Sharp Abdominal Pain: Diagnosis and Treatment Case Study

Subjective

• Patient: 17 years old Latino male
• Chief complaint: sharp abdominal pain

History of present illness

The main symptom is the sharp abdominal pain in the umbilicus area. The patient also has been having nausea with vomiting for the last 3 hours; he denies diarrhea. The abdominal pain is constantly sharp and moved to the right lower quadrant in a previous couple of hours. The pain was exceptionally intense at night; it has not disappeared by now; he describes the pain as sharp, constant, and shooting at the right side of his stomach. It is the first time the patient experiences such pain; its intensity has grown from rate 3 to 7 by now. He did not eat anything in the last 24 hours due to the pain, but he had a Taco and kale salad the day before. The patient denies urinary symptoms and burning, yet he felt hot. There were no recent injuries or accidents that could affect the patient’s health. He does not have any allergies to medication; he also took ibuprofen at 5:00 AM and 2:00 PM, with no effect on the pain.

Past medical history

The patient is an athlete and visits physical yearly, and the last time was 10 months ago. He did not have any measles, mumps, rubella, strep throat, or other childhood illnesses. There is no history of allergy or diabetes, the patient has never been hospitalized due to traumas or broken bones and has no previous surgeries and abdominal issues. The patient is not sure if the immunizations are up to date. The appendix is not removed; the patient has a Gallbladder as well; he denies urinary or groin pain. The patient is not sexually active and has never been. His family has some illnesses: the uncle had testicular cancer, the grandfather had prostate cancer, and the patient’s mother has high blood pressure.

• Medications: he gets no daily medications, except for vitamins.
• Review of systems: The patient states that he feels healthy, has no fever, fatigue, congestion, numbness, sore throat, or headaches. His weight, muscle strength, skin, hair, and overall mobility did not change. He denies problems with urination, ejaculation, has no constipation or diarrhea. The last bowel movement was yesterday morning without abnormalities; usually, it goes every day.
• Social history: The patient lives in an apartment with his mother and father, he is the only child. He claims that he feels safe at home, his mother drove him to this visit. He goes to high school and works at the local pool as a lifeguard. The patient frequently exercises as he is at a football team, runs, and lifts weights. He does not smoke, has up to two beers on weekends, and smokes marijuana with friends every other week. He does not do drugs like cocaine or heroin, and the marijuana doses are small as the patient is an athlete.

Objective

• Temp = 101.2
• R = 20
• BP = 110/64
• Hr= 110
• Spo2= 99% RA
• Height = 6 feet 2 inches
• Weight = 180
• BMI = 23.1

General Appearance

17 years old Latino male, NAD, looks distressed and holds his abdomen. He has normal bilaterality, not enlarged, no murmurs, or heart rhythm changes. His muscle, skeleton, and neurotic systems are in normal conditions. The abdomen is flat, and bowel sounds are hypoactive, right lower quad has positive tenderness, no masses.

Assessment

The patient has sharp continuing pain in the lower right quad, vomits, and positive tenderness at McBurney’s point. The first possible diagnosis is appendicitis (K35.80) due to vomiting and sharp pain. Another diagnosis is pancreatitis (K86.9) as the patient’s body temperature increased. The third diagnosis is an abdominal aortic aneurysm (I71.4) due to the constant pain around the belly button.

Differential Diagnosis

1. Appendicitis
2. Pancreatitis
3. Abdominal aortic aneurysm

Plan

1. Medications: no medical prescriptions, the patient is to refer to the surgeon;
2. Further testing: the surgeon will choose proper lab tests and other examinations;
3. Patient education: if the pain is constant and sharp, it is necessary to call an ambulance and visit the Emergency Department for the evaluation. It is incorrect to wait for more than 24 hours with pain before reaching out for help.
4. In case when the pain rate grows to 10, reach out to the emergency for help.
5. The patient’s overall health conditions will be examined during the following up in two weeks after visiting a surgeon.