Final/Working Diagnosis/ICD-9 Code: Acute appendicitis, 540
Chief Complaint: Severe abdominal pain for 2 days, referred by family physician.
Past Medical History (not comprehensive): Hypertension, Type 2 Diabetes. Social history: Lives alone, works as a teacher. Family history: Father had coronary artery disease. Habits: Smokes 10 cigarettes per day, occasional alcohol use.
Medications (not comprehensive): Metformin, Lisinopril (information from electronic record).
Allergies: NKDA
History of Present Illness: The patient presents with severe, sharp abdominal pain localized to the right lower quadrant, worsening over the past 48 hours. No previous episodes of similar pain. Recent visit to family physician who suspected appendicitis. No recent hospital admissions. No nausea or vomiting. No recent changes in bowel habits. No fever. No recent travel or exposure to infectious diseases. No significant response to over-the-counter pain medication.
Physical Examination: Patient appears in moderate distress. Vital signs: BP 130/85, HR 95, Temp 37.2°C, RR 18, SpO2 98% on room air. Abdominal examination reveals tenderness in the right lower quadrant with guarding.
Investigations: Blood work shows elevated white blood cell count. Abdominal ultrasound indicates an enlarged appendix with surrounding fluid.
Assessment/ Plan: I suspect acute appendicitis. Differential diagnosis includes gastroenteritis and ovarian cyst. Plan to admit for surgical consultation and possible appendectomy. Administer IV fluids and analgesics. Advise patient to avoid food and drink. Warn about signs of worsening pain or fever that would require immediate attention. Follow-up with surgical team post-operatively.
Possible imaging: CT abdomen/pelvis to confirm appendicitis; severe RLQ pain, elevated WBC.
Procedure: Not applicable
Course in ER: Not applicable
Follow-up for Primary care physician: See assessment/plan
Final/Working Diagnosis: Acute appendicitis
ICD-9 Code: 540
Dr. John Smith, ER Physician.
This note was created using AI/ambient scribe technology. Consent for usage was obtained from patient/guardian.
