Question

You are

. . . a Certified Medical Assistant working with Susan Lee, MD, a primary care physician at

Fulwood Medical Center.

Your patient is

. . . Mrs. Sandra Jacobs, a 46-year-old mother of four. Your task is to document her care.

Documentation

Mrs. Sandra Jacobs, a 46-year-old mother of four, presents in Dr. Susan Lee’s primary care

clinic with episodes of crampy pain in her right upper quadrant associated with nausea and

vomiting. The pain often occurs after eating fast food. She has not noticed a fever or jaundice.

Physical examination reveals an obese white woman with a positive Murphy sign. Her BP is

170/90. A provisional diagnosis of gallstones has been made. She has been referred for an

ultrasound examination, and an appointment has been made to see Dr. Stewart Walsh in

the Surgery Department.

I explained to her the etiology of her gallstones and the need for surgical removal of the

stones, and I discussed with her a low-fat, 1500-calorie diet sheet.

Luisa Guitterez, CMA. 10/12/12, 1430 hrs.

In which quadrant is Mrs. Jacobs having pain? The fact that she does not have jaundice rules out a disorder of the? What is a positive Murphy sign? What additional diagnostic procedure is she scheduled for?

Answer 1

1. Mrs. Jacobs is having pain in her right upper quadrant.

2. The fact that she does not have jaundice rules out a disorder of the liver.

3. A Murphy's test is performed in patients with suspected cholecystitis during the abdominal examination in a seated position. The patient is asked to take in a deep breath and hold a deep breath while the right subcostal area is palpated. If there is pain on inspiration, when the gallbladder comes into contact with the examining physician’s hand, Murphy's sign is said to be positive.

4. She is scheduled for an ultrasound examination.