Based on the patient’s history, physical exam, and objective data, I have a lower suspicion for an emergent cause of the patient’s abdominal pain at this time. The patient is overall well-appearing without peritoneal signs on exam.
Low suspicion for acute hepatobiliary disease (including acute cholecystitis or cholangitis), acute pancreatitis, peptic ulcer disease with perforation, acute infectious processes (pneumonia, hepatitis, pyelonephritis), acute appendicitis, vascular catastrophe, bowel obstruction, perforated viscus, or atypical ACS.
Given my current clinical suspicion, I do not believe CT imaging is indicated at this time. However, before discharge, I will counsel the patient on strict return precautions for new or worsening symptoms which could prompt reconsideration of the risk/benefit of further imaging.
If female:
Pregnancy test negative. Given location of pain and history, lower suspicion for pelvic etiology of abdominal pain, including emergent causes such as ectopic pregnancy, tubo-ovarian abscess, ovarian torsion, severe hemorrhagic cyst, or severe pelvic inflammatory disease.
At this time, the exact cause of this patient’s abdominal pain is unclear, but given their risk factors and my physical exam, I believe further diagnostic workup is indicated including with advanced imaging.
Will plan for broad laboratory workup including CBC/BMP/LFTs/lipase and further imaging with CT to evaluate for emergent pathologies, including acute hepatobiliary disease (including cholecystitis), pancreatitis, acute infectious process (including abscess and pyelonephritis), appendicitis, vascular catastrophe, bowel obstruction, or perforated viscus. I believe the benefit of imaging outweighs the risk given the overall clinical picture. Disposition pending imaging and laboratory workup as above.
Based on this patient’s history, physical exam, and objective data, their chest pain appears most likely non-cardiac in nature. The pain is non-exertional, not associated with nausea/vomiting, and not associated with dyspnea***. ECG is overall not concerning for active ischemia, and on exam, the patient is euvolemic, with no evidence of volume overload concerning for heart failure exacerbation. The patient has minimal risk factors for coronary artery disease, but I will plan for chest X-ray and single troponin ***.
Patient is hemodynamically stable, non-toxic, without increased oxygen requirements or increased work of breathing. I will review CXR and ECG as above, but based on my initial history and physical, I have lower suspicion that this presentation reflects a potentially-emergent condition such as pulmonary embolism, aortic dissection, pericarditis, myocarditis, pneumonia, pericardial effusion with tamponade, or esophageal rupture.
I anticipate likely discharge given my overall low suspicion for acute coronary syndrome or another emergent pathology, pending above workup. If discharged, will counsel patient on strict return precautions.
This patient is presenting with chest pain of unclear etiology, with no active ischemia on ECG but with significant risk factors for coronary artery disease. The patient appears euvolemic, without evidence of volume overload or shock.
While the exact cause of this patient’s pain is unclear, given their medical history and clinical presentation, I believe they are at high risk for a major adverse cardiac event and will likely require admission for inpatient risk stratification and further cardiac workup, such as formal echo, provocative testing, cardiac CT/MRI, or catheterization.