HOPI
This is a 45-year-old male with PMH of GERD and hernia repaired, who presented with ABD pain that started 5 hours ago. He had a large burger and fries last night and was not able to sleep d/t ABD pain. The pain is located in the RUQ and right shoulder or scapula. He rates the pain as 7/10. He describes the pain as a “constant and severe”, with associated symptoms of nausea, chills, and vomiting. He has vomited twice, which provided him some relief. He thinks the emesis was consist of yellow bile without blood or coffee-ground. He has never experienced this before.
He denied diarrhea, constipation, melena, rectal bleeding, jaundice, or dysuria. He has not been exposed to anyone who has been sick or traveled outside of us.
PMH: GERD …show more content…
GI: ABD pain with N/V. No constipation, diarrhea, Change in bowel habits, or rectal bleeding.
GU: No incontinence, blood in urine, or painful voiding.
MUSCULOSKELETAL: No trauma. No muscle pain or stiffness.
NEURO: No weakness, tremor, fainting, numbness, or tingling.
PSYCH: no depression or nervousness.
PHYSICAL …show more content…
He appears to be in a great deal of pain.
Skin/Nails: Warm and dry. Color WNL for the race.
Respiratory: Bilaterally clear to auscultation.
Cardiovascular: S1 and S2 heard without extra sounds. No bruit. No edema.
Abdomen: No distension or pulsation. + Bowel sounds, No bruits. On Percussion, ABD is tympanic. ABD is soft but tender to palpation in the RUQ. Liver span normal. The spleen is nonpalpable. No rebound tenderness. + Murphy sign.
Neurologic: Recent memory intact.
LABS/DIAGNOSTICS:
None
Assessment:
1) Biliary colic
2) acute cholecystitis
3) Cholelithiasis
4) GERD
Plan:
1) Most likely biliary colic: Completed HIDA scan or US. Lab: CBC with diff, LFT, Chem 7, serum amylase and lipase, consult general surgery. Pain management: Oxycodone 10mg Q4hrs PRN. Colace 100mg BID PRN and Senna 8.6 mg BID PRN if constipation present. If the WBC is elevated start on ATB. Gentle hydration with normal saline at 100ml/hr.
2) Likely acute cholecystitis: The same treatment plan is biliary colic.
3) Likely Cholelithiasis: The same treatment plan is biliary colic.
4) Unlikely GERD: Continue Nexium 40 mg
This is a 45-year-old male with PMH of GERD and hernia repaired, who presented with ABD pain that started 5 hours ago. He had a large burger and fries last night and was not able to sleep d/t ABD pain. The pain is located in the RUQ and right shoulder or scapula. He rates the pain as 7/10. He describes the pain as a “constant and severe”, with associated symptoms of nausea, chills, and vomiting. He has vomited twice, which provided him some relief. He thinks the emesis was consist of yellow bile without blood or coffee-ground. He has never experienced this before.
He denied diarrhea, constipation, melena, rectal bleeding, jaundice, or dysuria. He has not been exposed to anyone who has been sick or traveled outside of us.
PMH: GERD …show more content…
GI: ABD pain with N/V. No constipation, diarrhea, Change in bowel habits, or rectal bleeding.
GU: No incontinence, blood in urine, or painful voiding.
MUSCULOSKELETAL: No trauma. No muscle pain or stiffness.
NEURO: No weakness, tremor, fainting, numbness, or tingling.
PSYCH: no depression or nervousness.
PHYSICAL …show more content…
He appears to be in a great deal of pain.
Skin/Nails: Warm and dry. Color WNL for the race.
Respiratory: Bilaterally clear to auscultation.
Cardiovascular: S1 and S2 heard without extra sounds. No bruit. No edema.
Abdomen: No distension or pulsation. + Bowel sounds, No bruits. On Percussion, ABD is tympanic. ABD is soft but tender to palpation in the RUQ. Liver span normal. The spleen is nonpalpable. No rebound tenderness. + Murphy sign.
Neurologic: Recent memory intact.
LABS/DIAGNOSTICS:
None
Assessment:
1) Biliary colic
2) acute cholecystitis
3) Cholelithiasis
4) GERD
Plan:
1) Most likely biliary colic: Completed HIDA scan or US. Lab: CBC with diff, LFT, Chem 7, serum amylase and lipase, consult general surgery. Pain management: Oxycodone 10mg Q4hrs PRN. Colace 100mg BID PRN and Senna 8.6 mg BID PRN if constipation present. If the WBC is elevated start on ATB. Gentle hydration with normal saline at 100ml/hr.
2) Likely acute cholecystitis: The same treatment plan is biliary colic.
3) Likely Cholelithiasis: The same treatment plan is biliary colic.
4) Unlikely GERD: Continue Nexium 40 mg