CLINICAL CASE DISCUSSION 1
Review of Systems
Her ROS is positive for abdominal pain, nausea, and vomiting. She reports headache and lack of appetite. The ROS is questionable for diarrhea.
The ROS is negative for fever, chills, constipation, cough, runny nose, sore throat, abdominal bloating, acid reflux, neck stiffness, urinary urgency, dysuria, hematochezia, back pain, wheezing, SOB, or chest pain.
Relevant History
The patient’s medical history is significant for acne (onset age 14), obesity, hepatic steatosis, and mild intermittent asthma (onset age 8). She has no surgical history.
Her social history includes playing football and traveling with her family. She has two sisters and two brothers. She lives with her father and does not have much interaction with her mom.
She has been sexually active since age 16 with one male partner. Partner uses condoms.
Her family history includes diabetes (paternal grandparents), hypertension (father), and prostate cancer (paternal grandfather). She does not know his maternal family history.
Allergies
Medications
Benzoyl peroxide 4% topical QD.
Albuterol inhaler 2 puffs every 4–6 hours PRN.
Physical Examination
Vitals: T 37.5°C (99.5°F), P 93, R 19, BP 130/87, WT 95.25 kg (210 lbs), HT 177.8 cm (70 in.), BMI 30.1
General: Mild to moderate distress, obese.
Psychiatric: Cooperative, appropriate mood and affect.
Eyes: Conjunctiva and sclera clear.
ENT/Mouth: Within normal limit.
Neck: Supple, FROM.
Lungs: Clear to auscultation bilaterally.
Heart: Normal rate, regular rhythm, no heart murmur.
Abdomen: Tender abdomen throughout; greatest tenderness in right lower quadrant guarding even with mild palpation; McBurney point tenderness noted; psoas sign +; Rovsing sign questionable.
Neurologic: A&O×3.
Clinical Discussion Questions
1. What is the differential diagnosis?
2. What is the most likely diagnosis? Why?
3. Demonstrate your understanding about the pathophysiology in regard to the most likely diagnosis.
4. What are the next appropriate steps in management?