Case Study 4

Subjective/Story/Summary:

The patient is a 17-year-old male who is complaining of severe abdominal pain. The patient’s tentmates woke us at 6:30AM and said the patient had severe belly pain. Patient states the pain began yesterday at 10:00AM as “a bad bellyache cramping-like,” but is now “sharp.” He thought it was indigestion. It persisted all night and became “really uncomfortable” at about 10:00PM last night. The pain is across the lower abdominal quadrants, does not radiate, and is presently an 8 on a 1-10 scale. 

Objective/Observations/Findings:

Patient is obviously uncomfortable from the pain. Patient states the pain is worse when he walks, especially when he walks downhill or hops.  

Patient Exam: There is no point tenderness or rebound pain. No signs of injury or rigidity to the belly.

Vital Signs:

History:

• Symptoms: Patient is nauseous. No other complaints. 
• Allergies: Patient denies any allergies.
• Medications: Patient denies any medications.
• Pertinent medical history: Patient denies any history of abdominal problems. 
• Last intake/output: Patient has been well-hydrated and denies diarrhea. He ate very little for dinner last night. Reports normal bowel movement yesterday; no bowel movement yet today. Patient urinated clear urine this morning. He drank one cup of water this morning. 
• Events relevant to the incident/illness: patient’s tentmates are not ill. They say the patient moaned from the pain all night long, but did not want to wake up the leaders. The patient denies a blow to the abdomen.