[##]-year-old male with abdominal pain [additional symptoms] with
history and exam consistent with likely acute appendicitis.
Initial considerations in
this patient included acute appendicitis, mesenteric adenitis, gastroenteritis,
inflammatory bowel disease (Crohn’s disease, ulcerative colitis),
diverticulitis, ureteral stone, pyelonephritis, scrotal pathology (epididymitis,
testicular torsion), hernias, and bowel obstructions among others.
Patient presented with right
lower quadrant pain [with characteristic migration of pain from initial
periumbilical region] with associated [fever/nausea/vomiting/loss of appetite]
suggestive of appendicitis. The patient
[was noted to have no evidence of peritonitis/rebound tenderness and guarding]
on abdominal exam in the ED. Labs were
obtained to include a CBC [additional] and were [unremarkable/notable for
leukocytosis and left shift].
Appendicitis was considered [likely/highly likely] based on [history and
exam/Alvarado score >6], and [a CT scan of the abdomen was obtained/Surgery
was consulted for further evaluation].
The patient was noted to have findings consistent with acute
appendicitis on [exam by Dr. NAME of Surgery/CT scan of the abdomen
with/without evidence of perforation].
We discussed the diagnosis of acute appendicitis and plan for admission
for operative management with the patient, who demonstrated understanding and
agreement. We also discussed the case
with Dr. [Name] of General Surgery who agreed with the diagnosis and need for
admission to the [general
floor/pre-operative unit/OR] for further likely operative
management.
Patient noted to have [no]
evidence of significant systemic infectious symptoms [including fever/etc.]
with discussion with Surgery of [initiating antibiotics in the ED/holding off
on antibiotics at this time].
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