Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
Abdominal pain (typically dull aching, postprandial – after meals, may worsen with leaning forward)
Nausea / Vomiting
Early satiety (feeling full after eating a small amount)
Bloating
History of Present Illness:
Onset, duration, location, character, and severity of abdominal pain.
Frequency and relationship of symptoms to meals (postprandial).
Alleviating and aggravating factors (e.g., posture, medications).
Weight loss (if any).
Past Medical History:
Previous abdominal surgeries (may increase risk of adhesions mimicking MALS).
Underlying gastrointestinal conditions (e.g., peptic ulcer disease, irritable bowel syndrome) that could contribute to symptoms.
History of celiac disease or other conditions causing malabsorption.
Medications:
List all current medications, including any medications that may irritate the stomach (e.g., NSAIDs).
Social History:
Occupation involving heavy lifting or straining (may worsen symptoms).
Family History:
Not typically relevant for MALS.
Physical Exam:
Abdominal examination:
Tenderness in the epigastric region (upper middle abdomen) may be present.
Auscultation for normal bowel sounds.
Consider rectal exam to rule out other causes of abdominal pain.
Laboratory Tests:
Complete blood count (CBC) and electrolytes: Usually normal in MALS.
Lipase and amylase: May be elevated if pancreatitis is a concern.
Celiac serology: If celiac disease is suspected.
**Imaging Studies (as indicated):
Abdominal ultrasound: May be used to rule out other causes of abdominal pain like gallstones, appendicitis, or kidney stones.
Upper GI endoscopy: May be performed if peptic ulcer disease or other upper GI pathology is suspected.
Celiac disease serology: If symptoms suggest celiac disease.
The diagnosis of MALS is primarily clinical based on characteristic symptoms and absence of other identifiable causes. Confirmation with imaging tests like angiography or CT angiography is not routinely performed due to their invasive nature and limited accuracy.
Assessment:
Median arcuate ligament syndrome (MALS): Based on clinical presentation and absence of other identified causes, suspect MALS as the cause of abdominal pain.
Severity of symptoms: Describe the severity of the patient’s abdominal pain and its impact on daily activities.
Plan:
Conservative management: This is the first-line approach for MALS.
Dietary modifications (avoidance of large meals, irritating foods, chewing food thoroughly).
Lifestyle changes (weight loss if overweight, stress management).
Medications: Proton pump inhibitors (PPIs) for possible gastric acid irritation, antispasmodics for pain relief.
Referral to a gastroenterologist: If conservative measures fail to provide adequate pain relief, consider referral to a gastroenterologist for further evaluation and possible treatment options like laparoscopic median arcuate ligament release surgery.
Pain management: Address the patient’s pain with medications and non-pharmacological methods (e.g., heat therapy).
Education:
Educate the patient about MALS, symptoms, risk factors, and conservative management strategies.
Discuss the importance of dietary modifications and lifestyle changes.
Explain the role of medications and potential benefits and risks of surgery (if considered).
Disclaimer: This template is for informational purposes only and should be adapted to the specific needs of each patient. The diagnosis of MALS can be challenging, and a thorough workup is necessary to rule out other causes of abdominal pain. It is recommended to consult with relevant medical resources and MALS management guidelines for comprehensive care planning.