Chief Complaint: “I’ve been having stomach pain and vomiting”
History of Present Illness:
52 y/o female pt with PMH of osteoarthritis presents to the ER for LLQ abdominal pain that began 3 days ago. Pt was last here 3 days ago (09/18/24) for similar symptoms and was worked up with a CT scan which showed LLQ diverticulitis without abscess or free air. Pt was discharged home with ciprofloxacin/metronidazole. Pt admits that the pain improved and she started feeling better but now the pain began again last night in her LLQ. She states that the pain is now accompanied by nausea/vomiting. Denies radiation of pain and denies trying anything to help improve it. Also denies anything that aggravates it. Pt denies fever, chills, chest pain, SOB, myalgia, diarrhea, melena/hematochezia, or dysuria.
ED course: BP: 122/68 | Pulse: 68 | Temp: 36.3 °C (Oral) | Resp 18 | SpO2 98%
Patient received multiple doses of tylenol and one dose of ketoralac in ED.
Past Medical History:
Osteoarthritis
Past Surgical History:
No past surgical history.
Medications:
Ciprofloxacin 500 mg oral every 12 hours
Metronidazole 500 mg oral every 8 hours
Acetaminophen (Tylenol) 650 mg oral every 6 hours PRN
Meloxicam 15 mg oral daily
Allergies:
Penicillins
Social History:
Smoking: denies smoking.
Alcohol: Socially drinking.
Illicit drug use: Denies illicit drug use.
Review of Systems:
General: Denies fever, night sweats, weight loss or gain, generalized fatigue, or chills.
Head: Denies headaches, vertigo, or head trauma, dizziness
Eyes: Denies visual disturbances, photophobia, lacrimation, or pruritus.
Cardio: Denies chest pain, exercise intolerance, PND, and palpitations.
Respiratory: Denies cough, SOB and wheezing.
GI: Admits to LLQ abdominal pain, nausea, and vomiting. Denies diarrhea or constipation.
GU: Denies polyuria, dysuria, hesitancy, and nocturia.
MSK: Denies stiffness, joint swelling, and decreased ROM.
Physical Exam:
Vitals: BP: 122/68 | Pulse: 68 | Temp: 36.3 °C (Oral) | Resp 18 | SpO2 98%
General: Well appearing female not in any acute distress, A&O x 3, cooperative, thoughts & speech coherent.
Cardiac: Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.
Lungs: Clear to auscultation bilaterally. Chest expansion and diaphragmatic excursion symmetrical. No adventitious sounds.
Abd: LLQ abdominal tenderness, no guarding, non-distended abdomen, bowel sounds normoactive in all four quadrants.
MSK/extremities: Full ROM, non tender to palpation, no deformities, erythema, ulcerations, or edema present.
Differential Diagnosis:
- Acute diverticulitis: Worsening or reoccurring – Can be due to lack of medication/antibiotics adherence at home.
- Colonic Perforation: Worsening/severe pain along with nausea/vomiting. Need a repeat CT scan to see if there is free air.
- Gastroenteritis: Experiencing nausea/vomiting along with abdominal pain.
- Abscess formation: Complication of diverticulitis and may present with worsening pain and nausea. However, PE and previous CT didn’t show signs of it.
- Bowel obstruction: Inflammation from diverticulitis may cause adhesions or strictures leading to an obstruction. However, PE didn’t have signs of distension or absence of bowel sounds.
Labs:
CBC:
White Blood Cell 6.90 4.80 – 10.80 x10(3)/uL
Red Blood Cell 4.64 4.50 – 5.90 x10(6)/uL
Hemoglobin 12.3 13.3 – 17.7 g/dL
Hematocrit 37.0 40.0 – 50.0 %
Mean Cell Volume 88.9 80.0 – 100.0 fL
Mean Cell Hemoglobin 29.6 26.0 – 34.0 pg
Mean Cell Hemoglobin Concentration 33.2 31.0 – 37.0 g/dL
Red Cell Distribution Width 12.4 11.5 – 14.5 %
Platelet 206 150 – 400 x10(3)/uL
Mean Platelet Volume 10.2 8.0 – 11.0 fL
BMP:
NA: 138
K: 4.1
CL: 102
CO2:24
BUN: 14.6
CREAT: 0.58
Glucose: 111
Anion gap: 12
Ca: 9.7
Hepatic Panel:
TP: 6.5
ALB: 4.1
SGOT: 36
SGPT: 29
TBILI: 0.4
DBILI: 0.1
ALK: 74
Assessment and Plan:
52 y/o female pt with PMH of osteoarthritis presents to ER for LLQ abdominal pain accompanied by nausea/vomiting x 3 days. Pt was here 3 days and diagnosed with diverticulitis through a CT scan and was started on ciprofloxacin and metronidazole. Pt started feeling better but symptoms reoccurred last night. Admit patient to medicine for acute diverticulitis to determine cause of nausea/vomiting and symptom occurrence.
Acute diverticulitis:
Admit to medicine
Repeat CT scan to see if worserning/reoccurence of diverticulitis
Determine if cause of nausea/vomiting is due to diverticulitis or due to nonadherance of antibiotics prescribed 3 days ago.
Start Flagyl 500 mg IV Q8h and Ceftriaxone 1g daily
Tylenol 650 mg Q6h prn for pain control
Start on clear liquid diet
Osteoarthritis:
Tylenol PRN
Patient Education:
We are admitting you to medicine for further evaluation of your abdominal pain accompanied with the nausea/vomiting. The initial diagnosis was diverticulitis, and while you improved with treatment, your symptoms have returned. We will perform another CT scan to check if there is worsening of the diverticulitis or if other issues might be causing your symptoms. To better manage your condition, you will receive IV antibiotics, and we will provide pain relief as needed.
