Mr. Keenan had an appendectomy at age 11. However in a different patient, recalling that occasionally appendicitis presents outside of the traditional RLQ area, what additional physical examination techniques might you perform to assess for appendicitis?

Case Study Information/ answers for Oral Presentation RUQ Pain to write PHI

You are working at Dr. Hill’s family medicine office in a rural town.

Dr. Hill tells you: “I’d like for you to see Mr. Keenan this morning. He is a respected volunteer fireman in the community and has been a patient of mine for some time. He called me early this morning reporting severe abdominal pain. After a brief interview, I asked him to go to the emergency department, but he maintained he would rather come to the office if I could work him in. Please interview him and perform a physical exam, and see if you can come up with a diagnosis with a robust differential.”

42-year-old male with right upper quadrant pain

INTRODUCTION

HISTORY

Dr. Hill tells you about your next patient.

You are working at Dr. Hill’s family medicine office in a rural town.

Dr. Hill tells you: “I’d like for you to see Mr. Keenan this morning. He is a respected volunteer fireman in the community and has been a patient of mine for some time. He called me early this morning reporting severe abdominal pain. After a brief interview, I asked him to go to the emergency department, but he maintained he would rather come to the office if I could work him in. Please interview him and perform a physical exam, and see if you can come up with a diagnosis with a robust differential.”

HISTORY

HISTORY

You interview Mr. Keenan about his abdominal pain.

You introduce yourself to Mr. Keenan and begin taking a history.

“Tell me about what brings you here today.”

You reply, “Wow, I’m sorry you had such a rough night. Can you tell me exactly what you were doing when the pain started?”

“Tell me about the location of your pain. I’m specifically interested in where the pain started, and if it moved anywhere.”

“Did the pain move anywhere?”

“Did you have any heartburn?”

“Did you have any pain in your chest or jaw?”

“How about sweating, shortness of breath, or coughing?”

“Have you ever had this happen before?”

 

You ask Mr. Keenan about his past medical history and discover the following:

Past medical history: GERD, chickenpox (distant – childhood), obesity.

General state of health: Good.

Medications: Omeprazole. No other medications or supplements.

Surgeries: Appendix removed at age 11.

Hospitalizations: None other than an appendectomy.

Family History: No history of stroke or coronary artery disease.

While thinking about all of the potential causes of right upper quadrant (RUQ) abdominal pain, you obtain a thorough review of systems in an attempt to rule in or out as many etiologies as possible.

Review of Systems for RUQ Abdominal Pain

Renal causes

• Mr. Keenan reports no dysuria, polyuria, nocturia, or hematuria.

Gastrointestinal diseases

• Mr. Keenan has not had diarrhea, constipation, changes in stool color, floating stools, or blood in his stools.

Respiratory

• Mr. Keenan has not had a cough, shortness of breath, or chest pain.

Dermatologic causes

• Mr. Keenan doesn’t have any new skin rashes, itching, tingling, or bruising.

Musculoskeletal system

• Mr. Keenan reports no recent trauma.

Constitutional

• Mr. Keenan reports no fever or weight loss.

Cardiovascular

• He reports no chest pain, shortness of breath, peripheral edema, or dyspnea on exertion.

Social History

Mr. Keenan is a volunteer firefighter and a little league baseball coach in town. He tells you that he owns a chicken farm that he works with his 22-year-old son, and that his 19-year-old daughter is away at college. He is sexually active and monogamous with his wife of 23 years and believes she is monogamous with him as well. He says their marriage is “okay.” When you ask about drugs, he reports no illicit drug use and he proudly informs you that he quit smoking about 10 months ago. He admits he’s had a few cigarettes since then, but more or less feels he is “over them.” He tells you he drinks alcohol mostly on the weekends. When you ask about regular exercise, he explains that daily farming work provides a “good bit of exercise.” In response to your other questions, he tells you he hasn’t had any time to travel outside of the local county for the past year. He divulges that he is barely making ends meet lately and has been stressed about money.

You decide you have asked Mr. Keenan all the pertinent questions necessary for now. You tell him, “I’m going to step out of the room for a moment while you put this gown on. I’ll do a physical exam when I come back, if that’s all right with you.” He nods in assent and you leave the room while he changes.

Physical Exam

Vital signs:

• Temperature is 36.8 °C (98.2 °F)
• Pulse is 95 beats/minute
• Respiratory rate is 14 breaths/minute
• Blood pressure is 120/80 mmHg
• Weight is 99.3 kg (219 lbs)
• Height is 175 cm (69 in)
• Body mass index is 32.3 kg/m²

General: Mr. Keenan is a well-appearing male. He climbs onto the examination table without appearing to be in obvious pain. No jaundice of the skin was noted. Old, well-healed surgical scar over the right lower quadrant.

