CC Mrs. Newcomb is a 51-year-old female here today complaining of abdominal pain. HPI The patient tells me that she has trouble with abdominal pain on and off for several years. She, a little more than a year ago, went through an extensive evaluation with William E. Maher, MD in gastroenterology for abdominal pain and ultimately was told that this was likely IBS. She says at that time, she underwent evaluation with an ultrasound, HIDA scan, laboratory studies. She previously had a colonoscopy prior to that in 2009. Reportedly everything was normal. Ultimately, her symptoms resolved and she had been feeling well for quite some time. Recently, in the last couple of weeks, she started noticing a similar type of pain. It was on the left …show more content…
We reviewed differential diagnosis and at this point, because her pain has been persistent now for the last couple of weeks, it is mainly in the left and right upper quadrant, I have recommended that we move forward with an abdominal ultrasound and I will review those results when available. She will also be doing some laboratory studies. She knows that if her symptoms worsen acutely, she will seek care particularly if has vomiting, fevers or worsening abdominal pain. We also talked about possibly having her follow up with Dr. Maher, as well, but we will start the evaluation here. I am going to have her also do a trial of a proton pump inhibitor either Nexium or Prilosec over-the-counter to use for about a week to see if that helps her symptoms, also. She will follow up in one to two weeks with Dr. Murray or myself with sooner follow up as necessary. She is aware of what to watching for in the meantime. If she does develop any new symptoms or concerns, she will contact me so we can address each issue as they arise. She does understand also down the road, further evaluation with CT may be necessary, if her pain persists. All questions answered in the office