Discussion 1
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CHIEF COMPLAINT: Lower abdominal pain
HPI: Before going any further, I would investigate the presence of red-flag symptoms in this patient. I would also ask the 18 year
old male patient about associated symptoms (also see the review of symptoms). I want to point out, too, that we are told this is a
male patient. It is possible this is a transgender person and we should not assume, until we meet the patient and review the
chart, that we are in fact dealing with a male. The exam and differential would change some, for example, if this were a
transgendered male.
by Teresa Seright – Saturday, January 16, 2021, 3:21 PM
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Red flag issues would include: appendicitis that has burst, perforated peptic ulcer, intestinal obstruction, peritonitis, perforated
diverticulitis—all of which would likely present with a rigid abdomen and excruciating pain (Dains, Baumann, & Scheibel, 2016, p.
11). A dissection of aortic aneurysm would also be a redflag issue and would present with unstable vital signs and (Dains, et al.,
2016, p. 11).
The Alvarado model, which has a sensitivity of 81% and a specificity of 74%. (Dains, et al., 2016, p. 23) could be used to help
review systems and to determine if this is an appendicitis. A score of > 7 indicates a need for surgery (p. 23).
Assuming the patient is stable, I would use “OLDCARTS” to ascertain the onset, characteristics, and treatments for the chief
Onset: is this acute or chronic pain? If this is something that has gone on for months, I would lean toward a differential of colon
issues or diverticulitis. If the pain has a sudden onset (a few days) I would consider appendicitis, renal issues, or perforation. Can
the patient relate this pain to any particular activity: trauma (MVC, Fall, Blunt Trauma), something he ate, a recent illness?
Location: ”lower” covers a pretty big area—and, while the patient later states his pain is “right lower”, I would ask some more
questions about that. For example, when the pain started, where was it? Often appendicitis starts off as periumbilical. A testicular
torsion pain could radiate upward. And, it could be when the patient reported for care, that he was not clear in his description—
so specifically asking about testicular pain/changes in testicular appearance is important.
Duration: related to chronicity, but I also want to know if the pain is constant or remitting at times. For example, obstruction is a
constant, deep pain (Dains et al., 2016).
Characteristic: how would he describe the pain: burning, gnawing, colicky, sharp?
Aggravating/Alleviating: is there relief of the pain with positioning, or a certain time of day?
Radiation: does the pain stay localized or is there radiation to another area? Upper quadrant sources of pain could radiate to the
lower quadrants, for example.
Treatments: what has the patient tried—and at the same time, when was the last time the patient had oral intake (in case he
needs to go to surgery)?
Constitutional: Has the patient experienced fever, chills, anorexia, nausea, vomiting?
Generally, has the patient been ill and if so, has he been on antibiotics (C-Diff)
HEENOT: headaches? Sore throat? Neck swelling?
NEURO: passing out recently? Lightheadedness?
CARDIO: palpitations or chest pain?
RESP: recent respiratory illness (translocation??)
GI/GU: see ROS general and constitutional as well as HPI. Also: Any complaints of and duration of nausea, vomiting, diarrhea,
constipation, hematochezia, melena, and changes in stool ? Any dysuria, frequency, or hematuria? Last BM and last void?
MSKLTL: muscle aches, fatigue?
HEME/IMMUNITY: bleeding/clotting issues? Bruising easily?
Has the patient ever experienced pain like this before? This might give a hint to the nature, though no assumptions should be
made. Nephrolithiasis is a differential, and it would be interesting to know if the patient has a history.
There are a few high-risk familial things that I would ask specifically about. For example, I would ask about a history of
bleeding/clotting problems in any family member. I would ask about chronic diseases, like diabetes, which could put the patient
at risk for necrotic bowel. Patients with a family history/personal history of Vascular Ehlers-Danlos syndrome (vEDS) can present
with a life threatening vascular rupture, often of the sigmoid colon (Chaganti & Chao, 2019). If that rupture were in the ascending
sigmoid, it could translate to right sided abdominal pain.
Any family history of cancer or irritable bowel disease?
Any surgeries (thinking about adhesions and looking for other abdominal issues)?
Asking questions about ability to access and afford care may broaden the conversation about what the patient has tried up to
this point and if he has sought care elsewhere.
Alcohol and tobacco use should be asked.
Medications- medication reconciliation should be performed at the start of the visit. Specifically, I want to know if he’s been on
corticosteroids (which can mask pain) and if he’s been on antibiotics (C-Diff).
I also want to know if he is on anti-diabetic medications and if he is on anything that looks to be for Crohn’s disease, like a
monoclonal antibody (Vedolizumab) or a TNF blocker (Adilimumab).
Is he on any medications that might cause constipation?
Lastly, in the event this patient needs to go to surgery, I want to know if he is on any anti-coagulants or anti-platelet drugs,
including OTCs like aspirin and ibuprofen.
Allergies-gathered at admission
Focused Physical Exam:
VITALS: a full set of VS should be obtained—and actually, this would be my first assessment point. If the patient has red-flag
signs/symptoms, including unstable vitals (tachycardic, tachypneic, hypotensive) he should be transferred by ambulance to
definitive care.
Constitutional: in general—how does he appear? Is he writhing around, or very guarded and still?
HENT: what does his throat look like? Group A Strep should be considered in the pediatric population (and 18 falls into
pediatric) as there can be translocation of bacteria which can cause appendicitis (Dains et al., 2019, p. 16).
