Posted: July 8th, 2016

The role of patient history and physical exam in diagnosis.

Patient history and physical exam

A 49-year-old man presents to the office complaining of vague abdominal discomfort over the past few days. He states he does not feel like eating and has not moved his bowels for the last 2 days. His patient medical history includes an appendectomy at age 22 and borderline hypertension, which he is trying to control with diet and exercise. He takes no medications and has no known allergies. Positive physical exam findings include a temperature of 99.9 degrees Fahrenheit, heart rate of 98, respiratory rate of 24, and blood pressure of 150/72. The abdominal exam reveals abdominal distention, diminished bowel sounds, and lower left quadrant tenderness without rebound.

To prepare:

•Review this week’s media presentations and Part 12 of the Buttaro et al. text in the Learning Resources and other resources provided .

•Select one of the three case studies listed above. Reflect on the provided patient information including history and physical exams.

•Think about a differential diagnosis. Consider the role the patient history and physical exam played in diagnosis.

•Reflect on potential treatment options based on your diagnosis.

Post 1 to 2-page discussion on an explanation of the differential diagnosis for the patient in the case study that you selected. Describe the role the patient history and physical exam played in the diagnosis. Then, suggest potential treatment options based on your patient’s diagnosis.

Reference

Readings

• Buttaro, T. M., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2013). Primary care: A collaborative practice (4th ed.). St. Louis, MO: Mosby.

◦Part 12, “Evaluation and Management of Gastrointestinal Disorders” (pp. 612–722)

American Liver Foundation (n.d.). Retrieved November 28, 2012, from http://www.liverfoundation.org/

• Drugs.com. (n.d.). Retrieved November 28, 2012, from www.drugs.com

Media

•Laureate Education, Inc. (Executive Producer). (2013c). Case study: Male abdominal disorder. Baltimore, MD: Author

Laureate Education, Inc. (Executive Producer). (2013d). Case study: Female abdominal disorder. Baltimore, MD: Author.