upper abdominal copy

  • CC: year old with pertinent PMH/PSH presents with
  • Focused HPI
    • nb/nb vomiting
    •  hx of abd surgeries
    • Biliary related history:
      •  hx of gallstones
      •  recent fevers
      •  vomiting
      •  worse after eating
    • Ulcer risk factors:
      •  hx of ulcers
      •  BRBPR/tarry stool
      •  hx of heavy etoh use
      •  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 hypoxia
        • hypoxic
      • RR:
        • normal RR
        • tachypnic
    • PHYSICAL EXAM:
      • General:
        • well nourished
        • no distress
        • mild distress
        • moderate distress
        • severe 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 diffusely
        • TTP in RUQ
        • TTP in RLQ
      • Neuro:
        • \ Normal LOC.
        • \ No grossly focal neurological deficits.
        • Somnolent though protecting airway
      • MSK:
        • no deformities,
        • moving all extremities
        • Non-ambulatory.
      • Pysch:
        • Normal speech.
        • Demonstrates linear thinking.
        • No SI/HI.
        • Endorses SI
        • Endorses HI
        • Exam 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)
    • upreg
    • EKG (eval for atypical anginal presentation)
    • trop
    • 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
  • 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.