Setting : large urban city family practice clinic which employs physicians and nurse practitioners. Part 1 : Your next patient is a work in for…

Setting: large urban city family practice clinic which employs physicians and nurse practitioners.

Part 1:

Your next patient is a work in for abdominal pain.

When reviewing the chart you see that this is Patrick Smith, age 42. You met him last month when he brought his mother-in-law in for a sick visit. You remember because you treated him as well for a skin condition.

You enter the room and introduce yourself again to Patrick. He is not the jovial man you met last visit; he appears to be uncomfortable as he reaches forward to shake your outstretched hand.

Patrick says he is in a lot of pain. He thought it would go away but it is lasting and seems to be getting worse. He is also nauseous. He doesn’t think it is anything that he ate and no one at home has had the stomach flu. It is getting worse as he has been sitting in the office.  He cannot find a comfortable position to sit.


Woke up at 5 a. m.started out as pain on one side of his back. He thought he pulled a muscle. Now pain is spreading to his stomach and is getting worse. The pain sometimes shoots down into his groin. He feels nauseous. He seems to be going to the bathroom more often. He thinks he might have a fever because he has been sweating.


Describes health as good. Has hay fever and psoriasis, medication which was given at last visit worked, not using at this time. No previous back injuries. No daily medications. No herbal medication use.  Had his appendix out at age 10.. Previous hospitalization for broken leg requiring traction at age 8.  Smokes cigarettes, a pack a day. No ETOH or illicit drug use. Sleeps 5-6 hours a nightNKDA. Immunizations UTD. 


Married, has four children. Lives with his immediate family and in-laws. Works full time as a plumber. Work has been so busy no time lately for regular exercise.


Parents are deceased. Mother died at age 51 from a brain tumor and father died age 53 leukemia. Has one brother in good health.

Discussion Questions Part One:

  • What further questions do you have for Patrick at this visit??  Use OLDCARTS to guide your questions. Link the questions to your differential diagnoses.
  • What is your differential diagnosis list with ICD 10 for this visit thus far? Each differential diagnosis should include a one sentence pathophysiology statement supported by the literature or the textbook. List the patient’s signs and symptoms and include a rationale statement that explains how the diagnosis is appropriate for your patient.
  • Based on your differential diagnoses list, what focused PE would you perform? What labs or diagnostic tests would you order?


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