family medicine clinic with Dr. Medel
family medicine clinic with Dr. Medel
Today, you are working at a family medicine clinic with Dr. Medel. Together, you review her clinic schedule for the day and she suggests that you see Mr. Cesar Rodriguez, a 39-year-old uninsured male who recently moved to the U.S. from the Dominican Republic. This is Mr. Rodriguez’s first visit to the clinic.
Molly, Dr. Medel’s medical assistant, has already escorted Mr. Rodriguez to the examination room and has arranged for a Spanish-speaking interpreter to be present for the visit, since he speaks and comprehends very little English. Molly tells you that Mr. Rodriguez has been having “worsening abdominal pain over the past several months” and is “worried that something is wrong.”
Dr. Medel says to you, “How would you begin to think about what might be going on with Mr. Rodriguez?”
You reply, “Abdominal pain can be caused by a wide variety of conditions. I’ll need to get more information about his symptoms to form an appropriate differential diagnosis. At this point I’d have to consider several organ systems as potential etiologies of the pain.”
“Very good,” Dr. Medel responds. “Why don’t you go ahead and talk with Mr. Rodriguez and come find me afterward. Lola, our Spanish-speaking interpreter, can help.”
As you walk down the hall, Lola, the Spanish-speaking interpreter, gives you some tips on how to interview a patient with an interpreter.
You and Lola enter the room. You sit directly across from Mr. Rodriguez, with Lola sitting just off to your left and facing him. You sense that Mr. Rodriguez seems anxious about coming to the physician today. You introduce yourself and ask,
“What brings you in today?”
“Well, I’ve been having this abdominal pain, and it just seems like it won’t go away. It started probably a year ago. It used to happen a few times a week, now it hurts every day. It usually burns right here.” (He points to the epigastric area of his abdomen.)
“Is there anything that makes the pain better or worse?”
“It’s hard to say. Sometimes eating or drinking makes it better, or sometimes worse. Sometimes eating spicy foods makes it worse.”
“What worries you the most about your symptoms?”
“I don’t know,” he says nervously. “I just want to make sure nothing is wrong.”
Thinking about some of the common causes of abdominal pain, you conduct a focused review of systems:
· General: Reports no weight loss, fevers, chills, or night sweats. He has had no recent illnesses. Aside from a recent move to the U.S. from the Dominican Republic, he has not traveled recently.
· GI: Reports no dysphagia, regurgitation, nausea, vomiting, anorexia, early satiety, hematemesis, hematochezia, melena, diarrhea, or constipation.
· GU: Reports no dysuria, hematuria, or change in frequency.
· CVS/Respiratory: Reports no chest pain, cough, or shortness of breath.
You now direct your attention to Mr. Rodriguez’ medical history.
“Do you have any chronic medical problems?”
“I don’t really have medical problems, just the stomach pain.”
“Have you ever been hospitalized or had any surgeries?”
“I’ve never been hospitalized. Never been operated on.”
“Do you take any medicines or supplements?”
“Just ibuprofen if I’m tired and sore after work, probably most days of the week. I drink some tea that’s good for the stomach—Yerba Buena—but it doesn’t really help.”
“Does anyone in your family have any medical conditions—for example, heart or blood pressure problems? Diabetes?”
“My father had high blood pressure, my mother had diabetes.”
“Does anyone in your family have stomach problems or pain similar to yours?”
“I don’t know if anyone has these stomach problems like me.”
You ask Mr. Rodriguez a few more questions and discover that he works as a farm laborer. He has no known drug allergies. He smoked a few cigarettes daily but quit six months ago. He drinks three to four beers per week. He reports no other drug use. He has had no recent illnesses. Aside from a recent move to the U.S. from the Dominican Republic, he has not traveled recently.
You congratulate Mr. Rodriguez on quitting smoking and you thank him for answering all of your questions. You review in your mind what you’ve learned from Mr. Rodriguez so far, and find yourself still wondering about why he seems a little anxious. Before you go to get Dr. Medel, you inquire,
“It seems like this has really been bothering you. Is there anything else we haven’t talked about that seems important?”
“Well, I guess I would have come sooner, but I don’t have any health insurance and haven’t had the money to come to the doctor. I want to feel better, but I hope it’s not something serious.”
You reply, “Well, I’m glad you came in today, and I’ll be sure and share your concern with Dr. Medel. Thanks for telling me.”
You ask him to change into a gown, taking off his clothes. You reassure him that you will return with Dr. Medel momentarily, and you and Lola leave the exam room while Mr. Rodriguez changes.
In the hallway, you comment to Lola that you are concerned about why Mr. Rodriguez waited to come see a doctor.
You find Dr. Medel in the clinic precepting room, and she asks you, “Well, what have you learned so far?”
You summarize Mr. Rodriguez’s story for Dr. Medel.
Mr. Rodriguez
Summary of case study so far: Mr. Rodriguez is a previously well 39-year-old Latino immigrant who presents with chronic progressively worsening pain in his upper abdomen. He reports no vomiting, hematemesis, hematochezia, melena, or association with meals. He recently quit smoking and consumes alcohol occasionally and takes NSAIDs and traditional herbal teas.
The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:
Epidemiology and risk factors: 39-year-old previously well Latino immigrant.
Key clinical findings about the present illness using qualifying adjectives and transformative language:
