Emergency Medicine History and Physicals

History and Physical 1

Amber Shaikh

Emergency Medicine Rotation-NYPQ

Identifying data:

Name: MD

Age: 32

Sex: Male

Race: African American

Date and time: 6/3/2021

Location: NYPQ ER Acute

Source of referral: self

Source of information: self

Mode of transport: personal Vehicle

Chief complaint: Chest pain for 1 day

History of Present Illness:

MD is a 32 year old male with no significant past medical history who presents with intermittent midsternal chest pain that started one day ago. Patient says that the pain started after doing a workout with weights at the gym yesterday, and then came on again when he was running up 3 flights of stairs. He says the pain is in the middle of his chest and is intermittent, coming on with exertion and movement. Patient describes the pain as a sharp stabbing sensation that is localized and does not radiate. The pain is alleviated with ibuprofen and rest and is alleviated with movement, particularly twisting his torso, and with breathing on inspiration. Patient rates the pain as a 9/10 when the episodes happen, and says it’s a 2/10 when he is resting. He has taken ibuprofen with mild relief. Patient has never had similar episodes in the past, and denies any recent sick contacts or long travels. He has associated shortness of breath secondary to the pain, but denies any nausea, vomiting, abdominal pain, heartburn, diarrhea, palpitations, diaphoresis, arm pain, jaw pain, leg swelling, fevers, chills, or urinary changes. He is currently in the ED looking very uncomfortable and clutching his chest.

Past medical history:

Present illnesses: midsternal non-radiating chest pain

Hospitalizations: denies any prior hospitalizations

Immunization: patient is up to date on immunizations

Flu shot: Dec 2020
COVID vaccine: Pfizer March 2021

Screenings:

Patient is up to date on his depression and HTN screening (October 2020) . As per his PCP, no other screenings are required at this time.

Past surgical history:

Denies any surgeries

Medications:

Daily multivitamin

Patient does not take any other medications daily

Allergies:

Seasonal allergies to pollen and dust
Denies any allergies to medications or food

Family history:

Mother: HTN diagnosed at 56, controlled with medications. Alive and well
Father: HTN and HLD diagnosed at 45, controlled with medications. Alive and well

Social history:

Habits:

Patient admits to drinking 3 beers a weekend, but denies ever smoking cigarettes, or using any illicit drugs.

Travel:

Patients denies any recent travel

Marital history:

Patient is currently married to his wife for 2 years.

Occupational history:

Patient works as a Xray technician at the hospital

Sexual history:

MD is sexually active with his wife, and us condoms as contraceptive. He denies any history of being tested for any STDs

Home:

He lives in a private home

Diet:

Patient eats a healthy balanced diet or chicken and vegetables

Exercise:

MD exercises 4 days a week, and is very active daily

Sleep:

Patient gets 7 hours of sleep a night

Safety:

Patient adheres to all safety practices.

ROS:

General: patient denies any fevers, chills, fatigue, or night sweats

Head: denies trauma to head, LOC< headache, dizziness, or nausea

ENT: denies any congestion, sinus pain, sore throat, cough, ear pain or blurred vision

Pulmonary: patient admits to mild shortness of breath secondary to the pain, but denies any cough or wheezing

Cardiovascular: patient admits to midsternal chest pain, worse with movement and inspiration. He denies any palpitations, diaphoresis, syncope, ankle edema, or radiating pain

Gastrointestinal: denies any abdominal pain, nausea, vomiting, constipation, or diarrhea

Genitourinary: denies any pain with urination, increased frequency or urgency. Patient also denies any hematuria

Nervous: denies any weakness, numbness or slurred speech. Denies any localized weakness or headache

Musculoskeletal: denies any muscle pain, joint pain, stiffness or limp

Psych: patient is currently anxious, but denies any depression or emotional stress

Physical exam:

Vital signs:

BP: 115/62 right arm sitting, HR: 72 regular, temperature: 37.3C oral , oxygen: 98% on room air, Resp rate: 17, HT: 6’1’, Wt: 190, BMI: 25.1

General appearance: 32 year old male casually groomed male, well dressed who is anxious and is clutching his chest. He looks appropriate for his age. Alert and Oriented x 3 to person, place and time.

