Abdominal Pain Sample Patient Note

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HPI

50 YO MALE W C/O ABDOMINAL PAIN (MID-EPIGASTRIC, 8/10, TEARING, BEGAN 2 DAYS AGO, RADIATING TO BACK). PT ALSO COMPLAINS OF RUQ PAIN (5/10, ACHING, BEGAN 2 DAYS AGO, NON-RADIATING). NOTHING MAKES THE PAIN BETTER OR WORSE; PAIN IS GETTING WORSE AS TIME PROGRESSES; IT BEGAN SUDDENLY; NO PREVIOUS EPISODES. PATIENT ALSO COMPLAINS OF SWEATING. NO RELATIONSHIP TO FOOD, POSTURE, OR PHYSICAL ACTIVITY. NO HX OF TRAUMA, GALLSTONES, OR RENAL STONES.

ROS- NO NAUSEA, VOMITING, DIARRHEA, CONSTIPATION; NO CHILLS, FEVER, HEADACHES, FATIGUE, NIGHT SWEATS; NO UNUSUAL CHANGES IN BOWEL OR BLADDER; NO JOINT PAIN, HX OF INFECTIONS, OR RASH.

PMH/PSH- NOT CONTRIBUTORY

NKDA

MEDICATIONS/HOSPITALIZATIONS- NONE

SH- MARRIED; GOOD SOCIAL SUPPORT; LIVES WITH WIFE AND KIDS; DRINKS 6-10 BEERS DAILY; CAGE 3/4; WORKS AT AN ELECTRIC COMPANY.

FH- FATHER DIED OF CIRRHOSIS

PHYSICAL EXAM

GA- PATIENT IN MILD DISTRESS

HEENT- NC/NT, PINK CONJUNCTIVA, PINK PHARYNX

NECK- NO LUMPS, NO THYROMEGALY

ABDOMEN- NO SCARS, NO DEFORMITIES, SOFT, NT/ND, BS+, TYMPANIC 4X, PSOAS-, MURPHY-, REBOUND-, CVA TENDERNESS-.

PULSES- BRACHIAL+, RADIAL+, POPLITEAL+, PEDAL+.

DIFFERENTIAL DX

ACUTE PANCREATITIS

HISTORY PHYSICAL EXAM
EPIGASTRIC PAIN
RADIATING TO THE BACK
TEARING PAIN
SUDDEN ONSET
NOTHING MAKES IT BETTER OR WORSE
SWEATING
CAGE 3/4
FATHER DIED OF CIRRHOSIS
NO NAUSEA
NO VOMITING
NO DIARRHEA

AORTIC DISSECTION

HISTORY PHYSICAL EXAM
EPIGASTRIC PAIN
RADIATING TO THE BACK
TEARING PAIN
SUDDEN ONSET
NOTHING MAKES IT BETTER OR WORSE
SWEATING
CAGE 3/4
FATHER DIED OF CIRRHOSIS
NO NAUSEA
NO VOMITING
NO DIARRHEA

TESTS

CBC

ELECTROLYTES

ABD CT W/ CONTRAST

ABD XRAY

AMYLASE

LIPASE

Additional Readings:

USMLE CS Sample Patient Notes

1. Testicular Pain
2. Mid-Epigastric Pain
3. Back Pain

USMLE Step 2 CS Videos

1. Video of Cardiology Examination in a Clinical Setting
2. Video of Neurology Examination in a Clinical Setting
3. Video of Pulmonology Examination in a Clinical Setting
4. Video of Musculoskeletal Examination in a Clinical Setting
5. Video of Abdominal Examination in a Clinical Setting
6. Video of HEENT Examination in a Clinical Setting
7. Video and Description of Rinne Hearing Test
8. Video and Description of Weber Hearing Test

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