Emergency Initial Assessment

Emergency Department Initial Presentation: 34-year-old female, presenting with severe abdominal pain, presented to ED via Ambulance following a sudden onset of sharp, generalised abdominal pain radiating to her back. Presenting Complaint: Severe, acute abdominal pain. Triage Information: Triage Category: Category 2 (Emergency) Vital signs at presentation: BP 130/85 mmHg, HR 110 bpm, RR 22 bpm, SpO2 98% on room air, Temp 37.8°C, GCS 15. Mode of arrival and any urgency factors: Arrived by ambulance due to acute severe pain and concern for an acute surgical abdomen. History of Presenting Illness/Injury: Symptom onset and duration: Abdominal pain started acutely approximately 3 hours prior to presentation, while she was at home. Pain has been constant since onset. Progression of symptoms or injury: Pain rapidly increased in severity within the first hour and has remained severe. Associated nausea developed an hour after pain onset, with one episode of non-bloody, non-bilious vomiting. Associated features such as fever, vomiting, or bleeding: Reports feverishness at home, one episode of vomiting. No reported melena, haematochezia, or haematuria. Aggravating and relieving factors: Pain is aggravated by movement and relieved slightly by lying still. No specific food or medication provides relief. Pre-hospital care received: Paramedics administered 5mg IV Morphine, which provided minimal pain relief. IV access established. Past Medical and Surgical History: Relevant chronic conditions: Hypertension, well-controlled with medication. No known diabetes or cardiac history. Previous surgeries or procedures: Appendectomy at age 12, Caesarean section 5 years ago. Relevant psychiatric history: No known psychiatric history. Recent admissions or hospital contacts: No recent admissions or ED contacts in the last 12 months. Medications: Current regular medications and any recent changes, including anticoagulants, insulin, antibiotics, or psychotropics: Lisinopril 10mg OD (for hypertension). No recent changes. No anticoagulants, insulin, antibiotics, or psychotropics. Allergies: Known drug or substance allergies and nature of reactions: Penicillin (rash and hives). Social History: Smoking and alcohol status: Non-smoker. Occasional alcohol consumption (2-3 units per week). Recreational drug use: Denies recreational drug use. Living situation and available support: Lives with husband and two children. Good family support. Any vulnerabilities such as cognitive impairment, domestic violence concerns, or additional support needs: No identified vulnerabilities. Examination: General appearance and overall clinical impression: Patient appears distressed and uncomfortable, lying still on the trolley. Pale but not cyanosed. Vital signs on examination: BP 128/80 mmHg, HR 105 bpm, RR 20 bpm, SpO2 99% on room air, Temp 38.1°C, GCS 15. Cardiovascular examination findings: S1 S2 dual, no murmurs. Capillary refill <2 seconds. No peripheral oedema. Respiratory examination findings: Air entry good bilaterally. No adventitious sounds. Equal chest expansion. Abdominal examination findings: Abdomen generally distended. Guarding and rigidity noted throughout, more pronounced in the epigastric region. Tenderness to light palpation in all four quadrants. Bowel sounds present but diminished. No palpable masses. Neurological examination findings: Alert and oriented to person, place, and time. Pupils equal and reactive to light. No focal neurological deficits. Skin examination findings: Skin warm and dry. No rashes or lesions noted other than IV site on left antecubital fossa. Musculoskeletal examination findings: Full range of motion in extremities, no joint swelling or tenderness. Investigations: ECG findings: Sinus tachycardia, no ischaemic changes. Blood test results or requests: FBC, U&Es, LFTs, Amylase, Lipase, CRP, Coagulation screen, Group and Save requested. Initial FBC shows elevated WCC 15.2 x 10^9/L. CRP pending. Imaging results or requests: CT abdomen and pelvis requested due to acute abdominal pain and peritonism. Portable abdominal X-ray showed no free air under the diaphragm. Urinalysis results: Clear, negative for nitrites, leukocyte esterase, blood, or protein. Bedside test results: Glucose 6.8 mmol/L. Impression: Acute abdomen, likely peritonitis. Differential diagnoses include perforated viscus (e.g., peptic ulcer), acute pancreatitis, appendicitis (though history of appendectomy), mesenteric ischaemia, or ruptured ectopic pregnancy (patient denies being pregnant, urine HCG negative). Plan: Treatment commenced in ED: IV fluids (Normal Saline 1L bolus), IV Ondansetron 4mg for nausea, IV Paracetamol 1g, IV Morphine 2mg (further dose given). Patient has been kept NPO. Consults made or requested: Surgical review urgently requested for acute abdomen. Plans for admission or observation: Likely admission under surgical team following review and CT findings. Pending results and their expected actions: Awaiting CT abdomen and pelvis results and further blood tests. Will act on surgical recommendations following review. Advice given to patient and GP: Patient advised on likely admission and need for further investigations. Husband updated on patient's condition. GP to be informed via discharge summary/admission letter.