Skin: warm and dry, with no cyanosis, no rash. Good turgor, noncitric, no thickness or opacities, no notable scars or tattoos

Hair: normal distribution, good moisture

Head: atraumatic, no swelling or tenderness or lesions

Eyes: symmetrical OU without ptosis or strabismus, sclera is white and cornea is clear, PEARLA, EOMI.

Ears: no lesions or battle sings, symmetrical and even in size, AU external auditory canal is clear of any foreign bodies or discharge. TM is pearly gray and intact with light reflex in appropriate right and left position. Weber is midline and rinnes test AC>BC AU.

Nose: well hydrated without lesions, septal deviations or discharge. No step offs and nares patent bilaterally

Mouth and Pharynx:

Lips: well hydrated with no lesions or cyanosis

Oropharynx: well hydrated without lesions, no erythema, no postnasal drip present. No sign of tonsillar enlargement or exudates.

Neck: supple, no JVD. Thyroid is not enlarged or tender. No neck stiffness

Chest: Positive left midsternal tenderness to palpitation. no scars or lesions present, no obvious pulsations.

Cardiac: Regular rate and rhythm, S1 and S2 normal. S3 and S4 are not present. No carotid bruit. No splitting of heart sounds, gallops, friction rubs or palpitations.

Pulmonary: Patient is having short inspirations secondary to chest pain. No rales, wheezing or use of accessory muscles. Breath sounds are equal bilaterally.

Abdomen: no lesions or scars. Abdomen is soft, nondistended, nontender to palpation, no guarding or rebound tenderness. Hyperactive bowel sounds throughout.

GU: not assessed; however would have checked for any hernias, masses or lesions

Rectal: Not assessed; however would have checked for rectal tone, prostate, and any blood in the rectal vault

Peripheral vascular: extremities are normal in color, no cyanosis or edema. Normal size and temperature. 2+ pulses bilaterally PT and DP. No ulcerations or stasis changes seen.

Musculoskeletal: 5/5 strength in upper and lower extremities. No deformities or edema. No tenderness. Full range of motion to upper and lower extremities. Equal pulses in upper and lower extremities.

Neuro and Psych: cranial nerves grossly intact, strength and sensation grossly intact in both upper and lower extremities. Patient has no obvious psychological changes.

Differential Diagnosis:

Costochondritis

Acute MI

Stable angina ACS

Pulmonary embolism

Pulmonary contusion

Labs:

Troponin: <0.010 (06/01 at 12:36pm)

138 | 102 | 11.8

——————–< 73 Ca: 9.6 Anion Gap: 10 [06/01 @ 12:36]

4.6 | 26 | 1.08

WBC: 5.50 / Hb: 14.0 (MCV: 87.4) / Hct: 42.4 / Plt: 276 [06/01 @ 12:36]

Chest Xray: no signs of any acute pulmonary disease

EKG: sinus rhythm with early repolarization with no sign of MI. Patient advised to follow up with PCP

Assessment:

32 year old male with no past medical history comes in with two days of intermittent sharp midsternal chest pain that is nongraduating; and is worse with inspiration and movement. He says the pain started when he was working out with weights. Patient had a workup to rule out an acute MI and ACS. Troponins were negative and EKG did not show any ischemic changes and chest Xray does not show any abnormal findings, and lab work is within normal limits. Patient most likely has costochondritis, will continue to trend troponins and patient will most likely be discharged and advised to follow up with his primary care physician.

Plan:

-advise patient to reduce physical activity and advise against lifting heavy weights

-have the patient take acetaminophen to relieve the pain and NSAIDs such as Naproxen to reduce the inflammation.

