Clinical Analysis on Abdominal Pains

S: 46-year-old female presents today to the office with complains of abdominal pain lasting for 4 hours after eating a fatty meal. Patient states symptoms started couple months ago with an off and on discomfort after eating a fatty meal. She recalls a similar pain 3 weeks ago after eating a burger. Patient reports her pain started yesterday after dinner and lasted for 4 hours. She notes usually the pain goes away quickly but over the course of the few past months the pain comes more often after meals. Patient localizes her pain at her right upper quadrant radiating to the right shoulder. During the attack the pain was 8/10 and currently at the office 3/10 of pain. She describes her pain to be constant pulsating wave like pain. Patient states taking OTC Pepcid without good effect, using heating pad as well without significant improvement and Benadryl to help her sleep. Focused ROS-GEN: Patient denies any fatigue, +low grade fever, or weight changes. HEENT: Patient denies Headache, dizziness, sore throat, changes in vision or hearing. Neck: Denies neck pain, hoarseness, or difficulty swallowing. Chest: Denies cough, SOB, or difficulty breathing when sleeping or laying down. CV: Denies palpitations, and chest pain at this time. GI: Patient denies vomiting, diarrhea, constipation, + nausea, changes with bowel pattern, decrease of appetite, and/or heartburn. Patient reports normal food and fluid intake (24-hour recall: breakfast-granola, mil, blueberries. Lunch- handful of walnuts and strawberries. Dinner-steak, salad with blue cheese dressing and baked potato with sour cream.) GU: Patient denies dysuria, incontinence, or changes in voiding pattern. MUSC: Denies joint pain or swelling. Neuro: Denies syncope, muscle weakness or ataxia. PV: denies any extremities swelling. PSYC: Denies any changes in mentation or mood. Denies Depression. Patient works as an interior designer. She is married, sexually active with two kids ages (18 and 22). LMP 3 months ago. Patient denies tobacco use and illicit drug use. She drinks ETOH socially. Patient denies sick contacts, no past travel, immunization up to date.

PMH: HTN, taking hydrochlorothiazide 50 mg daily. Patient allergic to Keflex. Family history of paternal colon cancer at age 42 and a healthy mother. Preventative care- colonoscopy a year ago with a normal result.

O: PE
Gen: Alert and oriented, interactive, no signs of anxiety or nervousness, overweight well-groomed female.
VS: BP 147/87, HR 98, RR 18, T 97.8 (O), Sats 98%, BMI 32
HEENT: normocephalic, PERRLA, sclera and conjunctiva without redness or injection. Mucosa and gingivai pink and moist. Throat: mucosa pink, no lesions, tonsils +1. Trachea midline, No JVP, no bruits, no lymphadenopathy, no pain on palpation.
Lungs: Non-tender with symmetric expansion. Respiration regular and unlabored without cough. Breath sounds clear to auscultation.
CV: + pulses throughout, RRR, Positive S1, S2, no murmurs, rub or gallop at APTEM.
GI: Abdomen round, soft, symmetric with no apparent masses, skin with few straie noted, no scars or lesions, + BSx4, no bruits, tympany in RUO, RLQ, LUQ, dull in LLQ. Tenderness and inspiratory pause elicited during palpation on the RUQ reflecting a + Murphy sign. A palpable gallbladder or fullness of the RUQ is present.
Musculoskeletal: Full ROM.

Additional systems and maneuvers deferred at this time as unrelated to CC.

DD:
Peptic Ulcer Disease: The patient reports a burning or gnawing pain that occurs most often with an empty stomach, stress, and alcohol intake. The pain is relieved by food intake Some patients describe the pain is steady, mild, or severe and locates in the epigastrium.
Gastritis: Pain is a constant burning pain in the epigastric area that can be accompanied by nausea, vomiting, diarrhea, or fever. Alcohol, nonsteroidal anti-inflammatory drugs, and salicylates make pain worse.
Cholecystitis/Lithiasis: Occurs more often in adults and females. The pain is colicky in nature and progresses to a constant pain. The patient reports RUQ pain which can radiate to the right scapular area. The typical pain of cholelithiasis is constant, progressively rising to a plateau and falling gradually. The patient can also experience nausea and vomiting and given a history of dark urine and/or light stools. On physical examination, the patient will be tender to palpation or percussion in the RUQ. The gallbladder is palpable in about half of cases of cholecystitis.

A: Cholecystitis/Cholelithiasis

P: Recommend labs: CBC with differential, serum amylase and lipase levels, LFT, Chemistry panel. Diagnostic: ABD ultrasound, CT scan to rule out cancer. Pharm: antibiotics levofloxacin 500 mg PO once daily. Phenergan 12.5 mg PO prn for nausea and vomiting, Meperidine 50 mg Po every 4 hours as needed for pain.
Non-Pharm: Heat may be used as needed for pain.
Education: Take Phenergan with food, water, or milk to minimized GI distress. Meperidine swallow tablet whole. Do not crush, break, or chew it. Drink plenty of fluids. Lose weight slowly, maintain a healthy diet rich in fiber low fat, eat more fruits and vegetables. Avoid fasting and starvation diets, which can promote formation of calculi. Know symptoms of acute cholecystitis/cholelithiasis and when to call 911.
• If you have chest pain or trouble breathing.
• Severe pain in your abdomen.
• Urinate less than usual.
Contact healthcare provided if:
• You have fever and chills
• Pain when urinate
• Skin or eyes turn yellow
Referral: gastroenterologist for consideration of endoscopic retrograde cholangiopancreatography (ERCP) and/or General surgery for non-emergent cholecystectomy.
Follow-up: Return to clinic in 2 weeks for follow up, review of lab results and prn.

Reference

Bickley, L. (2021). Bates’ guide to physical examination and health assessment
(13th ed.). New York: Lippincott, Williams & Wilkins.
Dains, J.E., Baumann, L.C., & Scheibel, P. (2019) Advanced health assessment and clinical diagnosis in primary care (6th ed.). Boston: Elsevier.
Wynne, W., & Robinson, E.A. (2020). Pharmacotherapeutics for Advanced Practice Nurse Prescribers (5th ed.). F. A. Davis Company