[35M] With upper abdominal discomfort and gastrointestinal symptoms

Patient Description

A 35-year-old male presents with upper abdominal discomfort for the past four days, described as a dull pain on the left side, rated 2 out of 10 in severity. The patient reports no relief from the discomfort. Accompanying symptoms include yellow, loose stools occurring once daily, and excessive gas and burping. The symptoms began suddenly and are not associated with any recent dietary changes or travel. The patient recently started taking cephalexin 500 mg capsules and ibuprofen 600 mg once daily, but symptoms predate the initiation of cephalexin. Alcohol and caffeine consumption have not exacerbated the symptoms. The patient has no known allergies, pre-existing medical conditions, or other medications.

Arora's Assessment

What might be happening

Based on the symptoms you've described, here are some possible explanations:

Gastroenteritis: This is an inflammation of the stomach and intestines, often caused by a viral or bacterial infection. Symptoms can include abdominal pain, diarrhea, gas, and burping. It often resolves on its own, but staying hydrated is important.
- Treatment typically involves rest, hydration, and over-the-counter medications to manage symptoms. If a bacterial infection is suspected, antibiotics like cephalexin may be prescribed.
Lactose Intolerance: This is a common condition where the body cannot easily digest lactose, a sugar found in milk and dairy products. It can cause gas, bloating, diarrhea, and abdominal discomfort.
- Treatment involves avoiding lactose-containing foods or using lactase enzyme supplements.
Medication Side Effects: Both cephalexin and ibuprofen can cause gastrointestinal symptoms, including abdominal discomfort and changes in stool. Since your symptoms started before taking cephalexin, it's less likely to be the cause, but ibuprofen can irritate the stomach lining.
- Consider discussing with your doctor whether you should continue these medications.

What you can do

Stay Hydrated: Drink plenty of fluids, such as water or oral rehydration solutions, to prevent dehydration from diarrhea.
Dietary Adjustments: Try eating bland, easy-to-digest foods like bananas, rice, applesauce, and toast (the BRAT diet) until your symptoms improve.
Avoid Irritants: Limit caffeine, alcohol, and spicy or fatty foods, as they can exacerbate symptoms.
Symptom Tracking: Use MDandMe to journal your symptoms, track your progress, and share insights with your healthcare provider.