-Patient counseled on all findings, diagnosis and treatment plan. Patient’s questions and concerns addressed. Patient stable, discharged with instructions to follow up with PMD, and to return to ED at any time for worsening symptoms or any other concerns. Patient demonstrates proper understanding of the findings and the importance of appropriate follow up care

Patient education:

Costochondritis is an inflammation of the area where the ribs join with the cartilage that holds them to the breastbone. If this area is inflamed it can cause localized chest pain that can be reproducible with movement, inspiration, and by pushing on the cartilage itself. The chest pain that you might experience with this usually follows exercise, trauma, or a recent upper respiratory infection. The pain will be characterized as sharp and in the anterior chest area, and can even radiate to the back or the stomach. The more common sights where you might feel pain is the 4^th, 5^th, or 6^th ribs. Ways to control and reduce this pain is with NSAIDs, such as ibuprofen or naproxen. Since this is an inflammatory condition, local heat or ice can also help relieve the pain. It is important however that in this time you avoid heavy lifting or any strenuous activity.

History and Physical 2

Amber Shaikh

Emergency Medicine Rotation-NYPQ

Identifying data:

Name: FG

Age: 40 years old

Sex: female

Race: South Asian

Date and time: 6/14/2021

Location: NYPQ ER

Source of referral: self

Source of information: self

Mode of transport: personal Vehicle

Chief complaint: Vaginal bleeding for 2 weeks

History of Present Illness:

FG is a 40 year old female with a past medical history of anemia and uterine fibroids which were surgically removed in 2019, who is G3P2, presents with intermittent vaginal bleeding for 15 days. She says that her last menstrual cycle was 1 month ago, and since then the bleeding has continued intermittently. She says that for the week following her period the bleeding was light, however it then became very heavy. She has also been having associated cramps in her back and suprapubic area. At her heaviest bleeding, she says that she soaks through 5-8 pads. She rates the cramps at a 6/10 dull pain when they come on. Patient says that she has been taking Tylenol for the cramping pain with mild relief. Patient says that she is also having sensations of lightheadedness and dizziness for the past 4 days due to losing so much blood. She says that she feels very weak and feels like the room is spinning. She said that when she had her last fibroid episode 4 years 2 years ago, she had similar symptoms. Patient denies currently being pregnant. She had an appointment with her OB/GYN scheduled for tomorrow, however was told to come into the ED to be evaluated for her symptoms. Patient endorses having vaginal bleeding, cramps, lightheadedness and dizziness. She denies any associated nausea and vomiting, urinary changes (frequency, urgency, dysuria), fevers, chills, shortness or breath, chest pain, and denies being pregnant. She denies any recent travel or sick contacts.

Past medical history:

Present illnesses: vaginal bleeding for 15 days

Hospitalizations: hospitalized in 2009 and 2013 for childbirth. Hospitalized in 2019 for fibroid surgery

Immunization: patient is up to date on immunizations

Flu shot: November 2020
COVID vaccine: Pfizer April 2021

Screenings:

Patient is up to date on his depression, HTN, and cholesterol screening (December 2020).
Last Pap screen was in August 2020
As per his PCP, no other screenings are required at this time.

OB history:

Patient is G3P2

First child was born in 2009; male born at 37 weeks with no complications
Second child was born in 2013; female born at 38 weeks with no complications
Patient was pregnant a 3^rd time in 2015, but had a miscarriage at 13 weeks.

Past surgical history:

Surgery for fibroid removal in 2019; no complications

Medications:

Junel Birth control (estradiol/progesterone pill): patient takes one pill daily for the past 3 years.
Daily multivitamin

Allergies:

Seasonal allergies to pollen and dust

Denies any allergies to medications or food

Family history:

Mother: History of Diabetes diagnosed at age 50; controlled with medications. Alive and well
Father: HTN and HLD diagnosed at 55, controlled with medications. Alive and well

Social history:

Habits:

FG denies ever drinking alcohol, smoking cigarettes, or using any illicit drugs.

