Abdominal pain

[+] yes, present, positive
[-] no, absent, negative
[~] equivocal
[\] not applicable, not performed
[?] unknown, unsure, unavailable
{ } annotation, comment

PRESENTING COMPLAINTS OR ISSUES
Reasons for visit:
- abdominal pain

Pain location: 
[-] RUQ, [-] epigastric, [-] LUQ
[-] R Loin, [-] central, [-] L Loin
[-] RLQ, [-] suprapubic, [-] LLQ

Pain details:
  Onset: 
  Frequency: 
  Quality: 
  Radiation: 
  Severity /10: 
  Aggravating factors: 
  Relieving factors:

SYSTEMS REVIEW
General symptoms:
[-] chills
[-] fever
[-] sweats
[-] fatigue
[-] malaise
[-] weakness
[-] weight loss
[-] polyuria
[-] abnormal thirst
[-] jaundice

GIT Symptoms: 
[-] nausea
[-] vomiting
[-] heartburn
[-] dysphagia
[-] diarrhoea
[-] constipation
[-] haematochezia
[-] melaena
[-] altered stools

Genitourinary Symptoms: 
[-] dysuria
[-] frequency
[-] haematuria

Cardiopulmonary Symptoms: 
[-] cough
[-] dyspnoea
[-] orthopnoea

PAST MEDICAL HISTORY
[-] GIT surgery (?)
[-] GIT cancer (?)
[-] inflammatory bowel disease (?)
[-] peptic ulcer disease
[-] Helicobacter pylori infection
[-] gluten enteropathy # coeliac disease
[-] gluten intolerance
[-] FODMAP intolerance
[-] irritable bowel syndrome

[Medications and medical devices]

Current medications:
[-] NSAIDs
[-] antibiotics

SOCIAL HISTORY
Alcohol intake:

Recent travel:

VITAL SIGNS
Skin colour: 
Temp (Cel.): 
HR (bpm): 
Heart rhythm: 
BP seated (mmHg): 
BP standing (mmHg): 
BP lying (mmHg): 
Respiratory rate (/min): 
SpO2 (%):

PHYSICAL EXAMINATION
[-] jaundice
[-] distension
[-] tenderness
[-] Carnett sign
[-] rebound
[-] masses
[-] hepatomagaly
[-] splenomegaly
[-] inguinal hernia
[-] femoral hernia
[-] abnormal bowel sounds
[-] absent bowel sounds

PR examination:
[?] abnormalities

[Urinalysis]

(-, +, ++, +++)
Protein: 
Glucose: 
Ketones: 
Bilirubin: 
WBC: 
Nitrite:

Urine pregnancy test (U-HCG):

[Diagnostic investigation results]

Pathology:
[+] 
[-]

Imaging:
[+] 
[-]

Clinical summary:
[+] 
[?] 
[-]

Problems and issues:
[+]

Diagnosis/es:
[+]

Differential diagnosis:
  Right hypochondrium:
  [-] cholecystitis
  [-] biliary colic
  [-] pneumonia
  [-] cardiac ischaemia
  Epigastrium:
  [-] gastritis
  [-] oesophagitis
  [-] peptic ulcer
  [-] pancreatitis
  Left hypochondrium:
  [-] splenomegaly
  [-] pneumonia
  [-] cardiac ischaemia
  Right loin:
  [-] renal/ureteric colic
  [-] pyelonephritis
  [-] duodenal ulcer
  Umbilical:
  [-] early appendicitis
  [-] small bowel obstruction
  [-] peptic ulcer
  [-] ruptured aortic aneurysm
  [-] Crohn's disease
  [-] Meckel's diverticulum
  [-] mesenteric artery occlusion
  Left loin:
  [-] renal/ureteric colic
  [-] pyelonephritis
  [-] irritable bowel disease
  Right iliac fossa:
  [-] appendicitis
  [-] ureteric colic
  [-] salpingitis
  [-] Meckel's diverticulum
  [-] ectopic pregnancy
  [-] ovarian cyst
  [-] inguinal/femoral hernia
  Hypogastrium (suprapubic):
  [-] ruptured ectopic pregnancy
  [-] cystitis
  [-] endometriosis
  [-] pelvic inflammatory disease
  Left iliac fossa:
  [-] diverticulitis
  [-] ulcerative colitis
  [-] constipation
  [-] ureteric colic
  [-] salpingitis
  [-] Meckel's diverticulum
  [-] ectopic pregnancy
  [-] ovarian cyst
  [-] inguinal/femoral hernia

MANAGEMENT PLAN
Diagnostic investigations requested:
# Acute abdominal pain
[-] FBC, E/LFTs, CRP, Lipase, Amylase; Abdominal ultrasound, Abdominal CT.

# Chronic abdominal pain
[-] FBC, E/LFTs, Lipase, Amylase, CRP, Ferritin, Coeliac autoantibodies (Anti-tissue transglutaminase), Stool occult blood, Faeces M/C/S, Faeces OCP, Faeces PCR bacteria/protozoa, Faecal calprotectin, Abdominal CT.

Referrals:
-

Information and advice given:
-

Medication:
-

FOLLOW-UP
Outstanding issues:
-

Next appointment:
-

[dqref.com 260123]

Abdominal pain

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