[20F] With multiple symptoms including abdominal pain and muscle aches

Patient Description

A 20-year-old female presents with sharp abdominal pain in both the right lower and upper quadrants, which has been present for a week and rated as a 6 out of 10 in intensity. The pain has been gradually worsening and is not relieved by any measures. The patient also reports muscle pain that feels sore, rated as a 5 out of 10, and has been present for a week. The pain worsens with activities related to caregiving. Additional symptoms include fatigue, lack of energy, loss of appetite, headaches, weakness, lightheadedness, blurred vision, tingling in the fingers on and off, confusion, depression, anxiety, stress, insomnia, pallor, chills, lower back pain, unexplained weight loss, chest pain, and shortness of breath. The patient experiences irregular menstrual bleeding, which is lighter when not on her period and heavier during her period. She has not experienced nausea, vomiting, diarrhea, constipation, fever, or jaundice. Bowel movements are regular, and urine is yellow but more frequent. There is no history of gastrointestinal issues like gallstones, kidney stones, or appendicitis. The patient occasionally uses marijuana without any effect on her symptoms. She has a history of depression, anxiety, PTSD, ADD, and ADHD, diagnosed in 2016. She is allergic to penicillin and is not currently taking any medications.

Arora's Assessment

What might be happening

Based on the symptoms you've described, there are a few potential diagnoses that could explain your condition. Here are some possibilities:

Abdominal Pain and Related Symptoms

Gallbladder Issues (Cholecystitis or Gallstones)
- Rationale: Sharp pain in the right upper quadrant (RUQ) can be indicative of gallbladder problems. This pain can radiate to the back and may be accompanied by chills.
- Typical Treatments/Testing: An ultrasound or CT scan can help diagnose gallbladder issues. Treatment may include dietary changes, medications, or surgery.
Appendicitis
- Rationale: Sharp pain in the right lower quadrant (RLQ) can be a sign of appendicitis, especially if the pain has been gradually worsening.
- Typical Treatments/Testing: A physical exam, blood tests, and imaging studies like a CT scan can help diagnose appendicitis. Treatment usually involves surgical removal of the appendix.

Systemic Symptoms (Fatigue, Weakness, Dizziness, etc.)

Anemia
- Rationale: Symptoms like fatigue, weakness, dizziness, pallor, and shortness of breath can be indicative of anemia.
- Typical Treatments/Testing: Blood tests to check hemoglobin and iron levels. Treatment may include dietary changes, iron supplements, or other medications.
Thyroid Disorders (Hypothyroidism)
- Rationale: Fatigue, muscle aches, weight changes, and depression can be symptoms of thyroid disorders.
- Typical Treatments/Testing: Blood tests to check thyroid hormone levels. Treatment usually involves thyroid hormone replacement therapy.

Neurological Symptoms (Blurred Vision, Tingling, Confusion)

Vitamin Deficiencies (e.g., B12 Deficiency)
- Rationale: Blurred vision, tingling in fingers, and confusion can be symptoms of vitamin deficiencies.
- Typical Treatments/Testing: Blood tests to check vitamin levels. Treatment may include dietary changes and vitamin supplements.

Mental Health Symptoms (Depression, Anxiety, Stress)

Mental Health Disorders
- Rationale: Your history of depression, anxiety, PTSD, ADD, and ADHD could be contributing to your current symptoms.
- Typical Treatments/Testing: Consultation with a mental health professional for therapy and/or medication management.

What you can do

Abdominal Pain

See a doctor as soon as possible: Given the severity and duration of your abdominal pain, it's important to get a medical evaluation. Your doctor may recommend imaging studies like an ultrasound or CT scan to diagnose the issue.
Avoid heavy meals: Stick to light, easily digestible foods until you can see a doctor.
Stay hydrated: Drink plenty of water to stay hydrated.

Systemic Symptoms

Consult your doctor: A blood test can help diagnose conditions like anemia or thyroid disorders.
Eat a balanced diet: Ensure you're getting enough iron, vitamins, and other essential nutrients.
Rest: Make sure to get plenty of rest to help your body recover.

Neurological Symptoms

Consult your doctor: Blood tests can help identify any vitamin deficiencies.
Take breaks: If you're experiencing blurred vision, take regular breaks from screens and rest your eyes.

Mental Health Symptoms

Seek mental health support: Given your history of mental health conditions, it may be helpful to consult a mental health professional for therapy or medication management.
Practice self-care: Engage in activities that help reduce stress and anxiety, such as mindfulness, exercise, or hobbies you enjoy.

General Tips

Use MDandMe: You can use MDandMe to journal your symptoms, track your progress, get insights, and share longitudinal medical notes with your provider.

What you should look out for

Given the severity of your symptoms and the possibility of serious underlying conditions, you should seek medical care as soon as possible. Reasons to seek care even more urgently include:

Severe or worsening abdominal pain
Fainting or severe dizziness
Shortness of breath or chest pain
Unexplained weight loss
Severe confusion or changes in mental status

Remember, while I can provide information and suggestions, it's important to consult with a healthcare professional for a formal diagnosis and appropriate treatment.