Travel:

Patients denies any recent travel

Marital history:

Patient is currently married to her husband of 17 years

Occupational history:

Patient is currently not working; previously used to work as a nanny.

Sexual history:

FG is sexually active with her husband, she is on an oral contraceptive, and does not use condoms. She denies ever having or being tested for an STI.

Home:

She lives in a private home.

Diet:

Patient eats a healthy balanced diet of protein and vegetables, with occasional fast food

Exercise:

She walks daily and uses the stairs often

Sleep:

Patient gets 7 hours of sleep a night

Safety:

Patient adheres to all safety practices.

ROS:

General: Patient admits to fatigue secondary to the blood loss, but denies any fevers, chills, or night sweats.

Head: patient admits to dizziness, but denies any loss of consciousness, nausea or head trauma.

ENT: denies any congestion, sinus pain, sore throat, cough, ear pain or blurred vision

Pulmonary: Patient denies any shortness of breath, cough or wheezing.

Cardiovascular: Patient denies any chest pain, palpitations, diaphoresis, syncope, ankle edema, or radiating pain.

Gastrointestinal: Patient is having some suprapubic cramping, but denies any nausea, vomiting, constipation or diarrhea.

Genitourinary: denies any pain with urination, increased frequency or urgency. Patient also denies any hematuria

Gyn: Patient admits to having 15 days of vaginal bleeding. She has a history of fibroids. She denies currently being pregnant.

Nervous: Admits to having associated light headedness and weakness, but denies any numbness, slurred speech, or headache.

Musculoskeletal: denies any muscle pain, joint pain, stiffness or limp

Psych: patient is currently anxious, but denies any depression or emotional stress

Physical exam:

Vital signs:

BP: 146/78 right arm sitting, HR: 60 regular, temperature: 36.6C oral , oxygen: 100% on room air, Resp rate: 18, HT: 5’1’, Wt: 130, BMI: 24,6

General appearance: 40 year old female, casually and appropriately dressed. She looks appropriate for her age and is alert and oriented x 3 to person, place and time. She is anxious at this time.

Skin: warm and dry, with no cyanosis, no rash. Good turgor, noncitric, no thickness or opacities, no notable scars or tattoos

Hair: normal distribution, good moisture

Head: atraumatic, no swelling or tenderness or lesions

Eyes: symmetrical OU without ptosis or strabismus, sclera is white and cornea is clear, PEARLA, EOMI.

Nose: well hydrated without lesions, septal deviations or discharge. No step offs and nares patent bilaterally

Mouth and Pharynx:

Lips: well hydrated with no lesions or cyanosis

Oropharynx: well hydrated without lesions, no erythema, no postnasal drip present. No sign of tonsillar enlargement or exudates.

Neck: supple, no JVD. Thyroid is not enlarged or tender. No neck stiffness

Chest: No scars or lesions, no obvious pulsations. There is no tenderness to palpation.

Cardiac: Regular rate and rhythm, S1 and S2 normal. S3 and S4 are not present. No carotid bruit. No splitting of heart sounds, gallops, friction rubs or palpitations. Capillary refill is less then 2 seconds.

Pulmonary: Breath sounds equal bilaterally, no wheezes, rales or adventious breath sounds. No use of accessory muscles.

Abdomen: no lesions or scars. Abdomen is soft, nondistended, nontender to palpation, no guarding or rebound tenderness. Hyperactive bowel sounds throughout.

GU: No lesions or masses in the external genitalia. No tenderness to palpation. No ulcerations. Pelvic exam was done with a chaperone, and scant amount of blood was seen in the vaginal vault. Cervix was unremarkable. No tenderness with bimanual exam.

