S:

MF is a 45 yo female with chief complaint of “stomach pain.” The sharp epigastric pain began 3 days ago, has been continuous, and does not radiate. She reports 9/10 pain severity. This is the first occurrence. Admits diarrhea, vomiting, anorexia. Denies fever, chills, weakness, nausea, shortness of breath, dyspepsia, hematemesis, hematochezia, melena, dysuria. LMP 1/5/19. Tried Pepto-Bismol with no relief. Last BM this AM.

PMH: Left Ovarian Cyst, Appendicitis, Gallstones, Irregular Menses, Scoliosis

PSH: Appendectomy, Cholecystectomy

Allergies: NKDA

Medications: Acetaminophen (Tylenol) 325mg 1-2 tabs PO q4-6h prn for back pain

FHx: Unknown

SHx: Denies EtOH, Tobacco Use

O:

T 99.0°F | BP 126/80mmHg | P 84 BPM, regular | RR 12 breaths/min, unlabored | SpO2 96% RA

H 67in | W 150 lb. | BMI 23.5

Gen: Slender female, neatly groomed, looks her stated age of 45 years. Alert and cooperative. Holding abdomen. Some distress.

Skin: Warm and moist. Good turgor. Nonicteric.

HEENT: Symmetrical OU. No strabismus, exophthalmos, or ptosis. Sclera are white and nonicteric. Conjunctiva and cornea clear.

Mouth/Pharynx: Oral mucosa pink, well-hydrated. No masses, lesions.

CV: RRR. S1 and S2 are normal. There are no murmurs, S3, S4, splitting of heart sounds, friction rubs.

Pulm: Clear to auscultation and percussion bilaterally. Chest expansion symmetrical. No wheezing, rhonchi, rales, dullness.

Abd: Flat, symmetrical. No scars, striae, caput medusa. BS present in all four quadrants. No bruits over aortic/renal/iliac/femoral arteries. Tympanic to percussion throughout. Tender to light and deep palpation of epigastric region. No guarding or rebound, CVAT, organomegaly.

A:

45 yo female with epigastric pain, diarrhea, vomiting, anorexia x 3 days. Likely gastroenteritis.

Differential Diagnosis:

1. Ectopic Pregnancy
2. Myocardial Infarction
3. Gastroenteritis
4. Choledocholithiasis
5. Pancreatitis
6. Hepatitis

P:

Labs:

• Qualitative Beta-HCG with Reflex, R/O: Pregnancy
• Troponin, R/O: MI
• CBC, BMP, Lipase, LFTs, Bilirubin (total, direct, indirect)
• U/A, Urine Culture

 

Imaging/Tests:

• EKG, R/O: MI

Gastroenteritis:

• Start 1L Normal Saline IV
• Start Famotidine (Pepcid) 20mg PO qd
• Start Calcium Carbonate (Maalox) 2 Tabs PO prn; Max 12 tabs/24h
• Start Ondansetron (Zofran) 8mg PO q8h prn

Left Ovarian Cyst

• Surgical removal scheduled for Friday per patient

Irregular Menses

• Follow up with Dr. Chu (Patient’s OB/GYN)

Scoliosis

• Follow up with PMD
• Continue Acetaminophen (Tylenol) 325mg 1-2 tabs PO q4-6h prn for back pain

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student

 

Adjusted DDx After H&P: Ectopic Pregnancy Myocardial Infarction Gastroenteritis Choledocholithiasis Pancreatitis Hepatitis

Initial DDx Based on CC:

Gastritis

Gastroenteritis

GERD

PUD

Pancreatitis

Appendicitis

Cholecystitis

Cholelithiasis, Choledocholithiasis

Cholangitis

Hepatitis

Acute Splenomegaly

Nephrolithiasis

Pyelonephritis

Irritable Bowel Syndrome

Irritable Bowel Disease

Diverticulitis

Endometriosis

Ruptured Ovarian Cyst

Ectopic Pregnancy

Cystitis

Salpingitis/PID

Myocardial Infarction

Aortic Aneurysm