MDM //

Patient presents with mild epigastric pain with no guarding or rebound, worse with eating. Exam concerning for gastritis versus pancreatitis. Lower suspicion for cholecystitis as no right upper quadrant tenderness. Lower suspicion for appendicitis as no McBurney’s point tenderness. No peritoneal signs on exam. Doubt urinary tract infection or pyelonephritis as the patient denies flank pain or urinary symptoms. The patient is afebrile, does not appear septic. Will draw basic labs, give patient a GI cocktail and reassess. XXX Doubt pelvic etiology such as torsion or pelvic inflammatory disease based on exam. XXX Doubt testicular etiology based on history and exam. On reassessment, XXX his/her abdominal pain is much improved. Repeat abdominal exam is benign, no tenderness, rebound, or guarding. The patient’s lipase is within normal limits, doubt pancreatitis. Will prescribe the patient medications for GERD. Counseled the patient regarding lifestyle modifications such as eating less spicy food, limiting coffee and alcohol intake. The patient is a good candidate for outpatient care. The patient is well appearing and vital signs are stable. The patient was given instructions to follow up with their primary care doctor in 1-2 days. I explained the findings and plan to the patient, who expressed verbal understanding and agreed with plan for discharge and follow up. The patient was given after care instructions and welcomed to return to the ED for any new or worsening symptoms.



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