upper abdominal copy 0  CC: year old MFtransgendercustom with no pertinent PMH/PSH presents with  Focused HPIno custom nb/nb vomitingno custom hx of abd surgeries Biliary related history:no custom hx of gallstonesno custom recent feversno custom vomitingnot custom worse after eating Ulcer risk factors:no custom hx of ulcersno custom BRBPR/tarry stoolno custom hx of heavy etoh useno custom hx of high dose/prolonged NSAIDS no suspicious foods/sick contacts/recent travel HPI: Characteristics obtain from interview with patient: Pertinent positives:  Pertinent negatives:  REVIEW OF SYSTEMS: Much of this set of ROS can be generally obtained by asking: Are you sick now or recently sick? Any pain anywhere in your body other than what we spoke about? Any vomiting or changes in your bowel habits? Any bleeding from anywhere?  Constitutional:  ENT:  Eye:  Cardiac:  Pulmonary:  GI:  GU:  Nuero:  MSK:  Pysch: ID:  Endo:  EXAM:  VITALS: (overall impression of vital signs with repeat vitals in EMR as RNs re-access patient): HR: normal HR.tachycardic BP: normotensive.hypertensive (attempted to inform pt to advise to f/u with PMD).hypotensive. O2 sat: no hypoxiahypoxic RR: normal RRtachypnic  PHYSICAL EXAM:  General: well nourishedno distressmild distressmoderate distresssevere distress  HEENT: vision grossly intact. hearing grossly intact.  Cardiovascular: \ no r/m/g \ no LE swelling  Pulmonary: Lungs CBTA, No respiratory distress, Speaking comfortably in full sentences.I/E wheezing,rales,rhonchi,respiratory distress.  GI: \ abd soft, \ abd non-tender in all 4 quadrants,TTP diffuselyTTP in RUQTTP in RLQ  Neuro: \ Normal LOC. \ No grossly focal neurological deficits.Somnolent though protecting airway  MSK: no deformities, moving all extremitiesNon-ambulatory.  Pysch: Normal speech. Demonstrates linear thinking.No SI/HI.Endorses SIEndorses HIExam consistent with gravely disabled.No AH/VH.Agitated.Confused. Focus Exam (based upon chief complaint)Abdominal Exam: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)upregEKG (eval for atypical anginal presentation)tropRUQ US: no sonographic evidence cholecystititsCT (indications: suspicion for acute surgical abdominal processes: appendicitis, SBO, complicated diverticulitis, perforated viscus, AAA)Therapeutically:analgesia/anti-emetics Additional Diagnostics/Theraputics  ED COURSE and MDM:  Assessment/Plan: year old with PMH/PSH of presented with  evaluation is most consistent with   Concurrent evaluation for secondary problem is consistent with  DDx includes but in not limited to (pt does not meet reasonable likelihood/consistency with the dx to warrant additional pursuit of these entities (risks outweigh benefits of non-indicating testing)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.Endocrine:-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. Plan:   Re-evaluation:Unchanged on re-evaluation.Improved on re-evaluation.On re-evaluation, remains intoxicated. Hemodynamically stable. Will continue observation. Supplemental Documentation: OBSERVATION NOTE: CRITICAL CARE PROCEDURE NOTE:  COUNSELING: SUPERVISION:  Of note, follow up over-read mechanism in place for over-reads and follow up of pending diagnostics.