Findings:

Jill Smith is a 32 year-old female with a history of partial thyroidectomy of the right lobe, and x2
vaginal deliveries, presenting with 24 hours of constant acute abdominal pain in the umbilicus
and right lower quadrant. Jill rates her pain an 8/10, and states that the pain feels “cramping
and sharp”. The patient reports taking 400mg of Motrin without relief. Patient reports
associated symptoms of nausea, vomiting, low grade fever, and anorexia.

ROS:
General: +alert/oriented, +fever,
Pulm: -SOB
GI: +Umbilicus/RLQ pain, +N/V, +anorexia

Vital Signs:
Temperature-100.7
Pulse-96
Respirations-16
Blood Pressure-122/80

Questions:
· “Please tell me your height and weight, have you experienced any unintentional weight
loss?”
· “Do you have any known allergies?”
· “Were you doing anything before the initial first sign of abdominal pain (i.e. exercising or
heavy lifting, eating) or did the pain come on suddenly?
· “Are you experiencing any weakness or fatigue?”
· “Have you noticed any changes in your bowel or bladder habits?”
· “When was your last menstrual period?”
· “What is your sexual history?”
· “Do you take birth control or use methods of birth control (i.e. condoms)?”
· “Do you have a history of miscarriages?”
· “Have you ever had a sexually transmitted disease?
· “Do you have a family history of ovarian cancer?”
· “Are you experiencing any dysuria, hematuria, history of kidney stones?”
· “Are you experiencing any pain with movement?”

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 Medical, Family, Social Hx:
Has a medical history of: Vaginal delivery x2, partial thyroidectomy 5 years ago (benign). She
denies history of diverticulitis, GERD, and Ulcerative Colitis. Family history is significant for
ovarian cancer (mom), and myocardial infarction and diverticulitis (dad). Socially, she is married
with 2 young children. She denies any alcohol or tobacco use.

Questions:
· “When was your mother diagnosed with ovarian cancer?”
· “Are you experiencing any bloating, gas, dyspepsia, or pressure type pain?”
· “When was your father diagnosed with diverticulitis?”
· “Do you have a history of constipation?”

Physical Exam:
General: Appears mildly distressed, noted discomfort and facial grimacing when walking
Abdominal: Hypoactive bowel sounds, +rigidity/guarding, +Rosvings, +Obturator,
+Psoas/tenderness with palpation
Cardiac: Normal rate/rhythm, no murmurs or S3/S4 heart sounds
Lungs: Clear to auscultation in all fields

Diagnosis:
Acute Appendicitis

Treatment Plan:
-Could obtain CBC, would suspect WBC to be elevated
-Referral to Emergency Department as medical emergency/treatment

This study source was downloaded by 100000865811497 from CourseHero.com on 05-02-2023 19:14:10 GMT -05:00

https://www.coursehero.com/file/106210275/week-3-OSCE-docx/
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