CLINICAL SKILLS EVALUATION

PATIENT NOTE

HISTORY: Describe the history you just obtained from this patient. Include only information
(pertinent positives and negatives) relevant to this patient's problem(s).
Jessica Anderson is a 21 yo F who came in for the evaluation of RLQ abdominal pain that started this
morning. Abd pain was rated at 7/10, with slight relief with IBU prn, strong, cramping, steady pain,
sudden in onset, constant, with no similar episodes in the past, worsened by movement and relieved
by nothing aside from meds. She was complaining of LBM of 2 BM per day from the regular 1 BM
per day and N/V noted 2 hrs ago. She denies ever, gas in the abdomen, blood in the stool, and
jaundice.
ROS: none except above
PMH: no DM, HTN, UTI
Meds: IBU prn
ALL: NKA
FH: none
PSHx: one
OB Gyne Hx: G3P3 (3003) NSVD uncomplicated; STD x 6 months ago and was treated, Currently
sexually active with new partner but with no STD screening done; OCPS, no condom used; brownish
spotting noted, discharges
Menstrual History: 13 yo menarche, regular every 4 wks, consuming 3 pds, lasting for 7 days
SH: waitress, 1ppd
SH: waitress, no weight loss

PHYSICAL EXAMINATION: Describe any positive and negative findings relevant to this patient's
problem(s). Be careful to include only those parts of examination you performed in this encounter.
VS: BP 120/80l T 100.5F; R 20; HR 85
GS: sitting comfortably, nad
HEENT: no conjunctival lesions; clear oropharynx without tonsillar exudates and congestion; neck
supple without LAD
Abdomen: ND, positive RLQ tenderness, psoas, no rebound, nabs, tympanitic, positive rovsings, no
organomegaly

DATA INTERPRETATION: Based on what you have learned from the history and the physical
examination , list up to 3 diagnoses that might explain this patient's complaint(s). List your diagnoses
from most to least likely. For some cases, fewer than 3 diagnoses will be appropriate. Then, enter the
positive or negative findings from the history and the physical examination (if present) that support
each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis
(e.g. restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc.)

Diagnosis #1: Appendicitis

History Finding(s) Physical Exam Finding(s)

acute RLQ pain positive RLQ tenderness, psoas
N/V positive rovsings
fever

Diagnosis #2: PID

History Finding(s) Physical Exam Finding(s)

multiple sexual partners brownish spotting
history of STD positive RLQ tenderness, psoas

Diagnosis #3: ruptured ectopic pregnancy

History Finding(s) Physical Exam Finding(s)

LMP x 5 wks positive RLQ tenderness, psoas
sexually active, no condom, only ocps
brownishp spotting

Diagnostic Study/Studies
CBC with differentials
Rectopelvic exam
Urine BHCG
Urinalys with Urine culture
U/S of the Abd and pelvis
CT scan of the abd and pelvis