Ontario ER Template

Chief Complaint: Patient presents with severe abdominal pain lasting for 3 days. Past Medical History (not comprehensive): - Hypertension - Type 2 Diabetes - Family history of heart disease - Smokes 10 cigarettes per day, occasional alcohol use Medications (not comprehensive): - Metformin 500mg twice daily (patient report) - Lisinopril 10mg daily (patient report) Allergies: - Penicillin (rash) History of Present Illness: Patient reports a sudden onset of severe, cramping abdominal pain located in the lower right quadrant, radiating to the back. Pain is constant and worsens with movement. Associated symptoms include nausea and vomiting. No recent travel or dietary changes. No previous similar episodes. No fever or chills reported. Review of Systems: - Constitutional: No weight change, fever, or chills - Gastrointestinal: Nausea, vomiting, abdominal pain, no diarrhea or constipation - Genitourinary: No dysuria or hematuria - Musculoskeletal: No joint pain or swelling Physical Examination: - General appearance: Patient appears in moderate distress due to pain - Vital signs: Temperature 37.2°C, BP 140/85 mmHg, HR 95 bpm, RR 18 breaths/min, O2 saturation 98% on room air - Abdominal: Tenderness in the lower right quadrant, guarding present, no rebound tenderness Investigations: - Blood work: Elevated white blood cell count - Imaging: Abdominal ultrasound shows signs of appendicitis Assessment and Plan: - Most likely diagnosis: Acute appendicitis - Plan: Surgical consultation for possible appendectomy, pain management with IV morphine, IV fluids for hydration - Follow-up: Advise return to ED if symptoms worsen or new symptoms develop Final/Working Diagnosis: - Working diagnosis: Acute appendicitis