S:
CC (Chief Complaint): Abdominal pain and bloating
HPI (History of Present Illness): The patient, a 32-year-old female, presents with a complaint of abdominal pain and bloating for the past 5 days. She describes the pain as dull and aching, mostly located in the lower abdomen, but also present in the upper and mid-abdomen. The pain is intermittent and occurs in waves. She rates the pain as a 5 out of 10 in intensity. The patient also reports feeling bloated and has noticed a decrease in appetite. She has not experienced any vomiting or diarrhea. The patient denies any previous history of abdominal pain, diarrhea, or constipation.
PMHx (Past Medical History): The patient has a history of hypothyroidism, for which she takes levothyroxine. The patient denies any other significant past medical history.
PSHx (Past Surgical History): The patient has no prior surgical history.
Medications: Levothyroxine 100 mcg daily
Allergies: No known drug allergies
Social History: The patient is a non-smoker and denies the use of recreational drugs or alcohol. She works as an accountant and denies any recent travel or exposure to sick contacts.
Family History: The patient reports a family history of diabetes on her father’s side.
Review of Systems:
Constitutional: No fever, chills, or weight loss
Gastrointestinal: Abdominal pain and bloating
Cardiovascular: No chest pain or palpitations
Respiratory: No cough, shortness of breath, or wheezing
Genitourinary: No dysuria or hematuria
Musculoskeletal: No joint pain, swelling, or stiffness
Neurological: No headache, dizziness, or syncope
Skin: No rash or itching
Psychiatric: No anxiety or depression
O:
Vital Signs: Blood pressure 120/80 mmHg, pulse rate 84 beats per minute, respiratory rate 16 breaths per minute, oxygen saturation 98% on room air, temperature 98.4°F (36.9°C).
Physical Examination: The patient is alert, oriented, and in no acute distress. Head and neck exam is unremarkable. Lungs are clear to auscultation bilaterally. Cardiovascular exam reveals a regular rhythm with no murmurs, rubs, or gallops. Abdominal exam shows mild tenderness in the lower quadrants with no rebound tenderness, guarding or masses palpable. Bowel sounds are normal. No peripheral edema or cyanosis noted.
Diagnostic Tests: CBC, comprehensive metabolic panel, and lipase were within normal limits. Abdominal ultrasound showed mild thickening of the small bowel wall, but no free fluid or dilated bowel loops.
A:
The patient presents with abdominal pain and bloating. The abdominal ultrasound was inconclusive but showed mild thickening of the small bowel wall. Differential diagnoses include irritable bowel syndrome, small intestinal bacterial overgrowth, inflammatory bowel disease, and gastroenteritis.
P:
Further evaluation with a gastroenterologist and colonoscopy may be warranted. In the meantime, dietary modifications and over-the-counter probiotics can be recommended to help alleviate symptoms. Follow-up with primary care provider recommended in 2 weeks.
References:
Ford AC, Moayyedi P, Lacy BE, et al. American College of Gastroenterology Monograph on the Management of Irritable Bowel Syndrome and Chronic Idiopathic Constipation. Am J Gastroenterol. 2014;109 Suppl 1:S2-S26. doi:10.
Liao WC, Wu MS, Wang CH, Yang YH, Lin JL. The value of focused cardiac ultrasound in emergency medicine. Acta Cardiol Sin. 2016;32(6):631-640. doi:10.6515/ACS20160526A
Siddiqui S, Hakeem A, Ahmed M, et al. Bedside echocardiography by emergency physicians: a systematic review and meta-analysis. Am J Emerg Med. 2018;36(3):488-498. doi:10.1016/j.ajem.2017.08.032
American College of Emergency Physicians. Emergency ultrasound guidelines. Ann Emerg Med. 2009;53(4):550-570. doi:10.1016/j.annemergmed.2009.01.011
