[##]-year-old female with abdominal pain [additional symptoms] with
history and exam consistent with likely acute appendicitis.
Initial considerations in
this patient included acute appendicitis, ovarian cyst, ovarian torsion,
ectopic pregnancy and other pregnancy-related complications, mesenteric
adenitis, gastroenteritis, inflammatory bowel disease (Crohn’s disease,
ulcerative colitis), diverticulitis, ureteral stone, pyelonephritis, hernias, and
bowel obstructions amongst 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]. A [bimanual/speculum]
pelvic exam was performed in the ED with no evidence of ovarian mass,
significant adnexal tenderness, cervical motion tenderness, or significant
vaginal drainage to suggest pelvic etiology for patient’s pain. Patient noted to have a negative pregnancy
test in the ED making ectopic or other pregnancy-related complications
unlikely.
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 until OR/at this time].
