Before we look at a clinical case involving left upper quadrant (LUQ) pain, let’s review two key components of a medical evaluation.
First, remember the OLD CARTS (onset, location, duration, character, alleviating factors, radiation, temporal patterns, and symptoms) acronym, which can help you develop your history of present illness questions. Also, recall how to take SOAP (subjective, objective, assessment, and plan) notes. The subjective portion involves allowing the patient to tell you their symptoms. The objective portion includes your physical exam findings. As well, the assessment portion involves your differential diagnoses. Finally, the plan portion is how you plan to treat the patient.
Clinical case involving LUQ pain
This clinical case involves a 55-year-old female patient with a three-week history of LUQ pain.
First, think of your history of present illness questions using the OLD CARTS acronym, and ask the patient what brings them in today. The patient reports that her pain is in the left upper side and the upper middle abdomen. It has been intermittent and sharp in the left upper side for the last three weeks. She first noted pain in the left side six months ago. But, the pain was duller at that time.
The pain radiates to her back and is associated with nausea and reflux. She denies vomiting, diarrhea, or constipation. She also notes very dark stools over the last three weeks.
The patient has provided a lot of detail about the pain. You can organize her description using the OLD CARTS acronym, which will guide your questions and help create the differential diagnosis.
The onset (O) of the sharp pain was three weeks ago, it’s located (L) in the LUQ, and the duration (D) has been six months. She characterizes (C) the pain as intermittent and sharp. It radiates (R) to the epigastrium and back. Its associated symptoms (S) are nausea, reflux, and melena (e.g., dark tarry stools).
She has not mentioned anything that alleviates (A) the pain or any temporal patterns (T), so you directly ask her about those details. She admits that she drinks three cups of coffee a day and two or three glasses of wine a night. She smokes half a pack of cigarettes per day and has been smoking for twenty years. She also enjoys eating spicy food and comments that her symptoms are worse with food consumption.
When you ask about her medical history, she provides the following information:
- She has had two full-term pregnancies.
- She has hypertension, diabetes, and gastritis.
- She reports a history of two cesarean sections and a cholecystectomy.
- She takes lisinopril, metformin, and over-the-counter antacids.
- She denies any allergies.
The patient’s vitals are normal and stable, and she is afebrile. She has a body mass index (BMI) of 28 kg / m2, which is considered overweight. She has a Pfannenstiel incision and four small surgical incision scars.
She has bowel sounds in all four quadrants, and no abdominal aortic bruits. She has appropriate dullness with percussion over her liver and mild tympany over the small bowel near her umbilicus. Upon palpation, she has LUQ and epigastric tenderness. She also has left flank pain.
Based on the patient’s history and physical exam, a gastric etiology is high on the differential list. The patient’s alcohol consumption also puts pancreatitis on the differential. Her pain location, the fact that it radiates to the back, is worse with food, and her social history suggests a peptic ulcer. Her alcohol, tobacco, and spicy food consumption can all worsen gastritis, so gastroesophageal reflux disease (GERD) remains on the differential.
Peptic ulcer disease includes gastric or duodenal mucosa defects that extend through the muscularis mucosa, usually from acid production. About 80% of cases occur on the lesser curvature of the stomach. There is a prevalence of up to 15% in western populations.
The most common causes of peptic ulcers are Helicobacter pylori infections and long-term use of aspirin and nonsteroidal anti-inflammatory drugs. Complications of peptic ulcer disease include bleeding and perforation.
Now that you have a differential diagnosis based on the patient’s history and physical exam, you’re well on your way to diagnosing and treating the cause of the pain. The diagnosis may require further assessment with imaging modalities and laboratory findings.
The treatment plan involves medication and lifestyle modifications, with surgery as a last resort. This final component completes the SOAP for your patient with LUQ pain.
That’s it for now. If you want to improve your understanding of key concepts in medicine, and improve your clinical skills, make sure to register for a free trial account, which will give you access to free videos and downloads. We’ll help you make the right decisions for yourself and your patients.
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