ABDOMINAL PAIN Dr.Bandar saleh

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. Present History

Past Medical History : no thing Past Symptoms History : no thing Family History : no thing .

Denies current sexual activity, denies alcohol use or smoking 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. Social History

Differential Diagnosis -Gastritis/GERD -Parasites -Pregnancy -Gastroenteritis -Irritable Bowel Syndrome Differential Diagnosis

Laboratory Test 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 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.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, 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 ,giardiasis appears to be a common problem.