Upper Abdominal Pain

HISTORY:

‍Upper abdominal pain for ‍ ‍hoursdays

Onset: ‍gradualsudden, following ‍

Location: ‍diffuseepigastric

Radiation: ‍noneback

Severity: ‍mildmoderatesevere, ‍012345678910 / 10

Type: ‍crampingburning

Pattern: ‍constantintermittent

Episode duration: ‍ ‍secminhoursdaysweeksmonths

Worsening factors: ‍none

Alleviating factors: ‍none, ‍effectiveineffective

‍nausea

‍vomiting, ‍ episodes ‍per day, ‍

‍hematemesis

‍heartburn

‍dyspepsia

‍dysphagia

‍bloating

‍diarrhea, ‍ episodes ‍per day, ‍

‍constipation

‍changes in bowel habits

‍hematochezia

‍dark, tarry stools

‍fever, up to ‍°, over ‍ ‍hoursdays

‍chills

‍weight loss, ‍ ‍lbskg over ‍ ‍weeksmonths, ‍unintentionalintentional

‍chest pain

‍shortness of breath



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, ‍



ASSESSMENT:

‍Gastritis ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Blood work: ‍CBC, ‍CRP, ‍lytes, ‍creatinine, ‍glucose, ‍LFTs, ‍lipase, ‍ß-hCG, ‍troponin, ‍H. pylori antibodies

- Urinalysis, urine culture

- Abdominal X-ray

- Abdominal ultrasound

- CT scan of abdomen and pelvis

- Upper GI endoscopy

- Colonoscopy

- Stool tests: ‍FIT test, ‍calprotectine, ‍fecal pancreatic elastase

- ECG

- ‍PPIs

- Referral to gastroenterologist

- Referral to general surgeon

- Follow-up in ‍ ‍daysweeks

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