Using the case study below explain what additional physical examination techniques might you perform to assess for appendicitis?

PHI for Oral Presentation on RUQ Pain

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. Interview him and perform a physical exam, and see if you can come up with a diagnosis with a robust differential.”
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?

Using the case study below explain what additional physical examination techniques might you perform to assess for appendicitis?

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