HEENT: No icterus of the sclera. Teeth are in good condition. Oral mucosa moist. Otherwise unremarkable.

Lymph nodes: no palpable or tender cervical or supra/infraclavicular lymph nodes.

Pulmonary: Lungs clear to auscultation bilaterally in all fields; no rales or rhonchi.

Cardiac exam: Normal S1 and S2 with no murmurs, gallops, or rubs.

Abdominal exam:

“Mr. Keenan, could you please lie down and bend your knees so your feet are flat on the exam table? That position helps to relax your abdominal muscles.”

He does not appear in any pain with movement. His abdomen appears flat and non-distended. There are no obvious masses, dermatomal lesions, or vascular abnormalities (e.g., spider angiomas).

Normal bowel sounds without any abdominal bruits. No abdominal tenderness when pushing the stethoscope into the abdomen.

On percussion he has a liver of normal size. Palpation starts away from the area of reported pain. There is no abdominal rigidity, no masses, no guarding, tenderness, or rebound.

To elicit Murphy’s sign, you say: “Mr. Keenan, please breathe out slowly and completely.” You then gently place your hands under the right costal margin. “Please take a deep breath in,” you instruct. There is no tenderness elicited.

Back exam: No costovertebral angle (CVA) tenderness.

You exit the exam room to discuss the case with Dr. Hill. Then both of you return to Mr. Keenan’s room, and she confirms your interview and physical exam.

Question

Mr. Keenan had an appendectomy at age 11. However in a different patient, recalling that occasionally appendicitis presents outside of the traditional RLQ area, what additional physical examination techniques might you perform to assess for appendicitis?

 

Guidelines to write the PHI for oral presentation (use the information above).

What is an Oral Presentation?

An oral presentation is an important skill for medical providers to communicate patient care issues with other providers. The oral presentation is not a SOAP note – it is shorter and more focused to give the listener the pertinent data they need, rather than a comprehensive history.

TUC School of Nursing Expectations:

Interprofessional team members, preceptors and collaborating physicians may have slightly different requirements for your presentations. This guide provides general advice on how to organize and give oral presentations to the Touro faculty.

1. An oral presentation should include only what is relevant to the patient’s presentation (including differential diagnoses and a plan).

By giving the pertinent data in a logical format, the listener should be able to guess, and hopefully agree with, your differential diagnoses, even before the end of your presentation. Thus, it is crucial to convey the right information appropriately and succinctly. Your plan should reflect your diagnosis or diagnoses. It provides you with a chance to reflect on the information you have for your patient.

2. An oral presentation should allow you to hand off care of a patient to another provider.

Think of your presentation as a comprehensive sign-out. There are lots of skills that go into this: good data gathering, advanced physical exam skills, prioritization of often several concurrent patient issues, and your own knowledge base.  Each of these is a culmination of your current skills.

How to Present a New Patient

1. Opening Statement: The opening statement of an oral presentations begins with some basic demographic information, much like the first line of an HPI. This is also called the problem representation; present the most relevant, prominent features of the patient’s condition and a brief indication of time course. Think of your opening statement as what you would type into a Google search.

 

2. History of Present Illness: An HPI flows from the opening statement. The chief complaint is embedded into the HPI. This is different from a written H&P. Organization is key.
   1. Do: For most presentations, a chronological approach usually works well and is easy to follow. Begin the HPI with when the illness began, not with when they sought care. For some recurrent or chronic conditions, this may go back some time, so you should summarize the entirety of the course of the illness in a succinct way. Avoid organizing your HPI based on mnemonics you use to remember elements of the HPI. “OPQRST” is handy because it is alphabetical, but it is not actually presented in a logical format.
   2. Do: Include relevant ROS data with your HPI.
   3. Do Not: For the most part, you should not veer into other pieces of data (past medical history, exam, labs) before you’ve completely presented the HPI unless you’re certain that doing so is vital to understanding the patient’s presentation (e.g., “He was found in clinic today to have a creatinine of 4.7, above his baseline last month of 2.0” should be presented under Labs, not here).
   4. Special Cases: If the patient has sought care at other facilities, you can usually include that course at the end of the HPI. This may require you to present some labs and data out of order, but if it makes more sense to do it this way, this is a reasonable approach. If you have multiple problems to discuss, unless they are very closely tied together, consider presenting each one separately, following the above HPI format for each individual problem.
   5. Good Example: “Her symptoms began three days ago, when approximately 20 minutes after having a breakfast of a cheese omelet, she started to have ‘gnawing’ epigastric and right upper quadrant pain, which she rated 8/10. The pain lasted about two hours and resolved spontaneously but recurred approximately three times a day since then, each time 6 to 8/10, only associated with meals about half the time. Each episode lasted half an hour to three hours, resolving spontaneously. Overnight, however, the pain lasted for more than four hours, so she tried Pepto-Bismol, which did not help, so she came into the emergency room. She has not noticed the color of her stools, but noticed that her urine seems darker.” This has a chronological approach, which gives it a strong, logical flow. It has relevant ROS points at the end.
   6. Bad Example: “Her symptoms began three days ago 20 minutes after having breakfast of a cheese omelet. She tried Pepto-Bismol last night, which did not help. The episodes resolve spontaneously. The pain is a ‘gnawing’ pain, in her epigastrium and right upper quadrant. The pain is 6 to 8/10. Each episode lasts half an hour to three hours and occur three times a day since onset. She has not noticed the color of her stools, but noticed that her urine seems darker. Overnight, the pain lasted more than four hours, so she came into the emergency room.” This uses the OPQRST/AA format, and has a less logical flow.

