Case Study 1 – Abdominal Pain
HPI: 15 year old female comes to the clinic presenting with a chief complaint of abdominal pain. The abdominal pain is generalized in location, and described as a dull pain, non-radiating. She notes some acid reflex, and reports she has a history of gastritis. She also notes decreased appetite recently. Denies any nausea or vomiting, denies any recent bowel changes.
PMHx, PSHx, FHx: Non-contributory
Social Hx: Denies current sexual activity, denies alcohol use or smoking. LMP was 2 week ago.
Physical Exam: Unremarkable except some generalized tenderness in the abdominal region, no rebound, no guarding. Rectal/pelvic exam was deferred.
Brief Differential Dx:
-Gastritis/GERD
-Parasites
-Pregnancy
-Gastroenteritis
-Irritable Bowel Syndrome
Lab Tests: There are several parasitology tests that are available at the clinic, but we chose to do a simple microscopic examination (“Parasitologia Simple) as well as an cytologic examination of the fecal mucous (“Moco Fecal”). The microscopic exam simply examines a portion of stool under the microscope to look for any eggs, cysts, or other evidence of parasites. The fecal mucous test is a way to examine the cytology of stool, looking for any evidence of certain cells (e.g. neutrophils, eosinophils, etc.) The fecal mucous test helps to determine if a gastrointestinal infection is of viral or bacterial origin.
At least at the Belen clinic, there is no availability of testing for GERD (e.g. H. pylori antibodies, breath test, etc.). However, if we truly suspect gastritis/GERD and want to confirm the diagnosis, we can refer the patient to have an endoscopy.
Although we do have a urine pregnancy test available at the clinic, we did not order it, mainly based on the patient’s denial of sexual activity and recent menstruation.
Treatment Plan: We chose to treat the patient for gastritis/GERD symptoms, and started her on omeprazole (proton pump inhibitor) and metoclopromide (antiemetic and gastroprokinetic). Gastritis/GERD, which is common in the U.S., also appears to be common here as well. However, pending her stool results, we would also start her on an antiparasitic, the one commonly used here is tinidazole. The main side effect of tinidazole is that it can have a disulfiram-like reaction when drinking alcohol.
In many cases of abdominal pain here in Peru, especially abdominal pain in children, physicians will treat the patient with antiparasitics empirically, as it is such a common problem. Particularly within the patient population at the Belen Clinic, giardiasis appears to be a common problem.
Although pt denies sexual activity, I definetelly will do a pregnancy test. Most adolescent denies engaging in sexual activity. Therefore, HCG test will be priority of differential diagnoses. Pt is complains of abdominal pain, if HCG positive, ectopic pregnancy will be suspected.If HCG negative I will go with your treatment plan.
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