Hey, so my customer has, my patient has a stomach ache. What should I

Hey, so my customer has, my patient has a stomach ache. What should I offer to this patient? Or look for in this patient? Sorry.

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Now I have enough information for a solid, structured clinical answer. Here it is:

Approach to a Patient with Abdominal Pain ("Stomach Ache")

Abdominal pain is one of the broadest presentations in medicine. It can be benign and self-limited, or the first sign of a life-threatening emergency. Your job is to systematically narrow the differential.

Step 1: History - the most important tool

Ask about these key features:

Feature	What to ask	Why it matters
Onset	Sudden/explosive vs. gradual?	Sudden = perforation, AAA rupture, ischemia; gradual = appendicitis, cholecystitis
Location	Where exactly? Does it move?	Guides your differential (see below)
Character	Sharp, crampy, burning, steady, colicky?	Colicky = obstructed viscus; steady = inflammation/ischemia
Severity	Scale 1-10	Severe out-of-proportion to exam = ischemia
Radiation	Does it spread anywhere?	Epigastric to back = pancreatitis; RUQ to right scapula = cholecystitis
Timing	Constant vs. intermittent? Duration?	Chronic (>6 months) vs. acute vs. subacute
Aggravating/relieving	Food, movement, position, BMs, antacids?	Eating worsens pancreatitis; eating may relieve PUD
Associated symptoms	Nausea, vomiting, fever, diarrhea, constipation, bloody stool, jaundice, dysuria, weight loss	Fever + RLQ = appendicitis; jaundice = biliary/liver
Last menstrual period	In women of reproductive age	Ectopic pregnancy is a must-not-miss

Red flag features suggesting an organic/serious process: fever, night sweats, weight loss, appetite change, or nocturnal awakening from pain.

Step 2: Location-based differential

Region	Top diagnoses to consider
Epigastric	PUD, GERD, acute pancreatitis, gastritis, early MI
RUQ	Cholecystitis, hepatitis, biliary colic
LUQ	Splenic pathology, gastric ulcer
Periumbilical	Early appendicitis, small bowel obstruction, intestinal ischemia, AAA
RLQ	Appendicitis, ovarian cyst/torsion (women), Crohn's disease
LLQ	Diverticulitis, ovarian cyst/torsion (women), constipation
Suprapubic	UTI, pelvic pathology, bladder
Diffuse	Peritonitis, ischemia, IBS, early obstruction

Step 3: Physical Examination

Inspection: Distension, visible peristalsis, surgical scars
Auscultation: High-pitched or absent bowel sounds (obstruction vs. ileus)
Percussion: Tympany (gas/obstruction), dullness (fluid/mass), loss of liver dullness (free air)
Palpation: Tenderness location, guarding (voluntary vs. involuntary), rigidity, rebound tenderness
Special signs: Murphy's sign (cholecystitis), McBurney's point (appendicitis), Rovsing's, psoas/obturator signs
Don't miss: Hernial orifices (strangulated hernia), costovertebral angle tenderness (pyelonephritis), pelvic exam in women

Involuntary guarding + rebound + rigidity = peritonitis = surgical emergency

Step 4: Immediate triage - does this need urgent surgery?

Conditions requiring urgent surgical evaluation include:

Bowel perforation
Acute appendicitis
Strangulated hernia
Intestinal ischemia/obstruction
Ruptured ectopic pregnancy
Severe colitis with perforation risk
Acute cholecystitis (may need intervention)

Step 5: Investigations (guided by history/exam)

Labs: CBC (WBC elevation with infection/inflammation), CMP (liver enzymes, bilirubin), lipase/amylase (pancreatitis), urinalysis (UTI, kidney stone), beta-hCG in women
Imaging: Abdominal X-ray (obstruction, free air), Ultrasound (gallbladder, ovaries, appendix in thin patients), CT abdomen/pelvis (gold standard for most acute causes), MRI if concerned about radiation
ECG: In older patients - inferior MI can present as epigastric pain

