GI Sx

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of gastrointestinal symptoms

Symptoms include:

‍nausea

‍vomiting, ‍ episodes ‍per day, ‍, ‍hematemesis

‍bloating

‍flatulence

‍diarrhea, ‍ episodes ‍per day, ‍

‍constipation

‍changes in bowel habits

‍abdominal pain, ‍diffuse, ‍dull, ‍mild

‍heartburn

‍dysphagia

‍dyspepsia

‍loss of appetite

‍weight loss, ‍ ‍lbskg over ‍ ‍weeksmonths, ‍unintentionalintentional

‍fever, up to ‍°, over ‍ ‍hoursdays

‍chills

‍jaundice

‍dizziness

last menstrual period: ‍ ‍daysweeksmonths ago



Worsening factors: ‍none

Alleviating factors: ‍none, ‍effectiveineffective



Contributing factors:

‍smoking

‍excessive alcohol consumption

‍poor diet

‍stress

‍recent travel

no history of: ‍gastroesophageal reflux disease, ‍peptic ulcer disease, ‍gastrointestinal cancer, ‍chronic liver disease, ‍gallbladder disease, ‍abdominal surgeries

no use of: ‍nonsteroidal anti-inflammatory drugs, ‍antibiotics, ‍corticosteroids, ‍bisphosphonates, ‍iron supplements, ‍new medication

no family history of: ‍colorectal cancer





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:

‍Functional gastrointestinal symptoms ‍likelysuspectedpossible

DDx: functional gastrointestinal symptoms, gastroenteritis, irritable bowel syndrome, inflammatory bowel disease, GERD, peptic ulcer disease, appendicitis, diverticulitis, colorectal cancer, food intolerance, lactose intolerance, celiac disease, pancreatic insufficiency, biliary tract disease, intestinal obstruction, constipatin, medication side effects, small intestinal bacterial overgrowth, ischemic colitis, radiation enteritis, mesenteric ischemia, intestinal parasites, bacterial gastroenteritis, traveler's diarrhea, food poisoning, functional dyspepsia, chronic mesenteric insufficiency, giardiasis, cryptosporidiosis, whipple's disease, tropical sprue, intestinal tuberculosis, intestinal lymphoma, gastric cancer





PLAN:

Investigations:

- Blood work: ‍CBC, ‍CRP, ‍electrolytes, ‍creatinine, ‍glucose, ‍LFTs, ‍lipase

- Stools: ‍bacterial culture, ‍parasitic culture, ‍C. difficile toxin

- Abdominal X-ray

- Ultrasound of the abdomen

- Upper GI endoscopy

- Colonoscopy

Treatments:

- Dietary modifications: ‍avoid spicy foods, ‍increase fiber intake, ‍avoid trigger foods

- ‍GI medications

Further care:

- Referral to gastroenterologist

- Referral to dietitian

- Follow-up in ‍ ‍weeksmonths

- Return if symptoms worsen or if new symptoms develop such as weight loss, blood in stools, or fever