Problem based H&P: Abdominal pain, undifferentiated
History of Present Illness: #Abdominal Pain: Patient has had _ of _ duration with timing that is _ located _ that is described as _, with radiation _, improved by _, and worsened by _. At time of onset, patient was _. Associated symptoms include _. Patient has _ similar symptoms previously. Patient denies nausea, vomiting, diarrhea, constipation, melena, hematochezia, jaundice, dysuria, hematuria, oliguria, polyuria, fever, chills, unintentional weight loss, dysphagia or early satiety. Last bowel movement was _. Last menstrual period was _, lasting _ days, and typically occurs _. Patient denies recent medication changes, recent illness, sick contacts, or recent travel. Patient does not use NSAIDs on a regular basis. ED Course: Review of Systems: Constitutional: Denies weight loss, fever, chills, weakness or fatigue. Eyes: Denies visual changes or eye pain. Ears, Nose, Mouth, Throat: Denies dysphagia, hearing loss, sneezing, runny nose or sore throat. Cardiac: Denies chest pain/discomfort, palpitations, orthopnea or edema. Pulmonary: Denies shortness of breath, dyspnea on exertion, cough or sputum. Gastrointestinal: Denies anorexia, nausea, vomiting, constipation, diarrhea, abdominal pain or blood per rectum. Genitourinary: Denies dysuria, hematuria, frequency or urgency. Musculoskeletal: Denies muscle pain, back pain, joint pain or stiffness. Skin: Denies rash, jaundice or itching. Neurologic: Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities, or any change in bowel or bladder control. Psychiatric: Denies depression, anxiety, suicidal ideation or homicidal ideation. Endocrine: Denies sweating, cold or heat intolerance, polyuria or polydipsia. Hematologic: Denies bleeding or bruising. Allergic: Denies itchy/watery eyes. Medical History: Denies coronary artery disease (CAD) Surgical History: Denies appendectomy, Denies cholecystectomy, Denies colon resection, Denies total abdominal hysterectomy (TAH) Medications: reviewed and reconciled Allergies: no known allergies to drugs, iodine, eggs or shellfish Social History: Smoking: Never smoker Alcohol: Denies Drugs: Denies Diet: no new or uncooked foods Sexual History: _ partners in the last 6 months, _ protection used, _ known STI exposures Family History: Denies coronary artery disease (CAD) ---------------------------------------------------------------------- Vitals: reviewed and interpreted Physical Exam: Constitutional: well-developed, well-nourished, no acute distress Eyes: normal sclera bilaterally, no discharge observed EARS, NOSE, MOUTH, THROAT: normocephalic, normal oral mucosa, normal tonsils, no visible lesions or exudates, no cervical lymphadenopathy Cardiac: normal rate, regular rhythm, no murmurs, no rubs, no gallops, 2+ radial pulses bilaterally, 2+ dorsalis pedis pulses bilaterally, no peripheral edema Pulmonary: clear to auscultation bilaterally, no wheezes, no rales, no rhonchi, normal work of breathing Abdomen: soft, non-tender, non-distended, normal bowel sounds in all 4 quadrants, no rebound, no guarding, negative psoas sign, negative obturator sign, no discomfort with provider bumping the bed, no fluid wave, negative Murphy's sign, no McBurney's point tenderness, no hepatomegaly, no splenomegaly Musculoskeletal: moves all extremities without sign of pain, no visible deformities Skin: no visible lesions, no visible rashes Neurologic: alert and oriented to person/place/time/situation, moves all extremities freely Specialized Testing: #Digital Rectal Exam: normal brown stool observed, no melena, no blood, normal sphincter tone, no hemorrhoids. Bedside Ultrasound: Electrocardiogram: Labs: reviewed and interpreted Imaging: reviewed and interpreted ---------------------------------------------------------------------- Assessment and Plan: #Abdominal Pain, Undifferentiated: Patient’s current condition is described above. Differential diagnosis is broad and detailed below according to region. No signs of peritonitis or surgical abdomen at this time (to include rebound tenderness, abdominal rigidity or pain out of proportion to exam). If patient becomes unstable or develops signs of peritonitis, will consult general surgery for urgent surgical evaluation. Patient’s pain is primarily located _, making the below differential diagnoses associated with that region more likely. The most likely etiology at this time is _. If patient also has additional gastrointestinal symptomatology, will perform workup of that as well. Plan for workup and treatment as described below: -CBC, metabolic panel -Hepatitis serologies, hepatic function tests, lipase -Troponin, EKG, PT/PTT/INR, lactate -Urine HCG -Consider abdominal imaging US/CT/MRCP -Consider GI consultation for assistance with workup or endoscopic evaluation -Will urgently consult general surgery if patient becomes unstable or develops signs of peritonitis DIFFERENTIAL -Right Upper Quadrant Pain: cholecystitis, cholelithiasis, cholangitis, biliary colic, Sphincter of Oddi dysfunction, acute hepatitis, Budd-Chiari syndrome, portal vein thrombosis, hepatic abscess, Fitz-Hugh-Curtis syndrome, nephrolithiasis, pyelonephritis -Epigastric Abdominal and Left Upper Quadrant Pain: acute coronary syndrome, gastroesophageal reflux disease (GERD), pancreatitis, peptic ulcer disease (PUD), gastroparesis, esophagitis, gastritis, nephrolithiasis, pyelonephritis, splenic dysfunction (injury/infarct/abscess/enlargement) -Lower Abdominal: appendicitis, colitis (infectious vs inflammatory), diverticulitis, pyelonephritis, cystitis, nephrolithiasis, urinary retention -Pelvic Pain: ectopic pregnancy, pregnancy, menses, Mittelsmerz, pelvic inflammatory disease, ovarian torsion, ruptured ovarian cyst, endometritis, uterine fibroids -Variable Abdominal Pain: bowel obstruction, mesenteric ischemia, gastrointestinal perforation, gastroenteritis, spontaneous bacterial peritonitis, celiac disease, constipation, irritable bowel syndrome, inflammatory bowel disease, nephrolithiasis, pyelonephritis, ketoacidosis (diabetic/starvation/alcoholic) Preventive Medicine: Diet: VTE Prophylaxis: GI Prophylaxis: Code Status:
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