Skip to content
ホーム » “Every evening my belly feels like a balloon…” — Two Faces of Abdominal Bloating (Mock patient note)

“Every evening my belly feels like a balloon…” — Two Faces of Abdominal Bloating (Mock patient note)

Description

Abdominal bloating is one of the most common yet elusive complaints in clinical practice. While it is often functional and benign, it can sometimes signal serious pathology. This article presents two contrasting cases — one standard, one challenging — to sharpen your diagnostic approach.

🔍 Jump to Section

Case 1 – Standard Case: “Every evening my belly feels like a balloon…”

Doorway Information

  • Age: 32
  • Gender: Female
  • Chief Complaint: “My stomach feels really bloated, especially in the evening.”
  • Vital Signs: T 36.6°C, HR 72, BP 112/68, RR 14, SpO₂ 99%

Structured History

Opening
“My stomach starts to swell up by evening—it’s been happening for months.”

Shoreline
“It’s been like this for about 4 months. I feel fine in the morning, but by evening I look like I’m five months pregnant.”

Associated Symptoms

  • No nausea or vomiting
  • Bowel movements daily, but sluggish
  • Sometimes gassy, belching after meals

Mood / Function / Appetite / Sleep

  • Some anxiety around the symptoms
  • Appetite normal, avoids certain foods
  • No weight loss
  • Normal sleep

Medical History / Medication

  • Occasional PPI and laxative use

PAM HITS FOSS

  • P: No surgeries
  • A: No allergies
  • M: No regular medications
  • H: No chronic illness
  • I: Freelance designer; irregular meals
  • T: Regular cycles
  • S: Non-smoker, occasional wine
  • F: No family GI disease
  • O: Lives with partner
  • S: No substance use
  • S: Sexually active

Concerns & Questions
“Could this be cancer? Or hormone-related?”

Physical Examination

Positive Findings

  • Mild evening distension
  • Normal bowel sounds
  • Mild LLQ tenderness

Negative Findings

  • No guarding, rigidity, rebound
  • No hepatosplenomegaly or masses

Differential Diagnosis

1. Functional abdominal bloating (IBS-C subtype)

  • Time-of-day variation, mild constipation, psychological overlay

2. Small intestinal bacterial overgrowth (SIBO)

  • Gassy, food-related pattern, but no diarrhea or surgical history

3. Early ovarian neoplasm

  • Vague concern, no masses or menstrual irregularity

Clinical Reflection

“Her exam is reassuring, but the symptoms are real. She needs validation and a structured plan.”

Clinical Pearls

  • “Morning flat, evening full” = functional pattern
  • Red flags always matter: bleeding, weight loss, vomiting
  • Avoid dismissing patient’s concern as “just stress”

Challenging Questions

Q: “Is this cancer?”
A: “That’s one possibility, but we need more information. Several other conditions can cause this. We’ll do the right tests and support you step by step.”

Q: “Should I do a CT scan?”
A: “You don’t have alarm signs now, so let’s try symptom management first and re-evaluate if needed.”

Q: “Could it be hormone-related?”
A: “It doesn’t appear directly linked to your cycle, but we’ll watch for patterns.”

📝 SOAP Note

S: 32F with 4-month history of evening bloating. Normal bowel habits, mild constipation. No red flags. No weight loss.
O: T 36.6°C, HR 72. Abdomen soft, mildly distended. No mass or organomegaly.
A:
# Functional bloating (IBS-C)
# Rule out ovarian pathology
P:
- Diet/lifestyle education
- Consider fiber or osmotic laxative trial
- Pelvic US if symptoms persist
- Follow-up in 2–4 weeks

Case 2 – Challenging Case: “I thought I was just gaining weight…”

Doorway Information

  • Age: 58
  • Gender: Female
  • Chief Complaint: “My abdomen is getting bigger and tighter.”
  • Vital Signs: T 36.8°C, HR 84, BP 138/80, RR 16, SpO₂ 98%

Structured History

Opening
“My belly keeps growing, but I haven’t changed how I eat.”

Shoreline
“It started two months ago. My clothes no longer fit right.”

