■ Physician-patient:

Communicating effectively with patients to optimize their care

Telephone assessment of abdominal pain

Type of activity: Text case

Activity summary

This text case describes a situation in which a family medicine resident completes a telemedicine assessment of abdominal pain.  The facilitation questions and suggestions to faculty focus on helping learners to consider the differences between negligence and errors of judgment.

Case scenario

A 55-year-old female with hypertension, type II diabetes, and elevated BMI has a sudden onset of vomiting, diarrhea, and lower abdominal pain. During the previous 12 hours she has vomited 6 times and has had 3 moderately loose stools. Late on a Friday afternoon, she telephones her family physician's office for advice. She is concerned because her blood sugar is elevated and she has been unable to keep down her medications. She speaks to a resident working at her family physician’s clinic. 

At the time of the phone call, the resident determines that the patient has no signs or symptoms of dehydration, her heart rate and respiratory rate are reportedly normal, and that there are no reported symptoms of peritoneal irritation. The resident documents a diagnosis of gastroenteritis and advises the patient to consume clear fluids and use an antiemetic as required. He concludes the phone call by instructing the patient to seek reassessment if the vomiting persists into the next day, or if the abdominal pain worsens. 

Four days later, the patient presents to the emergency department with fever and worsening abdominal pain. An ultrasound shows an abscess requiring percutaneous drainage, and subsequently her appendix and a portion of distal ileum are removed. Her post-operative course is prolonged, but she eventually recovers fully.

Facilitation questions

  1. Do you think the diagnosis of gastroenteritis was reasonable in the circumstances? What would assist you in deciding whether the diagnosis was reasonable?  Discuss the difference between a breach of the standard of care and an error of judgment.  Was this a diagnosis that a reasonable resident in the circumstances would have made based on this information?
  2. What would you like to see in the documentation of the clinical findings?
  3. What would you advise the resident to include in the documentation of the discharge instructions?

Suggestions to faculty

Have learners discuss if a telephone consultation was appropriate in this situation. Would other supports make a virtual assessment more complete or more clinically appropriate? Learners should provide a rationale for their decision.

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