 

3. Past Medical History: Next include a few items from the past medical history that are directly relevant to the problem representation or HPI.
   1. Do: Be brief and focused.
   2. Do: List the diagnoses of PMH in decreasing order of relevance as they relate to the HPI and/or the care you provide them in the encounter. For example, T1DM may not be immediately relevant to the HPI, but will likely affect your plan for the patient.
   3. Do: Expand on relevant elements of the PMH. For example, if your patient is admitted with a CHF exacerbation, include a summary of their last echo.
   4. Do Not: Do not list irrelevant PMH (something that does not significantly impact HPI or your current care for the patient). However, recognize that your audience may look this up or ask you about it.
   5. Do Not: Do not copy and paste a problem list from previous encounters in an EHR.
   6. Good Example: “Mr. ___ is a 64-year-old man with a history significant for COPD who presents with shortness of breath (SOB) and fatigue.”
   7. Bad Example: “Mr. ___ is a 64-year-old man with a history of hypertension, COPD, sleep apnea, obesity, type 2 diabetes, lumbar fusion 6 years ago, who presents with difficulty breathing and fatigue.” See the difference?

 

4. Medications/Allergies:
   1. Do: Include the medications that are relevant to the patient’s presentation, current illness, and your treatment plan, if you have not mentioned them already. Use your judgment on whether knowing a dose and frequency of a medication is relevant. If it is highly relevant to the HPI, or if there is something non-standard about it, you should probably include it. Otherwise, recognize that your audience probably has a limited attention span for hearing a long list of names and numbers.
   2. Do Not: You do not always need to include every medication, particularly if the patient’s medication list is very long. Instead, be prepared to refer to or show a list if requested.

 

5. Social and Family History:
   1. Do: Include the elements that are relevant to the patient’s presentation, or your care of the patient (e.g., factors that may affect hospital discharge).
   2. Do: Add in some social context, especially if you think it would be helpful to contextualize the patient (e.g. family, living situation). This portion of the presentation may be useful to communicate information that you would not want to write into the patient’s chart.
   3. Do Not: Do not use vague terminology (e.g. occasionally, rarely). These terms are interpreted in highly variable ways by different persons. Give actual frequencies.
   4. Do Not: Although you do not need to present an entire genogram, avoid using “non-contributory” as a surrogate. If the absence of a particular condition in the patient’s family history is important, state it as such (e.g., “there is no family history of autoimmune disease”).

 

6. Review of Systems:
   1. Do Not: In most cases, you do not need to include a review of systems. Relevant pieces of the ROS should have been included in your HPI. If they are not relevant, do not include them in your presentation. However, if a setting does merit that you go over the review of systems (e.g., you wish to present it at a comprehensive preventive care visit), discuss which systems/ROS you reviewed rather than stating, “All systems negative.”

 

7. Vital Signs:
   1. Do: Include vital signs, as they are considered vital for a reason. Consider giving ranges or baseline data if relevant (e.g., “weight is 115 lbs., down from 140 lbs. six months ago”), or if it is variable (e.g., “pulse has ranged from 72 to 138 over the last 2 weeks”).
   2. Do Not: Do not use vague phrasing (e.g. “afebrile, vital signs stable”). Saying that something is stable for a new patient is meaningless, because stability implies a course of time; also, “stable” does not mean “normal.”