Rectal: Not assessed; however would have checked for rectal tone, prostate, and any blood in the rectal vault

Peripheral vascular: extremities are normal in color, no cyanosis or edema. Normal size and temperature. 2+ pulses bilaterally PT and DP. No ulcerations or stasis changes seen.

Musculoskeletal: 5/5 strength in upper and lower extremities. No deformities or edema. No tenderness. Full range of motion to upper and lower extremities. Equal pulses in upper and lower extremities.

Neuro and Psych: cranial nerves grossly intact, strength and sensation grossly intact in both upper and lower extremities. Patient has no obvious psychological changes.

Differential Diagnosis:

Fibroids

Benign neoplasm of vagina

Ectopic pregnancy

Symptomatic anemia

Endometrial polyps

Labs:

139 | 103 | 12.2

——————–< 79 Ca: 9.6 Anion Gap: 11

4.2 | 25 | 0.51

WBC: 6.41 / Hb: 10.9 (MCV: 83.8) / Hct: 36.7 / Plt: 458

— Diff: N:61.00% L:31.00% Mo:7.00% Eo:1.00%

Coags: PT: 12.0 / PTT: 27.6 / INR: 1.04

Prot: 7.1 / Alb: 4.0 / Bili: <0.1 / AST: 14 / AlkPhos: 66

BetaHCG: negative

UA — Appearance: Yellow / Clear, s.g.:1.007, pH: 7.5, glucose: Negative, protein: Negative, ketones: Negative, blood: Moderate, glucose: Negative, nitrite: Negative, leuk est: Negative

UA (micro) — RBC: 8, WBC: 0, Bacteria: Negative

US: Fibroids measuring up to 1.7cm, ovaries unremarkable, normal flow to both ovaries.

Assessment:

40 year old female with a history of fibroids and anemia presents to the ED complaining of 15 days of vaginal bleeding and dizziness. She says her last menstrual cycle was one month ago. She has had similar episodes before and had fibroid surgery done on 2019. On exam there is blood in the vaginal vault. History, exams and labs are most consistent with uterine fibroids. Patient’s Ob/GYN should be consulted.

Plan:

-Consult OB/GYN

-Give patient fluids and pain medication

-Encourage patient to continue taking birth control medication consistently

-continue taking Iron supplements for her anemia

-follow up with her OB/GYN and discuss options for repeat fibroid surgery.

-return for any further bleeding.

Patient education:

Uterine fibroids are also known as leiomyomas, which are growths of the uterus. They are very common and are not considered cancerous. They are related to hormones like estrogen and progesterone and can be influenced by genetics. Some can grow and shrink, where as others can grow and cause discomfort and bleeding. This can be controlled with NSAIDs, hormone pills, GnRH agonist, and iron and vitamins for anemia. Surgical treatment may be indicated if the bleeding is severe; the definitive surgery is myomectomy; which is when the fibroids are removed.

History and Physical 3

Amber Shaikh

Emergency Medicine Rotation-NYPQ

Identifying data:

Name: AN

Age: 26 years old

Sex: female

Race: South Asian

Date and time: 6/17/2021

Location: NYPQ ER

Source of referral: self

Source of information: self

Mode of transport: personal Vehicle

Chief complaint: abdominal pain for 4 days

History of Present Illness:

AN is a 26 year old female with a past medical history of GERD who comes in complaining of 4 days of intermittent sharp abdominal pain. She says the pain started on its own, and she did not eat or do anything different prior to symptom onset. She says the pain started in the epigastric area but is now more localized in the left lower quadrant. She describes the pain as intermittent and a burning sharp sensation. The pain migrates from the epigastrium to the left lower quadrant, but does not radiate other wise. She rates it s 8/10 at its worst. She says that this does not feel like her typical symptoms with her GERD episodes. Patient says that eating makes the pain worse, and rest alleviates the pain. She has not taken any medications for her symptoms. She said that for the first 3 days of her symptoms she was having constipation, however today she had 4 episodes of loose watery diarrhea. She denies any mucus or blood in her urine or bowels. She went to the urgent care today due to her symptoms and had a urinalysis done which did not show any abnormal findings. Her last menstrual period was 1 week ago, and was normal. She says she is only sexually active with her husband, and is not concerned for any STIs. AN has associated abdominal pain, history of constipation, diarrhea, nausea, decreased appetite and decreased water intake. She denies any vomiting, changes with urination (dysuria, frequency, urgency), blood in urine or stool, vaginal bleeding, chest pain, shortness of breath, fevers or chills. She denies any sick contacts or recent travels.