Common diagnoses at a glance

Diagnosis	Key clue
PUD	Epigastric burning, H. pylori risk, NSAID/aspirin use
Acute pancreatitis	Epigastric radiating to back, elevated lipase, alcohol/gallstones
Cholecystitis	RUQ pain after fatty meal, Murphy's sign, fever
Appendicitis	Periumbilical pain migrating to RLQ, anorexia, fever
Diverticulitis	LLQ pain, fever, older adult, elevated WBC
IBS	Chronic crampy pain, relieved by BM, no alarm features
GERD	Burning epigastric/substernal, worse lying down or after meals
Ectopic pregnancy	Women of reproductive age, pelvic pain + amenorrhea = emergency
Intestinal ischemia	Severe pain out of proportion to exam, cardiac risk factors

The key takeaway is: start with a thorough history and physical exam - those will direct your workup more than any single test. And always ask yourself first: "Does this patient need surgery or urgent intervention right now?"

(Goldman-Cecil Medicine, Chapter 118; Sleisenger & Fordtran's GI and Liver Disease, Chapter 12)

alopcia arreata images

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Here is a comprehensive visual overview of Alopecia Areata from the medical textbook library:

Alopecia Areata - Clinical Images

1. Classic Patchy Alopecia Areata (Scalp)

A single well-circumscribed, smooth oval patch of hair loss on the scalp - the most common presentation:

Fig. 87-1 - Patch of alopecia areata with mild peachy erythema and some fine residual hairs (Fitzpatrick's Dermatology)

2. Patchy Alopecia Areata (Multiple Confluent Patches)

Multiple patches coalescing across the scalp, with white/gray hairs typically spared:

Patient with patchy alopecia areata showing multiple areas of hair loss

Fig. 87-2 - Patient with patchy alopecia areata (Fitzpatrick's Dermatology)

3. Alopecia Areata with Exclamation Point Hairs

Close-up showing residual broken short hairs at the patch edge - the pathognomonic "exclamation point" hairs (tapered proximally, blunt distally):

Patch of alopecia areata with exclamation point hairs visible at the margin

Fig. 87-4 - Patch of alopecia areata with exclamation point hairs (Fitzpatrick's Dermatology)

4. Alopecia Totalis

Complete loss of all scalp hair:

Patient with alopecia areata totalis - completely bald scalp with absent eyebrows

Fig. 87-3 - Patient with alopecia areata totalis (Fitzpatrick's Dermatology)

5. Eyebrow Involvement

Loss of eyebrows - a characteristic extra-scalp manifestation:

Patient with alopecia areata of the eyebrows - near-complete eyebrow loss bilaterally

Fig. 87-5 - Patient with alopecia areata of the eyebrows (Fitzpatrick's Dermatology)

6. Pathogenesis Diagram

The underlying mechanism - CD8+ T cells attack the hair bulb, causing premature catagen transition (and why JAK inhibitors work):

Alopecia areata pathogenesis - IL-15 supports CD8+ T cells that cause premature catagen transition; JAK inhibitors block this pathway

Fig. 13-4 - Mechanism of alopecia areata and role of JAK inhibitors (Fitzpatrick's Dermatology)

Key Clinical Clues at a Glance

Feature	Description
Patch shape	Round/oval, well-demarcated, smooth scalp
Exclamation point hairs	Short, tapered at base - at patch borders
Black dots	Broken-off hair stubs in follicular openings (dermoscopy)
Yellow dots	Empty follicles filled with keratin/sebum (dermoscopy)
Nail pitting	Grid-like pitting in ~10% of patients
White hair sparing	Pigmented hairs targeted; white/gray hairs often spared
Variants	Patchy → Ophiasis → Totalis → Universalis

(Sources: Fitzpatrick's Dermatology, Andrews' Diseases of the Skin, Dermatology 2-Volume Set 5e)

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