HISTORY:
pain for
Onset: , following
Radiation:
Severity: , / 10
Type:
Pattern:
Episode duration:
Worsening factors:
Treatments tried: ,
, episodes ,
, up to °, over
, over ,
, ,
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Skin:
Extremities: , , cap refill , pulses ,
ASSESSMENT:
DDx:
PLAN:
- Blood work: , , , , ,
- Abdominal ultrasound
- CT scan of abdomen
- HIDA scan
- MRCP
- ERCP
-
-
-
- , if cholecystitis suspected
- Low fat diet
- Increase fluid intake
- Avoidance of rapid weight loss
- Referral to general surgeon
- Referral to gastroenterologist
- Follow-up in
- Return if pain worsens, fever develops, jaundice appears, or if new symptoms develop such as vomiting or changes in stool color
- Go to ER if severe abdominal pain, severe vomiting, or fever