Emergency Consult

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ID/CC:
N/A is a very pleasant N/A male who presents to the Emergency with abdominal pain in the right upper quadrant.

Past Medical History:
- Trisomy 21 (Down syndrome)

Medications:
- none

History of Present Illness:
- Presents with abdominal pain localized to the right upper quadrant.
- Pain has been occurring for the past several nights, typically after going to bed around 9 or 10 PM.
- During episodes, patient awakens screaming and is observed touching the right upper abdomen, occasionally holding both sides of the abdomen.
- Pain is nocturnal and recurrent.
- No associated symptoms such as fever, vomiting, diarrhea, or jaundice.
- Retains gallbladder; no history of prior cholecystectomy.
- Facial rash consistent with a CPAP mask, though patient denies using such a device at night.
- No recent trauma, travel, or dietary changes.
- No history of prior similar episodes or abdominal surgeries.

Physical Examination:
- Vitals: Blood pressure: 121/75 mmHg, Pulse: 66 bpm, Temperature: 36.7°C, Oxygen saturation: 99%.
- General Appearance: looks well, NAD
- Abdomen: Tenderness in the right upper quadrant upon palpation.
- Skin: Facial rash observed in a pattern consistent with a CPAP mask.

Procedures:

Impression and Plan:
1. Recurrent nocturnal right upper quadrant abdominal pain, concern for biliary pathology.
   - Differential Diagnosis: Biliary colic, cholecystitis, other biliary pathology.
   - Recommendations: Patient to remain NPO. Intravenous fluids (lactated Ringer's) at 100 mL/hour. Abdominal ultrasound scheduled to evaluate gallbladder. Liver function tests (including ALT and bilirubin) ordered. Intramuscular injection for pain management administered with discussion of possible side effects (dizziness, nausea, constipation).

Patient Instructions:
Patient and family informed regarding the current condition and potential causes, including possible biliary pathology. Abdominal ultrasound and liver function tests have been ordered to further evaluate the gallbladder and liver. Pain medication administered intramuscularly; advised regarding possible side effects such as dizziness, nausea, and constipation. Patient instructed to remain NPO and to notify staff of any worsening symptoms. Further management will be guided by test results.