Reviewed triage note:

”

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HPI (on my evaluation of patient):

_ nb/nb vomiting

no hx of abd surgeries

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

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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 (indications: suspicion for acute surgical abdominal processes: appendicitis, SBO, complicated diverticulitis, perforated viscus, AAA)

Therapeutically:

analgesia/anti-emetics

MDM:

DDx:

Hepato-Biliary:

-Doubt cholecystitis given US shows no sonographic e/o cholecystitis and labs not concerning for cholecystitis. Pt advised if worsening of symptoms to return given possibility of interval development of cholecystitis.

-Doubt cholelithiasis given US shows no gall stones, normal LFTs.

-Doubt pancreatitis given lipase wnl.

GU:

-Doubt atypical presentation for nephrolithiasis given no CVA tenderness, no hematuria on UA.

-Doubt pyleonephritis given no CVA tenderness, non-infectious UA systemically well.

Gyn:

-Doubt pregnancy related complications (e.g. ectopic, abruption, etc) given upreg neg.

-Doubt PID given location of pt’s complaints in upper quadrants and pt denies high risk sexual history and denies vaginal discharge.

-Doubt ovarian torsion given abd pain is in upper quadrants which would be exceedingly atypical for primary ovarian pathology.

GI:

-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.

-Atypical for appendicitis and given low pre-test probability based upon hx, exam, risks of radiation related malignancy outweigh potential benefits of CT.

-Doubt diverticulitis given location of pain in upper quadrants.

-Doubt incarcerated hernia given no hernia on exam, no tender/non-reducible hernia on exam.

Endrocrine:

-Doubt DKA given no elevated glucose with anion gap.

Vascular:

-Doubt AAA given age, risk factors, no palpable pulstile mass, and atypical presentation for AAA.

DIAGNOSIS:

PLAN:

DISPOSITION: