Essentials of Patient Care | Course Handouts

The Problem Focused Interview

The Hypothetico-Deductive Model

Initially, the clinician generates several hypotheses based on patterns of symptoms. Subsequent questions are directed to support or modify these hypotheses. An experienced clinician may go through the hypothesis generation and evaluation loop several times during the course of an interview.

The Archetype - Abdominal Pain

Time Course for Abdominal Pain

Was it preceded by other symptoms?
Does it come and go or is it progressing?
Has the location changed?
Has the quality changed?

Types of Abdominal Pain

Pain from Hollow Viscera
- crampy/paroxismal
- often poorly localized
- related to peristalsis
- patient writhing on exam table
Pain from Peritoneal Irritation
- steady/constant
- often localized
- patient lies still with knees up

Radiation of Abdominal Pain

Perforated Ulcer - Shoulder
Biliary Colic - RIght Scapula
Renal Colic - Costovertebral Angle
Dysmenorrhea/Labor - Low Back
Renal Colic (Groin) - Flank and Testicle
Pancreatitis - Upper Back

Associated Symptoms

Motility
- Nausea, Vomitting, Diarrhea, Constipation
Hemorrhage
- Frank Blood, "Coffee Grounds" Emesis, Black Stools
Urinary
- Frequency, Urgency, Discomfort
Reproductive
- Last Menstrual Period, Sexual Activity, Contraception, STD Exposure

Summary Tables

Abdominal Pain
	Location	Quality	Radiation	Timing	Worse	Better	Other
Appendicitis	periumbilical, then RLQ	crampy early, steady late		4-6 hour onset	movement late		anorexia, nausea, low grade fever
Cholecystitis	RUQ	steady ache	right scapula	gradual onset	movement, deep breath		anorexia, nausea, vomiting, fever
Renal Stone	flank	crampy, severe	groin on same side	sudden onset			vomiting, urinary symptoms, blood in urine
Gastroenteritis	variable	crampy	moves around	4-6 hour onset	food		nausea, vomiting, diarrhea. fever
Peptic Ulcer	epigastric	gnawing, burning, pressure	back	intermittent		food, antacids	nausea, vomiting, bloating, heartburn
Pancreatitis	epigastric	variable	back	variable	lying down	bending forward	nausea, vomiting, fever
Obstruction	variable	crampy		paroxysmal			vomiting bile (high), obstipation

Chest Pain
	Location	Quality	Radiation	Timing	Worse	Better	Other
Angina Pectoris	retrosternal	pressure	arms, neck, jaw	1-10 minutes	exertion	rest, NTG	SOB, nausea, sweats
Myocardial Infarction	retrosternal	pressure	arms, neck, jaw	20 min - few hours			SOB, nausea, vomiting, sweats, weakness
Dissecting Aneurusm	anterior chest	tearing	neck, back, abdomen	abrupt onset, persistent
Pleuritis	variable	sharp		variable	breathing, coughing	holding/lying on side
Espophagitis/Spasm	retrosternal	burning, pressure	arms, neck, jaw, back	variable	eating, drinking, lying	antacids, NTG	regurgitation, dysphagia
Chest Wall Pain	variable	sharp or dull ache		hours to days	movement		local tenderness

Headache
	Location	Quality	Onset	Duration	Worse	Better	Other
Tension	bilateral, front or back	ache or pressure	gradual	hours - days	driving, typing	relaxation	anxiety or depression, neck pain
Migraine	uni or bilateral	throbbing	rapid	hours - days	alcohol, food, noise	quiet, dark, sleep	nausea, vomiting, visual prodrome
Cluster	unilateral behind eye	steady, severe	abrupt	1-2 hours	alcohol		runny nose, tearing on same side
Sinusitis	cheek or eye	ache or pressure	gradual	daily	coughing	decongestants	nasal discharge, fever, local tenderness
Arteritis	over temporal artery	ache or throb	variable	week - months			fever, local tenderness
Meningitis	generalized	variable, severe	rapid	variable			fever, stiff neck
Tumor	variable	steady ache	variable	progressive	coughing, straining		nausea, vomiting, neurologic problems

Author: Richard Rathe, MD / rrathe@dean.med.ufl.edu Copyright: 1997 by the University of Florida Location: http://medinfo.ufl.edu/year1/epc/handouts/problem.html Created: October 1, 1997 Modified: October 6, 1997

Essentials of Patient Care | Course Handouts