First Aid for the USMLE Step 2 CS

Section 4. Practice Cases

Case 13. 48-Year-Old Woman with Abdominal Pain

DOORWAY INFORMATION

Opening Scenario

Sharon Smith, a 48-year-old female, comes to the clinic complaining of abdominal pain.

Vital Signs

BP: 135/70 mm Hg Temp: 98.5°F (36.9°C)

RR: 16/minute HR: 76/minute, regular

Examinee Tasks

1. Take a focused history.

2. Perform a focused physical exam (do not perform rectal, genitourinary, or female breast exam).

3. Explain your clinical impression and workup plan to the patient.

4. Write the patient note after leaving the room.

Checklist/SP Sheet

Patient Description

Patient is a 48 yo F, married with 4 children.

Notes for the SP

 Sit up on the bed.

 Show pain on palpation of the right upper abdomen that is exacerbated during inspiration.

 Exhibit epigastric tenderness on palpation.

 If ultrasound is mentioned by the examinee, ask, “What does ‘ultrasound’ mean?”

Challenging Questions to Ask

“My father had pancreatic cancer. Could I have it too?”

Sample Examinee Response

“It’s highly unlikely, as your symptoms are very unusual for pancreatic cancer. Regardless, some routine blood and x-ray tests should help us exclude that as a possibility.”

Examinee Checklist

Building the Doctor-Patient Relationship Entrance

 Examinee knocked on the door before entering.

 Examinee introduced self by name.

 Examinee identified his/her role or position.

 Examinee correctly used patient’s name.

 Examinee made eye contact with the SP.

Reflective Listening

 Examinee asked an open-ended question and actively listened to the response.

 Examinee asked the SP to list his/her concerns and listened to the response without interrupting.

 Examinee summarized the SP’s concerns, often using the SP’s own words.

Information Gathering

 Examinee elicited data efficiently and accurately.

Connecting with the Patient

 Examinee recognized the SP’s emotions and responded with PEARLS.

Physical Examination

 Examinee washed his/her hands.

 Examinee asked permission to start the exam.

 Examinee used respectful draping.

 Examinee did not repeat painful maneuvers.

Closure

 Examinee discussed initial diagnostic impressions.

 Examinee discussed initial management plans:

□ Follow-up tests: Examinee mentioned the need for a rectal exam.

 Examinee asked if the SP had any other questions or concerns.

Sample Closure

Mrs. Smith, there are a number of disorders that can cause pain similar to what you have described. Pain of this type is most commonly due to an ulcer, an abdominal infection, or a gallstone. We will have to run some tests to confirm the diagnosis and to rule out more serious illness. These tests will include a rectal exam, an ultrasound of your abdomen, blood tests, and possibly an upper endoscopy, which examines your stomach by means of a tiny camera passed through your mouth. Once we have made the diagnosis, we will be able to treat your condition and help alleviate your pain. Do you have any questions for me?

History

HPI: 48 yo F c/o intermittent, burning, nonradiating epigastric pain that started for the first time 2 weeks ago. The pain occurs at least once a day, usually 2-3 hours after meals. It is exacerbated by hunger and heavy, fatty foods and is alleviated by milk, antacids, and other food. It reaches 7/10 in severity and then diminishes to 0/10. It is sometimes accompanied by nausea. The patient vomited once yesterday: a sour, yellowish, nonbloody fluid. No diarrhea or constipation. No changes in weight or appetite. No changes in the color of the stool.

ROS: Negative except as above.

Allergies: NKDA.

Medications: Maalox, ibuprofen.

PMH: Arthritis in the knees, treated with ibuprofen. UTI last year, treated with amoxicillin.

PSH: 2 C-sections.

SH: No smoking, no EtOH, no illicit drugs. Sexually active with husband only.

FH: Father died of pancreatic cancer at age 55.

Physical Examination

Patient is in no acute distress.

VS: WNL.

Chest: No tenderness, clear breath sounds bilaterally.

Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops.

Abdomen: Soft, nondistended, C-section scar, epigastric tenderness without rebound, © Murphys sign, © BS, no hepatosplenomegaly

Differential Diagnosis

CASE DISCUSSION

Patient Note Differential Diagnoses

Although the causes of abdominal pain are many, this presentation should prompt you to ponder the common etiologies:

 Cholecystitis: Several features suggest this diagnosis, including pain following fatty meals, nausea and vomiting, and the patient’s age and gender (“female and forty”). However, the pain in acute cholecystitis is usually unremitting and is not alleviated by milk or antacids. The patient’s intermittent pain may be due to “biliary colic,” representing transient obstruction of the cystic duct, usually due to gallstones. The positive Murphy’s sign is sensitive for cholecystitis, and the location of the pain is classically the RUQ.

 Peptic ulcer disease: The history of NSAID use and burning epigastric pain alleviated by antacids and food are consistent with this diagnosis (although the clinical history cannot accurately distinguish duodenal from gastric ulcers). In addition, the abdominal exam reveals epigastric pain, the classic location for pain related to peptic ulcers. Although the positive Murphy’s sign is more suggestive of cholecystitis, the maneuver itself could easily cause discomfort in any patient with upper abdominal pain because of the deep palpation that is required to perform it.

 Gastritis: Gastritis is a common cause of epigastric pain, nausea, and vomiting in patients taking NSAIDs, but the pain associated with gastritis is typically milder than that of peptic ulcer disease. Although epigastric pain more likely signals the presence of an ulcer, true differentiation would best be made on upper endoscopy.

Additional Differential Diagnoses

 Functional or nonulcer dyspepsia: This is the most common cause of chronic dyspepsia. After thorough evaluation, no obvious organic etiology is discovered.

 Perforated ulcer: These patients appear toxic and have severe diffuse abdominal pain with rebound tenderness and involuntary guarding.

 Gastric cancer: Although this patient does not have early satiety, anorexia, weight loss, or a left supraclavicular mass (Virchow’s node), it should be noted that signs and symptoms are minimal until late in the course of this rare disease.

 Other etiologies: Less likely possibilities include pancreatitis, atypical GERD, choledocholithiasis, mesenteric ischemia, and extra-abdominal causes.

Diagnostic Workup

 Rectal exam, stool for occult blood: May document occult blood loss due to peptic ulcer, gastritis, cancer, or other causes.

 U/S—abdomen: A quick, inexpensive imaging technique with which to examine a patient with suspected acute cholecystitis (it may show stones, pericholecystic fluid, a thickened gallbladder wall, and a sonographic Murphy’s sign).

 Upper endoscopy: Peptic ulcer, gastritis, and gastric cancer have lesions that can be visualized (biopsy is required for gastric cancer diagnosis and is sometimes necessary for the diagnosis of H pylori).

 Noninvasive H pylori testing: Serologic tests for antibodies to H pylori are adequate for diagnosis but not to document cure, as antibody levels often remain detectable after treatment (indicating exposure, not necessarily active infection). The urease breath test is a useful means of confirming H pylori eradication in peptic ulcer disease.

 AST/ALT/bilirubin/alkaline phosphatase, lipase: To look for evidence of hepatocellular injury, biliary obstruction, or pancreatitis.

 HIDA (hepatobiliary) scan: Uses scintigraphy with technetium-99m DISIDA (a bilirubin analog) to diagnose acute and chronic cholecystitis. HIDA can reveal obstruction of the cystic duct and is usually ordered if ultrasound fails to establish a diagnosis.



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