history and physical exam.Conversation between Patient and Provider:Patient:I’ve had this pain for months now (points to right upper quadrant). It’s constantly there. I just hate going to the hospital so I’ve dealt with it the best I could.Provider: Does the pain go anywhere else, or worsen after eating?Patient:The pain is just in that one spot. And it doesn’t get better or worse with anything. It just hurts.Provider: How would you describe the pain?Patient:I guess it’s sharp. Maybe even stabbingProvider: Have you had fever or chills? Nausea, vomiting or diarrhea?Patient:None of that. But I have lost a lot of weight here recently. About 65 pounds in the last year. I guess that could be because I haven’t had an appetite. I also feel like my belly is swollen all the time. I know I’m not the smallest guy, but this is big even for me.Provider: Have you noticed black or tarry stools that stick to the toilet bowl, or bright red blood in your stools?Patient: No Sir.Provider: Have you been constipated?Patient: I’m constipated most of the time. I guess my diet is probably not as good as it could be.Provider: Do you drink alcohol?Patient: Oh I drink about 6 or 8 beers a night and sometimes a fifth of liquor with that. I’ve been doing that for years now. Nothing else to do.Provider: Do you use any drugs?Patient: I’ve smoked cigarette for 40 years now, but I don’t do any of that stuff on the streets.Provider: Do you have a known history of liver failure or disease? Hepatitis? Cancer?Patient: I don’t really see doctors but nobody ever told me that I have any of those things.Provider: Have you ever had any surgeries on your belly?Patient: I had my appendix taken out when I was just a kid.Provider: How have you been treating your symptoms at home?Patient: I have been taking hot baths and those help for a bit. An I’ve been taking aspirin.Provider: Do you have any changes in vision, a sore throat, shortness of breath or a cough, chest pain, urinary urgency or frequency, leg pain, weakness or one arm or leg, or new rashes?Patient: I have shortness of breath because I’m a smoker, but it’s gotten worse here lately.Provider: Does it get worse when you exert yourself? Does it worsen when you lie down?Patient: Mostly when I exert myself, but it’s there all the time.
PHYSICAL EXAMINATION FINDINGS:Well-developed but thin and cachectic appearing male. Scent of alcohol on his breath. Dry mucous membranes. Sclera are icteric. Jugular venous distention is present. Heart rate is irregular and tachycardic. There is a 2/6 systolic murmur heard best over the left sternal borderand a S3 gallop. Breath sounds are diminished throughout and there are diffused wheezes and crackles at the bases. Abdomen is soft and tender in the right upper quadrant with voluntary guarding, but no rebound. Hepatomegaly two finger breaths below the right costal margin. There is an ascitic wave. He has full body jaundice. 2+ pitting edema of the bilateral lower extremities and chronic stasis dermatitis changes. No calf tenderness. Faint distal pulse. No focal deficits. He is alert and cooperative.
ANSWER KEY: What your write up of a case should look likeCC:The patient is a 68 year old male who presents with abdominal pain.HPI:The patient is a 68 year old male with abdominal pain. The patient reports that for the past few months he has had constant non-radiating right upper quadrant abdominal pain. No modifying factors to pain, including worsening after eating, and he describes it as sharp and stabbing in nature. No nausea, vomiting, constipation, or diarrhea. No melena or hematochezia. No fevers or chills. He has hada weight loss of about 65 pounds in the last year, which he attributes to a loss of appetite. He also has the sensation of abdominal bloating and distension. The patient has been taking hot baths at home and has taken aspirin with little relief. Otherwise, he has had a worsening of his chronic and exertionally related shortness of breath recently, but denies orthopnea, visual changes, a sore throat, chest pain, cough, urinary urgency or frequency, leg pain or swelling, unilateral weakness, or rashes.No known history of liver failure or disease, hepatitis, or cancer but the patient does not follow a primary care physician regularly. He has longstanding history of alcohol use, drinking 6-8 beers daily plusan occasional fifth of liquor, and has smoked for 40 years. He denies any recreational drugs. Surgical history includes an appendectomy in childhood.REVIEW OF SYSTEMSConsitutional: Positive weight loss and anorexiaIntegumentary: No rashMusculoskeletal: No leg painHEENT: No sore throat or visual changesNervous: No unilateral weaknessCardiovascular: No chest pai or orthopneaRespiratory: Positive dyspnea. No coughDigestive: No nausea, vomiting, diarrhea or constipation. Positive abdominal pain and abdominal distention and bloating.Genitourinary: No urinary urgency or frequencyAllergic/Immunologic: No fever of chillsHematologic/Lymphatic: No melena or hematocheziaPHYSICAL EXAMConsitutional: Well developed but thin and cachectic appearing male. Scent of alcohol on his breath.Integumentary: Full body jaundice. Chronic stasis dermatitis changesMusculoskeleta: No calf tendernessHEENT: Dry muscous membranes. Sclera are icteric.Nervous: No focal deficits. He is alert and cooperative.Cardiovascular: Irregular and tachycardic. 2/6 systolic murmur heard best over the left sternal border and an S3 gallop. Jugular venous distention also present. 2+ pitting edema bilateral lower extremities and faint distal pulses.Respiratory: Breath sounds are diminished throughout and there are diffuse wheezes and crackles at thebase.Digestive: Soft and tender I the right upper quadrant with voluntary guarding but no rebound. Hepatomegaly 2 finger breaths below the right costal margin. There is an ascitic wave.