[##]-year-old [male/female] 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,
diabetic ketoacidosis (DKA), [ectopic or other pregnancy-related complications,]
urinary tract infection (UTI), pyelonephritis, hernias, and bowel obstructions
among others.
Patient presented with [mother/father/parents]
with complaint of [right] lower quadrant pain [with characteristic migration of
pain from initial periumbilical region] with associated
[fever/nausea/vomiting/loss of appetite] concerning for appendicitis. The patient [was noted to have no evidence of
peritonitis/rebound tenderness and guarding] on abdominal exam in the ED. Labs were [not] obtained [ and were
unremarkable/notable for leukocytosis and left shift]. Patient noted to have a Pediatric
Appendicitis Score of [##] consistent with [low/equivocal/high] risk for
appendicitis, which prompted us to [discuss low risk for appendicitis and plan
for 24/48 hour follow up with strict return precautions/obtain an ultrasound
for further evaluation/consult Pediatric Surgery for further evaluation]. The patient was noted to have [no other] 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].
Prior to discharge, we
discussed return precautions, specifically for evidence suggestive of acute
appendicitis, symptomatic treatment, and follow up in [24/48 hours] for repeat
evaluation, and the patient’s [mother/father/parents] demonstrated
understanding and agreement with this plan.
https://www.mdcalc.com/pediatric-appendicitis-score-pas
https://www.mdcalc.com/pediatric-appendicitis-risk-calculator-parc
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