For my Ambulatory Medicine Rotation, I had the pleasure of presenting my patient cases to Professor Rachwalski. Out of the 2 cases I presented, I found the case about the 8-year-old male with vomiting and diarrhea for one day the most interesting. The patient had been accompanied by his mother, was up to date on immunizations and presented with a cough, abdominal pain, and vomiting for 1 day. The patient reported sharp, constant pain that started the previous night in the epigastric region which then radiated to the suprapubic region. Pain was exacerbated by bowel movements, walking, laying down, and getting up from supine position. He rated the pain 7/10. The patient had taken Motrin at 7am without any relief. He also had 3 episodes of non-bilious, non-bloody vomiting and loss of appetite. His last meal was at 7pm the previous night and had not been able to keep solids or liquids down. His last bowel movement was the night before. He denied fever, chills, diarrhea, SOB, chest pain, bloody stools, or recent sick contacts. 

My initial differential diagnoses based on history were gastroenteritis, appendicitis, small bowel obstruction, testicular torsion, and nephrolithiasis.

On exam, the patient appeared uncomfortable, holding his belly due to pain, but still able to speak clearly in full sentences. He was also tender to palpation in the RLQ and LLQ and mildly distended. He also had a (+) Rovsing sign and (+) rebound tenderness. 

No labs or imaging were ordered due to the nature of the practice.

Based on the physical exam findings, my leading differential was appendicitis, although the patient could have very likely had a bad case of gastroenteritis. It was difficult to determine the cause of his symptoms as we were unable to perform labs or imaging for appendicitis in the urgent care practice.

After receiving feedback from my site evaluator, it was discussed to include more differentials after the physical exam. It was also pointed out to be mindful of what I include in my ROS as I had left out that the patient admitted to diarrhea. Another suggestion that was made was to make my H&P more concise by condensing parts of the physical exam into one liners and paragraphs. For example, the mouth and pharynx exam in my HPI is separated into lips, mucosa, palate, teeth, gingivae, tongue, oropharynx and tonsils.