Deborah Arnaudin / Virginia Lee
54 y/o 5′ 6″ (168 cm) 165.0 lb (75.0 kg)
Reason for encounter: Abdominal pain
Virginia Lee
54 y/o 5′ 6″ (168 cm) 165.0 lb (75.0 kg)
Abdominal pain
History Questions
- How can I help you today?
- Do you have any other symptoms or concerns we should discuss?
- Do you have any pain in your abdomen?
- When did your abdominal pain start?
- What are the events surrounding the start of your abdominal pain?
- How long does the pain in your abdomen last?
- Does the pain in your abdomen come and go?
- What does the pain/discomfort in your abdomen feel like? (cramping, burning, stabbing, aching, tingling, squeezing)
- Where more precisely…..
Reason for encounter: abdominal pain
Physical Exams Required
- Weight
- Height
- cognitive status
- SpO2
- temperature
- blood pressure
- pulse
- respiration
- temperature
- auscultate heart
- auscultate lungs
- perform …….
Case Problem Statement
A 54 year old female with a past history of multiple abdominal surgeries including cholecystectomy, presents to the emergency department with acute, progressive, non-radiating, mid-abdominal pain and early satiety for 2 days and with non-bloody, bilious emesis, and bloating for 1 day. She reports a history of hyperlipidemia and heavy alcohol use and denies fever, flatus, and bowel movements. The physical examination shows tachycardia without fever or hypotension, absent bowel sounds, tympanic abdominal distention, periumbilical discomfort with diffuse tenderness to palpation, and unremarkable cardiorespiratory findings.
