Abdominal Pain

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of abdominal pain

Onset was ‍gradualsudden, started ‍whileafter ‍

Location is ‍diffuse

Radiation ‍none to ‍

Rated at ‍012345678910 / 10 ‍

Described as ‍crampingburning

Pattern ‍constantintermittent, worse during the ‍day

Episodes last for ‍ ‍, recur ‍ times per ‍

Worsening factors: ‍none

Alleviating factors: ‍none, ‍effectiveineffective



Associated symptoms: *Try using right-click for negatives*

‍nausea

‍vomiting, ‍ episodes ‍per day, ‍, ‍hematemesis

‍diarrhea, ‍ episodes ‍per day, ‍

‍constipation

‍changes in bowel habits

‍hematochezia, ‍bright reddark red, ‍around stoolsmixed with stools, ‍withwithout clots

‍black tarry stools, ‍withwithout strong foul smell

‍bloating

‍flatulence

‍fever, up to ‍°, over ‍ ‍hoursdays

‍chills

‍weight loss, ‍ ‍lbskg over ‍ ‍weeksmonths, ‍unintentionalintentional

‍loss of appetite

‍heartburn

‍dyspepsia

‍chest pain, ‍retrosternal, ‍aching, ‍on exertionat restwith deep breath, ‍mild

‍pelvic pain

‍missed period, ‍one cycles missed, ‍possibility of pregnancynot sexually active

‍vaginal bleeding

‍abnormal vaginal discharge, ‍clear, ‍thin, ‍withwithout fishy odor

‍dysuria

‍urinary frequency

‍hematuria



Contributing factors:

‍heavy alcohol consumption

‍smoking

‍recent travel

‍high fat diet

no history of: ‍food allergies or intolerances, ‍irritable bowel syndrome, ‍peptic ulcer disease, ‍abdominal surgeries, ‍pregnancy, ‍anxiety

no use of: ‍NSAIDs, ‍oral contraceptives, ‍new medication, ‍opioids, ‍antibiotics





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

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

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍guarding, bowel sounds ‍normal, ‍, ‍CVA tenderness ‍

Anorectal: DRE ‍normal, prostate ‍normal, ‍blood, ‍mass, anus ‍

Pelvic: external genitalia ‍normal, vagina ‍normal, cervix ‍normal, uterus ‍normal, adnexa ‍normal, ‍cervical motion tenderness

Genital: penis ‍normal, testes and epididymis ‍normal, ‍inguinal hernia

Extremities: ‍warm, ‍dry, cap refill ‍< 3> 3 sec, pulses ‍intact, ‍edema ‍bilaterally, ‍





ASSESSMENT:

‍Gastroenteritis ‍likelysuspectedpossible

DDx: gastroenteritis, gastritis, appendicitis, gallstones, cholecystitis, pancreatitis, diverticulitis, peptic ulcer disease, irritable bowel syndrome, inflammatory bowel disease, small bowel obstruction, renal colic, kidney stones, pyelonephritis, hepatic abscess, hepatitis, ectopic pregnancy, ovarian cyst rupture, ovarian torsion, mesenteric ischemia, abdominal aortic aneurysm, herpes zoster, diabetic ketoacidosis, myocardial infarction, pneumonia with referred pain, sickle cell crisis





PLAN:

Investigations:

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

- Urinalysis

- Abdominal X-ray

- Abdominal ultrasound

- CT scan of abdomen and pelvis

- Upper GI endoscopy

- Colonoscopy

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

Treatments:

- ‍PPIs

Further care:

- Referral to gastroenterologist

- Referral to surgeon

- Follow-up in ‍ ‍daysweeks