Abdominal Pain

 Abdominal Pain, ED Physician Note:

Clinical History:

A ؟؟-year-old male with known history of T2DM, HTN, Hyperlipidemia, and Obesity.

 Chief Complaint of: Described as acute, constant mid-abdominal pain, a deep, central cramping and aching sensation, non-traumatic, Denies radiation to the chest, back, flank, or groin, Rates pain 7/10 at its worst, Currently 6/10, Started spontaneously approx. 4 hours prior to presentation. and not positional. Not relieved by antacids or defecation, 

Reports one episode of non-bloody, non-bilious emesis approximately 2 hours ago. Denies fever, chills, diarrhea, constipation, or hematochezia/melena.

Denies chest pain, exertional dyspnea, diaphoresis, syncope, or jaw/arm pain. 

Denies back pain or pulsatile abdominal mass. 

Denies yellowing of the skin/eyes (jaundice) or dark urine. Pain is not primarily epigastric or right upper quadrant.

Denies history of PUD, recent NSAID use, or recent foreign travel. Denies bloody stool.

Physical Exam.:

VITALLY stable: T: 36.8C; HR: 105 (Tachycardia noted); BP: 130/80 mmHg; RR: 16; SpO2: 98% Room Air (RA); Pain Score: 7/10.

Abdomen: Obese. Soft, non-distended. Mid-abdominal tenderness to deep palpation. No rebound, guarding, or rigidity (no signs of peritonitis). No organomegaly. Bowel sounds are present but hypoactive. No obvious pulsatile mass noted.

General: Obese male, appears acutely uncomfortable but in no acute cardiopulmonary distress, Skin is warm and dry.

HEENT: Normocephalic, atraumatic, Conjunctivae pink, sclerae anicteric (not jaundiced). Oral mucosa moist.

Cardiovascular: Tachycardic, regular rate and rhythm. S1/S2 clear. No murmurs, rubs, or gallops (MRG). Capillary refill <3 seconds. Distal pulses 2+ and symmetric in all four extremities.

Pulmonary: Lungs clear to auscultation bilaterally (CTAB). Good air entry.

Extremities: No clubbing, cyanosis, or edema (NCE). 

Neurological: Alert and Oriented $\text{(A\&O) \times 4}$. No focal sensory or motor deficits.

Abdominal Pain; Disposition Consultant Note:

Abdominal pain adult male;

Given the large differential diagnosis for @NAME@, the decision making in this case is of high complexity.

After evaluating all of the data points in this case, the presentation of @NAME@ is NOT consistent with AAA; Mesenteric Ischemia; Bowel Perforation; Bowel Obstruction; Sigmoid Volvulus; Diverticulitis; Appendicitis; Peritonitis; Cholecystitis, ascending cholangitis or other gallbladder disease; perforated ulcer; significant GI bleeding, splenic rupture/infarction; Hepatic abscess; GI bleeding, or other surgical/acute abdomen.

Similarly, this presentation is NOT consistent with ACS or Myocardial Ischemia; Pulmonary Embolism; fistula; incarcerated hernia; Pancreatitis, Aortic Dissection; Diabetic Ketoacidosis; Kidney Stone; Ischemic colitis; Psoas or other abscess; Methanol poisoning; Heavy metal toxicity; or porphyria.

Similarly, this case is NOT consistent with testicular torsion, prostatitis, hernia, STI, or other testicular issue.

Similarly, this presentation is NOT consistent with acute coronary syndrome, pulmonary embolism, dissection, borhaave's, arrythmia, pneumothorax, cardiac tamponade, or other emergent cardiopulmonary condition.

Similarly, this presentation is NOT consistent with sepsis, pyelonephritis, urinary infection, pneumonia, or other focal bacterial infection.

Strict return and follow-up precautions have been given by me personally to the patient/family/caregiver(s).

Data Reviewed/Counseling: I have reviewed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

Abdominal pain adult female;

Given the large differential diagnosis for @NAME@, the decision making in this case is of high complexity.

After evaluating all of the data points in this case, the presentation of @NAME@ is NOT consistent with AAA; Mesenteric Ischemia; Bowel Perforation; Bowel Obstruction; Sigmoid Volvulus; Diverticulitis; Appendicitis; Peritonitis; Cholecystitis, ascending cholangitis or other gallbladder disease; perforated ulcer; significant GI bleeding, splenic rupture/infarction; Hepatic abscess; or other surgical/acute abdomen.

Similarly, this presentation is NOT consistent with ACS or Myocardial Ischemia or cardiac etiology; Pulmonary Embolism; fistula; incarcerated hernia; Pancreatitis, Aortic Dissection; Diabetic Ketoacidosis; Kidney Stone; Ischemic colitis; Psoas or other abscess; Methanol poisoning; Heavy metal toxicity; or porphyria.

Similarly, this case is NOT consistent with Fitz-Hugh-Curtis Syndrome, Ectopic Pregnancy, Placental Abruption, PID, Tubo-ovarian abscess, Ovarian Torsion, or STI.

Similarly, this presentation is NOT consistent with acute coronary syndrome, pulmonary embolism, dissection, borhaave's, arrythmia, pneumothorax, cardiac tamponade, or other emergent cardiopulmonary condition.

Similarly, this presentation is NOT consistent with sepsis, pyelonephritis, urinary infection, pneumonia, or other focal bacterial infection.

Strict return and follow-up precautions have been given by me personally to the patient/family/caregiver(s).

Data Reviewed/Counseling: I have reviewed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

Abdominal pain adult female;

Given the large differential diagnosis for @NAME@, the decision making in this case is of high complexity.

After evaluating all of the data points in this case, the presentation of @NAME@ is NOT consistent with intussception; bowel perforation/obstruction; volvulus; appendicitis; peritonitis; cholecystitis, ascending cholangitis or other gallbladder disease; significant GI bleeding, splenic rupture/infarction; hepatic abscess; or other surgical/acute abdomen.

Similarly, this presentation is NOT consistent with incarcerated hernia; pancreatitis, DKA; kidney stone; ischemic colitis; psoas or other abscess; methanol poisoning; heavy metal toxicity; porphyria; or abuse.

Similarly, this case is NOT consistent with Fitz-Hugh-Curtis Syndrome, Ectopic Pregnancy, Placental Abruption, PID, Tubo-ovarian abscess, Ovarian Torsion, or STI.

Similarly, this presentation is NOT consistent with sepsis, pyelonephritis, urinary infection, pneumonia, otitis media, or other focal bacterial infection.

@NAME@ is not currently dehydrated and is tolerating POs.

Strict return and follow-up precautions have been given by me personally to the family/caregiver(s).

Data Reviewed/Counseling: I have reviewed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.