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44 year old lady has been having epigastric pains for the past 4 weeks…
44 year old lady has been having epigastric pains for the past 4 weeks
Radiation of pain
Left arm/neck => myocardial ischemia. Other sx: diaphoresis; exertional dyspnea; nausea; fatigue
Back => pancreatitis. Other sx: nausea/vomitting; postprandial pain; relieved on bending forward; signs of retroperitoneal hemorrhage, e.g. flank bruising (Grey Turner's sign) or umbilicus bruising (Cullen's sign); check for cause: gallstones, alcohol i.e. binge drinking; hx of ERCP; hypertriglyceridemia. Chronic if: initially episodic epigastric pain followed by continuous epigastric pain; steatorrhea due to pancreatic insufficiency; new/worsening diabetes
Other associated sx
Asymptomatic; sx due to other conditions
Gastritis. Other sx: bloating; feeling full after eating a small amount; decreased appetite; nausea/vomiting (containing blood); precursor to ulcers but mucosa intact; alarm sx: anemia, weight loss, recent onset/rapid progression of sx, melena/hematemesis, SOB
Pericardial process, e.g. effusion. Other sx: fatigue; SOB; elevated JVP; edema
Variable
Aortic aneurysm (AA). Depends on which structures are compressed. If compression of tracheobronchial tree = wheezing, cough, hemoptysis, SOB, pneumonitis. If erode into adjacent spine = back pain
Vague and intermittent sx => paraoesophageal hernias. Other sx: postprandial fullness; nausea; retching
Dysphagia => Oesophageal pathology e.g. oesophagitis. Other sx: food impaction; chest pain doesn't respond to antacids; GERD-like sx/refractory heartburn.
Also refer to gastric cancer
.
Epigastric distension/tenderness => Gastroparesis. Other sx: nausea/vomiting; early satiety; acid reflux; abdominal bloating; loss of appetite; weight loss
Weight loss
Gastric outlet obstruction (GOO). Other sx: nausea/vomiting; early satiety, abdominal distension, weight loss; elicit succussion splash
Gastric cancer (unlikely based on age). Other sx: asymptomatic early then causes vague constant epigastric pain; pain has no relationship to meals; tumour bleed = hematemesis/melena; late sx = early satiety, vomiting undigested food; dysphagia; loss of appetite
Pancreatic cancer (also unlikely based on age). Other sx: Head of pancreas tumour may present with obstructive jaundice; body/tail cancer may present with chronic progressive epigastric pain radiating to the back
Postprandial pain?
Present
Often after fatty meals => biliary colic (pain if impacted gallstones are squeezed against the gallbladder outlet). Other sx: nausea/vomiting
Peptic ulcer disease. Other sx: pain relieved by vomiting; may have melena/hematemesis due to bleeding; peritonitis due to perforation; check for
H. pylori
risk factors e.g. past hx, contact hx, travel hx, smoking*
Eating alleviates pain
Eating alleviates pain => GERD. Other sx: heartburn; pain exacerbated by lying flat; acid brash (acid taste in mouth due to reflux