Reviewed triage note:
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HPI (on my evaluation of patient):
_ nb/nb vomiting
no hx of abd surgeries
_Female specific HPI:
no hx of gallstones
no recent fevers
no vomiting
not worse after eating
no hx of ulcers
no BRBPR/tarry stool
hx of heavy etoh use
hx of high dose/prolonged NSAIDS
no suspicious foods/sick contacts/recent travel
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Review Of Systems:
Constitutional: no recent fever
Integument: no rashes
Eye: no acute vision changes
ENT: no current rhinorrhea/sore throat
CV: no chest pain, no syncope
Resp: no SOB, no new productive cough
GI: as detailed above in HPI
GU: no dysuria
MSK: no recent trauma/fall to any extremity
Neuro: no focal weakness
Psych: no confusion
PMH/PSH: as noted in HPI
FH: reviewed, non-contributory to patient’s current complaint
Physical Examination:
General: NAD, Alert,
Skin: No rash, warm, dry
Eye: PEERL, EOM intact
CV: RRR, no r/m/g
Resp: Lungs CBTA, respirations non-labored
GI: Abd soft, non-tender
LEs:No LE swelling, palpable pulses
Neuro: Alert and oriented, normal mentation, no focal motor/sensory deficit
Psych: Normal speech, linear
MSK: No deformitites, normal ROM
Pelvic exam: on bi-manual exam no CMT, no adnexal tenderness, no abnormal discharge, no vaginal bleeding. No masses palpable.
Chaperoned by female RN for patient’s comfort: _
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ED COURSE/MDM/A/P:
Diagnostically:
cbc (to eval for luekocytosis or significant anemia)
bmp (to eval for electrolyte derangements)
LFT’s, lipase (to eval for labratorial evidence of hepato-biliary pathology)
UA (to eval for atypical presentation of UTI/pyelo)
_ upreg
_ EKG (eval for atypical anginal presentation)
_ RUQ US: no sonographic evidence cholecystitits
_ CT (eval for acute surgical abdominal processes)
Therapeutically:
analgesia/anti-emetics
MDM:
DDx:
_Gyn:
-Doubt pregnancy related complications (e.g. ectopic, abruption, etc) given upreg neg.
-Doubt PID given no CMT, no adnexal tenderness on pelvic exam.
-Doubt UTI given non-infectious UA.
_Testicular:
-Doubt testicular torsion given pt denies testicular pain and GU exam reveals non-tender testicle, normal lie.
-Doubt ure
GI:
-Doubt diverticulitis given age make pre-test probability less likely, no diarrhea, no hx of diverticulitis.
-Unlikely appendicitis given low pre-test probability based upon hx, exam (no RLQ pain), risks of radiation related malignancy outweigh potential benefits of CT.
-Considered gastritis (infectious or ulcerative). Pt advised to f/u with PMD and if sx persist, to request GI referral for endocscopy for definitive diagnosis. Given possibility of gastritis/ulcer and relatively benign side effect profile, pt offered to start empiric trial of famotidine (OTC).
-Doubt bleeding ulcer given no hx of BRBPR/melena, no signs of anemia on exam nor significant anemia on cbc.
-Doubt perforated viscus given abd exam benign, pt well appearing, no significant labratorial abnormalities, non-severe pain, and tolerance of PO challenge in ED.
-Doubt incarcerated hernia given no hernia on exam, no tender/non-reducible hernia on exam.
GU:
-Doubt atypical presentation for nephrolithiasis given no CVA tenderness, no hematuria on UA.
-Doubt pyleonephritis given no CVA tenderness, systemically well.
Hepato-Biliary:
-Doubt cholecystitis given lower abd pain atypical for hepato-biliary pathology, LFTs not c/w cholecystitis. Pt advised if worsening of symptoms to return given possibility of interval development of cholecystitis.
-Doubt cholelithiasis given above rationale.
-Doubt pancreatitis given lipase wnl.
Endrocrine:
-Doubt DKA given no elevated glucose with anion gap.
Vascular:
-Doubt AAA given age, low likelihood based upon lack of risk factors, no palpable pulsitile mass
DIAGNOSIS:
PLAN:
DISPOSITION:
COUNSELLING: Patient/family educated on diagnostics, assessment, treatment plan. Patient/family amendable and in agreement with proposed plan. All questions and concerns addressed and answered.
SUPERVISION: Discussed and obtained approval/confirmation of evaluation (history/exam/diagnostics) and plan (assessment/interventions/disposition) with ED attending physician
*This information is intended for educational purposes only and not intended for use in patient care (which requires a trained credentialed attending physician and individualization of the medical care plan to the specific patient).