Surgery

27 year old male presents with abdominal pain

Sindhura Kodali on Jan 26, 2014

27 year old male presents to your rural hospital emergency room complaining of abdominal pain. 

He reports that he has sharp abdominal pain that began earlier this night. The pain woke him from sleep. Over the past two days he has not been feeling well. He has had several episodes of non-bloody, non-biliious emesis and several episodes of crampy, watery diarrhea over the past few days. His last bowel movement was yesterday evening. He denies any blood in his stools. He has been able to take some small sips of water but has been nauseated and vomited whenever he has eaten. Last night the pain worsened to the point where he felt he needed to go to the hospital. 

Medical History: He reports that he is otherwise generally healthy and not taking any medications regularly.

Surgical History: He reports that he was diagnosed with a congenital choledochal cyst which was treated with open surgical excision and formation of a Roux-en-Y anastamosis to the biliary duct. Patient also had a laparoscopic appendectomy in college. 

Medications: Sonata PRN for sleep

Allergies: None

Family History: No known family history of inflammatory bowel disease or GI problems

Social History: Patient works as a healthcare consultant. He does not smoke cigarettes, drinks alcohol occasionally and denies any history of illicit drug use.  

 

 

Since you are in a rural hospital and it is the middle of the night and resources are limited, you know you will have to rely mostly on your history and physical exam. However, the patient is complaining that his pain has gotten much worse in the past hour since he arrived, so you decide you need to focus your history. Which of the following questions will you prioritize?

Select all that apply
Expand all answers
Is the patient passing gas?
This is important to ask now because it provides information about the status of his bowels, but also, whether or not there is concern for a partial or complete obstruction.


Post-operative complications, bleeding problems, or issues with anesthesia?
Since you know the patient had a surgical procedure, it would be important to ask now if there were any significant complications. You also would want to know if the patient had any issues with bleeding or anesthesia should he require any kind of procedure or intervention.


Sexual history?
This information would be important if the patient was a female of reproductive age, or if you were very concerned for STIs, but it is not particularly relevant for a potentially emergent situation. Once the patient is stable, you might consider asking about sexual history, particularly to assess for HIV risk, since the presentation can vary widely.


Travel history or sick contacts?
This is not particularly important if the patient is decompensating. You can keep infection on your differential to consider whether or not to give antibiotics, but it may not help you manage the patient's current problem.


Prior hospitalizations?
Although the patient has said he is generally quite healthy, young patients who are generally quite healthy may not report previous hospitalizations unless you ask pointed questions.


27 year old male presents to your rural hospital emergency room complaining of abdominal pain. 

He reports that he has sharp abdominal pain that began earlier this night. The pain woke him from sleep. Over the past two days he has not been feeling well. He has had several episodes of non-bloody, non-biliious emesis and several episodes of crampy, watery diarrhea over the past few days. His last bowel movement was yesterday evening. He denies any blood in his stools. He has been able to take some small sips of water but has been nauseated and vomited whenever he has eaten. Last night the pain worsened to the point where he felt he needed to go to the hospital. 

Medical History: He reports that he is otherwise generally healthy and not taking any medications regularly.

Surgical History: He reports that he was diagnosed with a congenital choledochal cyst which was treated with open surgical excision and formation of a Roux-en-Y anastamosis to the biliary duct. Patient also had a laparoscopic appendectomy in college. 

Medications: Sonata PRN for sleep

Allergies: None

Family History: No known family history of inflammatory bowel disease or GI problems

Social History: Patient works as a healthcare consultant. He does not smoke cigarettes, drinks alcohol occasionally and denies any history of illicit drug use.  

 

 

Since you are in a rural hospital and it is the middle of the night and resources are limited, you know you will have to rely mostly on your history and physical exam. However, the patient is complaining that his pain has gotten much worse in the past hour since he arrived, so you decide you need to focus your history. Which of the following questions will you prioritize?

Select all that apply
Expand all answers
Is the patient passing gas?
This is important to ask now because it provides information about the status of his bowels, but also, whether or not there is concern for a partial or complete obstruction.


Post-operative complications, bleeding problems, or issues with anesthesia?
Since you know the patient had a surgical procedure, it would be important to ask now if there were any significant complications. You also would want to know if the patient had any issues with bleeding or anesthesia should he require any kind of procedure or intervention.


Sexual history?
This information would be important if the patient was a female of reproductive age, or if you were very concerned for STIs, but it is not particularly relevant for a potentially emergent situation. Once the patient is stable, you might consider asking about sexual history, particularly to assess for HIV risk, since the presentation can vary widely.


Travel history or sick contacts?
This is not particularly important if the patient is decompensating. You can keep infection on your differential to consider whether or not to give antibiotics, but it may not help you manage the patient's current problem.


Prior hospitalizations?
Although the patient has said he is generally quite healthy, young patients who are generally quite healthy may not report previous hospitalizations unless you ask pointed questions.


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