 

 

8. Physical Exam:
   1. Do: Explain the relevant parts of the physical exam in detail, including both pertinent positives and pertinent negatives.
   2. Do Not: Avoid saying “normal” or “intact” for the relevant parts of your exam.
   3. Do Not: Do not include the comprehensive, exhaustive exam. If a component of the exam is not relevant, leave it out, knowing that you can provide that information if asked about it. Avoid providing stock phrases because you are accustomed to including them (e.g., “no clubbing, cyanosis, or edema”) without a good reason for doing so.
   4. Good Example: “On cardiac exam, her PMI was displaced laterally. She had a normal S1 and soft S2 without any murmurs. There was no S3. Carotid up strokes were brisk without delay.”
   5. Bad Example: “Her heart was normal except for a laterally displaced PMI.”

 

9. Labs and Studies:
   1. Do: Include the relevant labs explicitly; state the actual numbers.
   2. Do Not: Do not include all the labs. As with medications, your audience will not have an attention span for a string of numbers. Have additional labs available to report if asked.
   3. Do: Include comparison labs if there has been a change, even if the comparison is not from the current presentation if that information is pertinent.
   4. Do: Attribute studies to the appropriate individuals if you did not do the interpretation yourself (e.g., “Per the radiology report, the ultrasound showed…”).

 

10. Summary Statement: The summary statement is essentially the “opening argument” of what diagnosis (or diagnoses) you think are most likely, and primes your audience for why this is the case by providing evidence. While the beginning of your summary statement mirrors the opening statement of your HPI with demographics and relevant PMH, it should include more information.
    1. Do: Keep the summary statement short with one or (rarely) two sentences that include only the most relevant pieces of information (history, exam, labs and studies).
    2. Do Not: Do not simply repeat the opening sentence from your HPI without modification.
    3. Good Example: “Ms. ____ is a 64-year-old woman with a history of type 2 diabetes who presents with recurrent, post-prandial, severe mid-abdominal pain with exam findings of a low-grade fever, minimal abdominal tenderness, and a leukocytosis of 18,000.”
    4. Bad Example: “Ms. ____ is a 64-year-old woman with a history of type 2 diabetes who presents with abdominal pain.”

 

11. Assessment and Plan: Formulating an assessment and plan often is done in a problem list format. Each “problem” is a specific issue (disease, symptom, aspect of health care, etc.) you would like to specifically address. The presenting condition should always be included and usually is the first problem you address. For each problem, present an assessment and a plan. The assessment is your sense of which diagnosis/-es are most likely and why, or your understanding of the patient’s state (e.g. “worsening renal function” or “with wound dehiscence”). The plan is what you intend to do about it (diagnostics, treatment, or both).

Classically, the assessment and plan are presented together by problem, one problem at a time: present problem A, given your assessment for it and provide a plan, then move on to problem B and repeat. In giving your assessment, explain your thought process; in giving the plan, explain how the plan relates to your assessment. It is important to commit to a diagnosis as being most likely and to be specific about your plan. This may seem intimidating early on, as you may be unsure given your lack of experience and knowledge. Recognize that the cognitive processes of committing to a diagnosis and a specific plan are part of the learning process, however, more so than just being right.

1. Do: Consider the alternatives for your differential diagnoses. Think “VINDICATE,” and what data you need to rule in or out each possibility. Which alternatives are “can’t miss,” and which are “most likely”?
2. Do: Are any of your findings pathognomonic for a specific condition?
3. Do: Include a sentence outlining your thought process for every clinical assessment. This is called “clinical reasoning.”
4. Do: Before you offer your plan, make sure you have an assessment for every diagnosis.
5. Do: Articulate a clear plan for each assessment.
6. Do: Prioritize your assessment/plan. Typically, the most serious problems and the ones relating to the chief complaint/HPI go first.
7. Do Not: Avoid vague plans, such as “give some antibiotics.”
8. Good Example: “The first problem is her sudden hypoxia and chest pain. Most concerning given her recent surgery and immobility as well as history of autoimmune disorders is a pulmonary embolism, especially given the acute nature and pleuritic chest pain. Acute coronary syndrome is also possible given her age and risks of hypertension and hyperlipidemia, though the pleuritic chest pain is less likely. Additional considerations include pulmonary edema with mobilizing her intra-operative fluids or nosocomial pneumonia. For my plan, I am obtaining an EKG and troponins immediately as well as a creatinine, as I plan to get a CT angiogram to evaluate for PE if these are negative. The CT should also give me some information regarding pulmonary edema and pneumonia. Given that she so recently had major abdominal surgery, I am holding off anticoagulation until I determine if she has a PE or ACS.”
9. Bad Example: “First problem is hypoxia and chest pain, so I’m getting an EKG, troponins, and a CT.”
10. Special Cases due to Interacting Problems: In a patient with multiple interacting problems, it can be confusing to determine when to present the assessments and plans. If your problem list is prioritized, you will generally explain the most significant problems first, but it is often permissible to separate this out and let your audience known (e.g., “The steroids will affect his poorly controlled blood sugar, which I will explain when we get to ‘diabetes.'”).
11. Special Cases with ICU Patients: In a severely ill and complicated patient, the problem list is often presented by body system. For example, you would present “cardiac” as a system and then discuss all the problems related to the cardiac system, including their assessments and plans, before moving on to “pulmonary,” and so forth. Even if you use the body systems approach, the body systems should be prioritized, with the most critical ones to your patient presented first.

