Chief Complaint: “stomach ache” x 1 weeks

Subjective:

22 y/o female with PMHx of mild-persistent asthma and anemia presents with intermittent left upper quadrant pain and epigastric pain x 1 week. The pain is sharp and worsen with walking. Pain occasionally radiate to right lower quadrant. Pt also took OTC gas relief medication and Peptobismol, but didn’t seem to relieve her pain. She thought her pain is due to gas in her stomach. However, her pain is not going away. Pain scale is 6/10. Admits to fatty food, decreased of appetite, and darker stool. Denies fever, weight change, chills, night sweats, fatigue, N/V/D, heartburn/acid reflux, indigestion, dysphagia, hematemesis, and urinary symptoms.

Objectives:

Allergies: none

Current Medication:

Ferrous Sulfate 325 mg tablet, 1 tablet orally twice a day

Albuterol Sulfate 0.083% nebulization solution 3ml Inhalation once a day, as needed

Albuterol Sulfate 108 mcg/act aerosol powder breath 1 puff as needed inhalation every 4hr

Flovent HPA 110 mcg/act aerosol 1 puff inhalation 2x per day

Vitals:

BP 98/60, sitting position, left arm

HR 95 bpm, RRR

RR 16 breaths per minute, regular

O2 98%, room air

T 98.0 oral

Ht 5ft 2 in    Wt 122 lbs     BMI 22.31

Physical exam:

General: in mild distress, good hygiene, A/O x 3

HEENT: Head: NC/AT.  Neck: supple, no lymphadenopathy. Eyes: no redness, PERLLA. Nose: no deviation, no nasal discharge, no inflammation. Throat: tonsils are normal, no exudates or redness. Ears: normal tympanic membrane

CV: RRR, normal S1 S2, no murmurs, clicks, gallops.

Resp: clear to auscultation bilaterally, no adventitious sounds.

GI: Flat/soft abdomen, normal BS throughout, LUQ and epigastric tenderness, neg rovsing sign and neg rebound tenderness, no CVA tenderness, no masses palpated.

Extremities: no edema/swelling, pulses 2+ b/l

MSK: no swelling/deformity

Neuro: CN II-XII grossly intact

Assessment:

22 y/o female presents with 1 week of LUQ and epigastric pain. History and epigastric tenderness most consistent with gastritis.

Differential Diagnosis:

Acute Gastritis

Peptic Ulcer Disease

GERD

Pancreatitis

Renal colic

Appendicitis

Plan:

• Acute Gastritis without bleeding:

Order abdominal ultrasound

Start Pantoprazole Sodium tablet, 40mg, 1 tablet orally, once a day

• Mild persistent asthma:

Stable, status checked, continue with current treatment

• Anemia:

Stable, status checked, continue with current treatment