Neck: Normal range of motion, No tenderness, Supple, No stridor. No thyroid masses or enlargement.
Cardiovascular: I would listen for tachycardia and murmurs, specifically.
Thorax & Lungs: Note adventitious sounds
Abdomen: The order of the abdominal exam is important: auscultate, percuss, palpate (Bickley, 2020). I would assess the patient,
looking for confirmation of my hypotheses of differential diagnoses. Are bowel sounds normal? Is the abdomen soft or rigid? Is
there tenderness, masses, or pulsatile masses? Is there abdominal distention, which could point to: fluid (peritonitis), feces
(constipation), flatus (gas), full bladder, and a fatal tumor (Dains, et al., 2016,p. 19). Rigidity and guarding are signs of peritonitis
and appendicitis, so observing for those reactions during the exam, as well as how the patient holds himself will provide some
We know there is a positive psoas sign (pain during right hip flexion-reisted or pain during passive right hip extension) (Bickley,
2020). After auscultation and percussion, I would ensure the patient is still lying flat and supine with his knees bent. Confirming
assessments for a differential diagnosis of appendicitis would include: Rovsing sign (right-sided pain during left-sided pressure);
and obturator sign (pain with right hip flexion and internal rotation) (Bickley, 2020). We could also ask this patient to cough,
which typically elicits sharp pain.
A positive Murhphy’s sign, elicited by palpating the liver edge and asking patient to take a deep breath—and note if pain stops
on inspiration, might point to a differential of cholycystitis (Bickley, 2020).
Skin: Look for coloration on the abdomen (bluish—vascular; reddened) general skin temperature and moisture
Back: CVA and or flank tenderness?
Genitalia/Groin: palpate for signs of testicular torsion, such as absent cremasteric reflex and sever testicular pain (Dains, et al.,
2016, p. 20).
Rectal Exam: and assess for tenderness (could point to an appy that has created a fistula) and assess for stool/impaction; frank
bleeding and test for occult blood (Dains et al., 2016, p 20).
Extremities: Intact distal pulses? Edema? (esp unilateral) tendermess?
Neurologic: any general focal deficits?
Diagnostics will be driven by exam and may include:
· Radiology: A Computed tomography (CT) is the imaging diagnostic of choice for R/L lower quadrant pain, according to
guidelines provided by the American College of Radiology (ACR) (2018).
· Lab:
o CBC with differential; BUN, CRT, UA
It is important to keep in mind that a normal WBC count does not rule out an appendicitis (Penner & Fishman, 2020).
o Electrolytes and calcium (pancreatitis); alkaline phosphatase (cancers, liver issues), and bilirubin (liver issues)
o Lipase and/or amylase (pancreatitis)
o Serum iron, total iron binding capacity, and ferritin (iron issues associated with IBD)
o TSH if constipation is suspected as the cause of pain
o Rapid Strep if fever and throat exudates
Differential DX
· Clostridioides difficile (C-Diff) (if fever, peritoneal signs –indicating perforation—and depending on where that perforation
occurred, could be lowere right quadrant)
· Nephrolithiasis (possible if the patient has passed stone and it is sitting down lower-referred from the right ureter; the
characteristic of this pain might be peristaltic in nature; a CT should help identify that; typically patients are afebrile)
· Pyelonephritis (suspect if there are systemic symptoms, like fever, rigors, CVA tenderness—typically the pain would be in the
flank area, but the patient could be in distress and the pain could feel more diffuse)
· Colitis (usually presents with diarrhea and temperature)
· Constipation
· Diverticulitis (pain is usually constant and has gone on for a few days; sometimes with n/v)
· Testicular Torsion (hx and exam will tell us more)
Acute Appendicitis: this patient has classic symptoms of psoas sign are present-CT would confirm—this is the likely diagnosis
with what little information we have been given.
Assuming this is an appendicitis—and was not ruptured (ie he would be in an ambulance by now) I would arrange for transfer to
definitive care for surgery. The patient should receive education on why the appendectomy needs to be performed and the risks
of foregoing surgery.
The patient can expect to go to surgery fairly soon. I would arrange for all assessment items to go with the patient, including labs
and radiology. I would ensure there is an accepting physician (EMTALA).
American College of Radiology. (2018). ACR appropriateness criteria for evaluation of right lower quadrant pain. Retrieved
January 16, 2021 at
Bickley, L. S. (2020). Bate’s guide to physical examination and history taking (13th ed.). Philadelphia, PA: Wolters Kluwer Health |
Lippincott Williams & Wilkins.
Chaganti, P., & Chao, J. H. (2019). Bent Out of Shape: A Case of Abdominal Pain. Pediatric Emergency Care, 35(12), e245–e247.
Dains, J., Baumann, L., Scheibel, P. (2015). Advanced health assessment & clinical diagnosis in primary care (5th Ed). St. Louis, MO:

Discussion 1
An 18 year old male presents to the office complaining of lower abdominal pain. He has no PMH, no allergies and No Primary Care
Provider. Physical exam reveals pain in the right lower quadrant, + Psoas, + Obturator, . Develop a SOAP note remember to include the
differential Diagnoses and Diagnostics. Then critique the Soap note of the two people who posted before you. You must use clinical
practice guidelines in your post. Your critique should identify at least one positive and one area for future growth.
Please see the Nursing Syllabus Standards & University Policies document in the Course Documents section of the course for the Discussion
Guidelines & Rubric.


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