Past medical history:

Present illnesses: left lower quadrant abdominal pain for 4 days

Hospitalizations: denies any hospitalizations

Immunization: patient is up to date on immunizations

Flu shot: January 2021
COVID vaccine: Pfizer April 2021

Screenings:

Patient is up to date on his depression, HTN, and cholesterol screening (December 2020).
Last Pap screen was in February 2020
As per his PCP, no other screenings are required at this time.

OB history:

Patient has never been pregnant

Past surgical history:

Denies any past surgeries or blood transfusions

Medications:

Omeprazole

Daily multivitamin

Allergies:

Seasonal allergies to pollen and dust
Denies any allergies to medications or food

Family history:

Mother: alive and well
Father: HTN diagnosed at 42, controlled with medications. Alive and well

Social history:

Habits:

FG denies ever drinking alcohol, smoking cigarettes, or using any illicit drugs.

Travel:

Patients denies any recent travel

Marital history:

Patient is currently married to her husband of 2 years

Occupational history:

Patient is a graduate student

Sexual history:

FG is sexually active with her husband, she uses condoms as contraceptives. She denies ever having or being tested for an STI.

Home:

She lives in a private home.

Diet:

Patient eats a healthy balanced diet of protein and vegetables, with occasional fast food

Exercise:

She walks daily and uses the stairs often and goes to the gym 2 times a week

Sleep:

Patient gets 7 hours of sleep a night

Safety:

Patient adheres to all safety practices.

ROS:

General: Patient denies any fatigue, fevers, chills or night sweats.

Head: Patient denies any dizziness, loss of consciousness, nausea or head trauma.

ENT: denies any congestion, sinus pain, sore throat, cough, ear pain or blurred vision

Pulmonary: Patient denies any shortness of breath, cough or wheezing.

Cardiovascular: Patient denies any chest pain, palpitations, diaphoresis, syncope, ankle edema, or radiating pain.

Gastrointestinal: Patient admits to having abdominal pain, worse in the left lower quadrant, with constipation (now resolved), diarrhea, and nausea. She denies any vomiting, or blood in the stool.

Genitourinary: denies any pain with urination, increased frequency or urgency. Patient also denies any hematuria or vaginal bleedings.

Nervous: Denies lightheadedness, weakness, numbness, slurred speech, or headache.

Musculoskeletal: denies any muscle pain, joint pain, stiffness or limp

Psych: denies any depression or emotional stress

Physical exam:

Vital signs:

BP: 119/73 right arm sitting, HR: 93 regular, temperature: 36.8C oral , oxygen: 100% on room air, Resp rate: 18, HT: 5’4’, Wt: 132, BMI: 22.7

General appearance: 27 year old female, casually and appropriately dressed. She looks appropriate for her age and is alert and oriented x 3 to person, place and time. She is in no acute distress at this time.

Skin: warm and dry, with no cyanosis, no rash. Good turgor, noncitric, no thickness or opacities, no notable scars or tattoos

Hair: normal distribution, good moisture

Head: atraumatic, no swelling or tenderness or lesions

Eyes: symmetrical OU without ptosis or strabismus, sclera is white and cornea is clear, PEARLA, EOMI.