Associated Symptoms

  • Early satiety
  • Mild shortness of breath
  • Occasional pelvic discomfort
  • No bleeding, vomiting, bowel changes

Mood / Function / Appetite / Sleep

  • Anxiety about cause
  • Appetite decreased
  • Disturbed sleep from pressure

Medical History / Medication

  • Hypertension (on amlodipine)
  • Menopause at 52

PAM HITS FOSS

  • P: No surgeries
  • A: No allergies
  • M: Amlodipine only
  • H: Hypertension
  • I: Retired
  • T: Menopausal
  • S: Non-smoker
  • F: Sister with breast cancer
  • O: Married
  • S: No substance use
  • S: Not sexually active

Concerns & Questions
“Could this be something serious like cancer?”

Physical Examination

Positive Findings

  • Distended abdomen with shifting dullness
  • Mild lower abdominal tenderness

Negative Findings

  • No palpable mass
  • No hepatosplenomegaly
  • No edema

Differential Diagnosis

1. Ovarian cancer with malignant ascites

  • Postmenopausal status, family history, ascites

2. Liver cirrhosis with ascites

  • No liver disease signs, no alcohol use

3. Peritoneal carcinomatosis from GI source

  • No GI symptoms, but not excluded

Clinical Reflection

“This is no longer ‘just bloating.’ The clues point toward something serious — time for action.”

Clinical Pearls

  • Ascites in postmenopausal women = ovarian cancer until proven otherwise
  • CA-125 is helpful but not definitive
  • Ultrasound is first step, not CT

Challenging Questions

Q: “Do you think it’s cancer?”
A: “We’re concerned and will investigate quickly. We’ll explain each step clearly and support you.”

Q: “Did I wait too long?”
A: “You came as soon as you felt something wasn’t right. That was the right decision.”

Q: “Will I need surgery?”
A: “Depending on results, yes—but we’ll review all the options together.”

📝 SOAP Note

S: 58F with progressive abdominal distension over 2 months, early satiety, decreased appetite. No bleeding or vomiting.
O: T 36.8°C, HR 84. Abdomen distended with shifting dullness. No edema.
A:
# Ascites in postmenopausal woman
# Suspicion of ovarian malignancy
P:
- Pelvic ultrasound
- Tumor markers: CA-125, CEA
- CBC, CMP
- Refer to gynecologic oncology

🧠 Take Home Messages

  • Bloating is often subjective — validate the experience.
  • Constipation + time-of-day variation → functional cause likely.
  • “Weight gain” in older women warrants deeper evaluation.
  • Don’t forget to check shifting dullness.
  • Ultrasound first, not CT, in most initial workups.

💡 Clinical Tips

  • “Flat in morning, full at night” = functional pattern
  • Distinguish between distension and true weight change
  • Always ask about menstrual and sexual history
  • Early satiety is a red flag
  • Red flags: age >50, weight loss, bleeding, palpable mass

📖 Medical English Glossary

TermDefinition
BloatingSubjective fullness/swelling in abdomen
Shifting dullnessSign of ascites on physical exam
AscitesFree fluid in the abdominal cavity
Early satietyFeeling full after small amounts of food
CA-125Ovarian tumor marker
IBSFunctional bowel disorder
Functional bloatingNon-organic bloating
Peritoneal carcinomatosisWidespread peritoneal cancer involvement

🔗 Related Articles

📚 References

  1. Gynaecologic Oncology. Diagnosis and management of ovarian cancer.
  2. Rome IV criteria for functional gastrointestinal disorders.
  3. UpToDate: Approach to the adult with abdominal bloating.
  4. BMJ Best Practice: Evaluation of ascites and peritoneal carcinomatosis.
  5. ACG IBS Guidelines (2021)

🧰 Recommended Resources

  • First Aid for the USMLE Step 2 CS
  • The Patient History: An Evidence-Based Approach
  • Case Files: Internal Medicine
  • Pocket Medicine
  • Da Vinci’s Snap Diagnosis Cases (JP)
Tags:

Leave a Reply

Your email address will not be published. Required fields are marked *