LCSE Med School Flashcards
Brief Summary
The patient is a 39-year-old male who presents with Left lower quadrant pain that began 4 days ago. The pain has worsened and is now associated with fever.
where is the pain located
LLQ (left lower quadrant)
Duration of the ongoing pain
4 days
Characteristic of the pain
dull, constant and worsening
Any fever monitored by the temperature
Temperature was monitored and it was 101 F
Does the pain interfere with your work?
You are a laborer and the pain has prevented you from working for the past two days
Opening Statement
I have pain on the left side (point toward LLQ)
Characteristic of the pain
dull and present all the time
gradual scale of the pain
3/10 but it is getting worse over the four days and currently a 8/10
Any tachypnea
Yeah the patient is breathing rapidly by taking breath in middle of the sentence
Current scale of the pain
8/10
How long have the fever been going on?
For the past 24 hours
Any attempted medications?
Took Tylenol and Motrin every 4 hours in alternating cycles
Last time of the attempted medications
2 hours ago
Effects from the medications
Decreased the fever but did not affect the pain
Does the pain radiate?
The pain move to the left groin when straightening my left leg
Any recent bowel movement
Usually have one bowel movement per day but haven’t experienced one for the past two days
Have you experienced this type of pain before
Yes I have experienced this pain after I ate some popcorn
Any recent weight gain or loss
No
Any nausea or vomiting
No
Have you been in recent contact with anyone with similar symptoms
No
Have you traveled out of the immediate area for the past six months
No
Past Medical/Surgical History
no chronic conditions and describe myself as healthy
Have no surgical history
Past allergies
Allergic to bee stings (reaction: my throat closed up)
Any medication
Not currently on long-term medications but the patient has taken Tylenol and Ibuprofen over the past few days
Social Hx
single and have never been married
no children
have not had any unprotected sexual encounters in the past two years
Substance Hx
drink one six-pack of beer per week on average since I was 21
Do not smoke
Do not use illicit drugs
Family Medical Hx
Both of your parents are still living but neither have experienced symptoms of the pain you described today. Both are generally in good health. You have no siblings
How old is the patient
39 years old
Date of Birth
1/23/ 1984
Pulmonary Exam Finding
Tachypneic with breath sounds bilaterally and clear without rales or rhonchi
Differential diagnosis for the cause of the pain
Diverticulitis (inflammation of the wall of your large intestine)
Appendicitis (inflammation of the appendix)
Inflammatory bowel disease
pyelonephritis (inflammation of the kidney)
Aggravating factors
Made worse by moving around, walking and straightening your left leg
Alleviating factor
lying still, drawing left leg up to the abdomen
Patient overall appearance
presence of fever, tachycardia, elevated RR, acute distress due to pain
What is the type of diet?
Eat anything on the go fast food and food trucks
Do you exercise?
No I work as a laborer
Are you currently sexually active?
No
