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CC: Abdominal pain
HPI – 49 yo Caucasian female presents complaining of constant abdominal pain that began yesterday shortly after eating lunch consisting of pizza, wings, and garlic bread with coworkers, none of them has similar symptoms. Admits prior history of similar pain typically goes away in a half-hour, occurring every couple of months for the last year or so. This time the pain is not going away. She describes the pain as cramping, occurring in the epigastric area, traveling though the body to the right upper back. Intensity 9/10 cycling to a low of 3 and then up again. Denies exacerbation with any particular foods. Pepto-Bismol, 1 TBS taken 2 x yesterday and 1 x today without effect. Admits feeling warm, but did not take temp. Vomited after lunch day prior – food substances and clear fluids once in evening. Avoided supper and breakfast this AM. Slight amount of diarrhea this AM without blood. Denies icterus, dyspepsia, weight loss or gain, fatigue, shortness of breath, pain elsewhere.
Social history: Diet – eats out frequently, caffeine – 1 or 2 cups of coffee per day, tobacco - none, etoh - one glass of wine a couple days a week, occupation – works at a medical office
Surgical Hx: Carpal tunnel release L hand one month ago without complications and good relief
Medical Hx: Hypothyroidism
Hosp Hx: None
Allergies: None
Medications: Synthroid 0.125 mg daily
FDLMP: 3 weeks ago
Family history: Mother 72 – good health, father – 75 – good health, sister – good health, brother with htn
VS: BP 120/84, Resp 22, P 108, T 99.0F, Wt 148 lbs, Ht 5'4"
General: Moderate distress, holding epigastrium
HEENT: No icterus, throat without erythema or exudate
Lungs: Clear to auscultation throughout. Shallow inspiration. Pain in abdomen with deep breath during auscultation
Heart: Regular rhythm, S1 S2 without S3 or S4, murmur
Abdomen: Insp - rounded, no masses. Ausc - normoactive bowel sounds times 4 quads. Guarding in the RUQ with tenderness to light and deep palp. Perc tympanic at gastric bubble and left lower quadrant also with RUQ tenderness. Positive Murphy sign. No rebound tenderness.
Cholecystitis
Rule out choledocholithiasis
Doubt pancreatitis
Doubt gastroenteritis
Doubt hepatitis
Place IV: Run NS at 125 cc/hr
IV antibiotic and analgesic
CBC, AST, ALT, Alk Phos, total/direct bilirubin, BUN/Creat, Na, K, Cl, pregnancy test, urinalysis
CT scan of abdomen
Return to room to offer rectal exam
Surgical consult