 

How to Present a Known Patient in the Inpatient Setting

When you are presenting a patient whom you have presented very recently (such as on daily rounds on an inpatient service), your presentation will be much shorter, more focused, and generally only include what is new, changed, or updated as follows:

1. HPI/Interval History: The HPI will typically be replaced with an “interval history,” which summarizes all events that occurred with the patient since your last presentation, as well as a “subjective” portion which explains how the patient is feeling and includes the patient’s own description of how he or she is feeling.
   1. Good Example: “Overnight, he had an episode of shortness of breath with sats down to the low 80s. A rapid response was called, and respiratory therapy suctioned a large amount of mucus. After that, his sats came up to upper 90s on 2 liters of oxygen. This morning, he has no shortness of breath and no mucus production, and the nurse has weaned him off oxygen.” The remainder of this history portion is generally left out, except for select medications if you are tracking them. For example, if you are providing the patient with antibiotics, it is common to state something such as, “She is on day four of five of ceftriaxone.”
2. Vital Signs: If the patient is hospitalized, it is often useful to give a range of vital signs rather than just the most recent, as you wish to summarize the patient’s vitals over the course of the day since your last presentation, not just the moment you are giving your presentation.
3. Physical Exam: The physical exam should be very brief and typically not comprehensive. Focus on the portions of the physical exam that you are actively following for the patient’s active problems (even if normal) and anything that has changed from previous exams.
4. Labs/Studies: These should be limited to what is pertinent, what actively needs to be followed, and what is relevant to your assessment/plan. This is especially the case if your patient has fallen prey to the overuse of daily labs; not all daily labs are relevant. In these cases, it is often acceptable to summarize the labs as “normal.”
5. Summary Statement: Since the patient should be known to the audience, your summary statement can include a reminder of who the patient is rather than an argument (for example, “Mr. ____ is our 64 year old patient with gallstone pancreatitis”). If something significant has occurred in the hospital stay (birth, surgery, intubation, etc.), you may wish to include how many days it has been since that event.
6. Assessment/Plan: For problems you are working up, the assessment/plan is as above. If a problem has resolved, mention it briefly if it is still relevant; otherwise, do not include it.

 

How to Present a Return Patient in the Outpatient Setting

Because most outpatient encounters are on a much shorter timeline than inpatient encounters, it is vital that your outpatient presentations be succinct and brief. In this way, you should only limit your presentation to the most pertinent information. The presentation of a brand new patient in an outpatient setting follows the pattern above. If a patient is known to you because they are returning for a follow-up visit, much of the information can be omitted.

1. Past Medical History: In general, this can be left out if the patient is known to your audience, with the relevant portions listed in HPI.
2. Medications: Stick to what’s pertinent to the reason the patient is being seen.
3. Family and Social History: Only include if important to the presenting complaint. Most often, you will leave most or all of this out.
4. Physical Exam: Be very focused on your exam, again only included what is pertinent to the patient’s visit.
5. Labs/Studies: Include only what is relevant. Often, there are monitoring labs in outpatient visit that may or may not be relevant, so you can typically describe only what stands out or is relevant to your assessment/plan.

Assessment/Plan: Typically, you only want to include an assessment and plan for each problem for which the patient is presenting and any chronic issues (even if stable) for which the patient is following up. If your clinic encounter is focused (e.g., a problem-focused visit or a specialist visit), you will typically not have an assessment/plan for the problems that do not pertain to that visit.

 

Resources:

Aquifer  Aquifer | Your Trusted Source for Clinical Learning – Virtual Patient Cases

Family Medicine 15: 42-year-old male with right upper quadrant pain

Author: Pamela Rockwell, DO; Associate Editor: Martha P. Seagrave RN, PA-C