gastroenterology

ABDOMINAL EXAM RE-EVAL

The patient appears comfortable and states that pain is improved. Tolerating oral intake. Vital signs reviewed and are normal. On repeat physical exam, the abdomen is soft and nontender All diagnostics tests reviewed and discussed with the patient.

ABDOMINAL PAIN DISCHARGE RE-EVAL

On repeat examination prior to discharge, the patient has a soft abdomen with no peritoneal findings. The patient was able to tolerate oral intake. The patient was advised that even though there is no evidence of a surgical emergency at this time, sometimes this is not visible on ***IMAGING*** or in the labs early in a disease course and that if there is additional pain they are to return for repeat evaluation. The patient stated understanding of this, has decisional making capacity and is discharged in stable condition. The patient was instructed to return to the emergency department for re-evaluation in 8-12 hours and sooner if they feel worse in any way.

ABDOMINAL PAIN D/C INSTRUCTIONS

Please return to the emergency department immediately should you feel worse in any way or have any of the following symptoms: increasing or different abdominal pain, persistent vomiting, fevers or shaking chills. Please return to the emergency department for a recheck in 8-12 hours if the pain is persistent or worse so we can re-evaluate you and ensure that you are not developing a problem that would require surgery or hospitalization.

I had a discussion with the patient and we shared decision making regarding emergent CT of the abdomen. Risks and benefits were reviewed and discussed and radiation exposure vs. diagnostic uncertainty were reviewed. Based on overall clinical presentation and diagnostic data, it was felt the risk of life-threatening or serious pathology was low. Importance of strict follow up was stressed. The patient was warned to return to the ED with worsening or recurrent pain or if their condition worsened in any way.