Nose: well hydrated without lesions, septal deviations or discharge. No step offs and nares patent bilaterally

Mouth and Pharynx:

Lips: well hydrated with no lesions or cyanosis

Oropharynx: well hydrated without lesions, no erythema, no postnasal drip present. No sign of tonsillar enlargement or exudates.

Neck: supple, no JVD. Thyroid is not enlarged or tender. No neck stiffness

Chest: No scars or lesions, no obvious pulsations. There is no tenderness to palpation.

Pulmonary: Breath sounds equal bilaterally, no wheezes, rales or adventious breath sounds. No use of accessory muscles.

Abdomen: Soft, nondistended. No masses or lesions. Left lower quadrant is tender to palpation. Mild left CVA tenderness. Hyperactive bowel sounds throughout.

GU: Not assessed; however would have checked for vaginal bleeding, lesions and tenderness

Rectal: Not assessed; however would have checked for rectal tone, prostate, and any blood in the rectal vault

Peripheral vascular: extremities are normal in color, no cyanosis or edema. Normal size and temperature. 2+ pulses bilaterally PT and DP. No ulcerations or stasis changes seen.

Musculoskeletal: 5/5 strength in upper and lower extremities. No deformities or edema. No tenderness. Full range of motion to upper and lower extremities. Equal pulses in upper and lower extremities.

Neuro and Psych: cranial nerves grossly intact, strength and sensation grossly intact in both upper and lower extremities. Patient has no obvious psychological changes.

Differential Diagnosis:

Gastroenteritis

Diverticulitis

Left ovarian cyst

Colon

Urinary tract infection

Labs:

140 | 104 | 12.8

——————–< 75 Ca: 9.6 Anion Gap: 11

4.2 | 25 | 0.80

CBC + DIFF: Mean Platelet Volume: 11.2 (H)

Hepatic function panel: Bilirubin Total: 1.3 (H)

Bilirubin Indirect: 1.1 (H)

Lipase: normal

BetaHCG: negative

GFR: 90

UA:

Urine Color: Yellow

Urine Appearance: Clear

Urine Glucose (Urinalysis): Negative

Urine Bilirubin: Negative

Urine Specific Gravity: 1.025

Urine Ketones: 15 (A) Negative mg/dL

Urine Blood: Negative

Urine pH: 5.0

Urine Protein: Negative

Urine Urobilinogen: 0.2

Urine Nitrite: Negative

Urine Leukocyte Esterase: Negative

Endovaginal transabdominal ultrasound:

1. No sonographic evidence of ovarian torsion.

2. 2.3 cm complex left ovarian cyst with internal septations.

3. Small pelvic free fluid.

Assessment:

26 year old female with a past medical history of GERD presents with 4 days of left lower quadrant pain. Patient says she is also having 4 episodes of diarrhea. On exam, the patient is tender to her left lower quadrant. Labs and UA are unremarkable. Ultra sound shows a ovarian cyst. Abdominal pain is most likely due to gastroenteritis, rule out diverticulitis.

Plan:

-will do repeat labs

-give patient a bolus of IV saline.

– Will treat with Pepcid 20 mg IV, Toradol 15 mg IV, Zofran 4 mg IV, and Maalox 30 ml PO

– advised to follow-up with OB/GYN as outpatient due to the ovarian cyst.

-Patient informed to obtain repeat US in 6-8 weeks.

-follow up with her PCP and return for any worsening of her symptoms.

Patient education:

-Gastroenteritis is the inflammation of the gastrointestinal tract involving the stomach and intestines. It can be caused by viral infection, medication reaction, food allergy, food poisoning, or alcohol abuse. Symptoms include fatigue, lack of appetite, abdominal pain, nausea, vomiting, and diarrhea. The symptoms are often brief and can resolve on their own. Ways to control symptoms include eating a bland diet, drinking enough fluids, and staying away from acidic foods. If symptoms worsen and progress it is important to be seen by the doctor to get proper imaging and lab work in order to rule out any serious diseases.