Abdominal Pain

HISTORY:

Abdominal pain for ‍ ‍hoursdays

Location: ‍diffuse

Radiation: ‍none

Severity: ‍mildmoderatesevere, ‍012345678910 / 10

Type: ‍crampingburning

Onset: ‍gradualsudden, following ‍

Pattern: ‍constantintermittent, worse during the ‍day

Episode duration: ‍ ‍secminhoursdaysweeksmonths

Worsening factors or triggers: ‍none

Alleviating factors: ‍none, ‍effectiveineffective

‍nausea

‍vomiting, ‍ episodes ‍per day, ‍

‍diarrhea, ‍ episodes ‍per day, ‍

‍constipation

‍changes in bowel habits

‍fever, up to ‍°, over ‍ ‍hoursdays

‍chills

‍weight loss, ‍ ‍lbskg over ‍ ‍weeksmonths, ‍unintentionalintentional



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Pelvic: vulva ‍normal, vagina ‍normal, cervix ‍normal, uterus ‍normal, adnexa ‍normal, ‍no cervical motion tenderness

Genital: ‍normal, testicles ‍normal, penis ‍normal

Extremities: ‍edema, ‍warm, cap refill ‍< 3 sec> 3 sec, pulses ‍normal, ‍



ASSESSMENT:

‍Gastroenteritis ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Blood work: ‍CBC, ‍lytes, ‍creatinine, ‍glucose, ‍LFTs, ‍lipase, ‍CRP, ‍ß-hCG

- Urinalysis

- Abdominal X-ray

- Abdominal ultrasound

- CT scan of abdomen and pelvis

- Upper GI endoscopy

- Colonoscopy

- ‍Dietary modificationsNPO

- ‍PPIs

- ‍Analgesics

- ‍Antiemetics

- Referral to gastroenterologist

- Referral to surgeon

- Follow-up in ‍ ‍daysweeks

- Return if pain worsens or if new symptoms develop such as fever, vomiting, or blood in stools