Lower Abdominal Pain

HISTORY:

‍Lower abdominal pain for ‍ ‍hoursdays

Onset: ‍gradualsudden, following ‍

Radiation: ‍none

Severity: ‍mildmoderatesevere, ‍012345678910 / 10

Type: ‍crampingburning

Pattern: ‍constantintermittent, worse during the ‍day

Episode duration: ‍ ‍secminhoursdaysweeksmonths

Worsening factors: ‍none

Alleviating factors: ‍none, ‍effectiveineffective

‍nausea

‍vomiting, ‍ episodes ‍per day, ‍

‍hematemesis

‍diarrhea, ‍ episodes ‍per day, ‍

‍constipation

‍changes in bowel habits

‍bloating

‍inability to pass gas

‍fever, up to ‍°, over ‍ ‍hoursdays

‍chills

‍weight loss, ‍ ‍lbskg over ‍ ‍weeksmonths, ‍unintentionalintentional

‍loss of appetite

‍pelvic pain

‍vaginal bleeding

‍hematuria

‍dysuria

‍urinary frequency

Last menstrual period: ‍ ‍daysweeksmonths ago



EXAM:

General appearance: ‍well-appearing

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

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

CVA tenderness: ‍negativepositive on Rpositive on L

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

Genital: ‍normal, testicles ‍normal, penis ‍normal



ASSESSMENT:

‍Diverticulitis ‍likelysuspectedpossible

DDx: ‍



PLAN:

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

- Urinalysis, urine culture

- Abdominal X-ray

- Abdominal ultrasound

- CT scan of abdomen and pelvis

- Upper GI endoscopy

- Colonoscopy

- ‍Dietary modificationsNPO

- ‍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