Emergency Medicine Initial

Chief Complaint: Severe abdominal pain lasting for 3 days. Past Medical History (not comprehensive): - Hypertension - Social history: Lives alone, works as a teacher - Family history: Father had coronary artery disease - Social history including smoking, alcohol consumption, and drug use habits: Smokes 10 cigarettes a day, occasional alcohol use Medications (not comprehensive): - Lisinopril 10mg daily; information from electronic record Allergies: - Penicillin - causes rash History of Present Illness: The patient presents with severe abdominal pain that started 3 days ago, located in the lower abdomen, and described as sharp and constant. No previous occurrences of similar pain. The patient reports nausea but no vomiting, and denies any changes in bowel habits. No recent hospital admissions. The patient took over-the-counter ibuprofen with minimal relief. No associated fever or chills. Review of Systems: - Constitutional: No weight change, no fever, no chills, no night sweats, fatigue present - Gastrointestinal: Nausea, no vomiting, no diarrhea, no constipation, abdominal pain present, no heartburn, no dysphagia, no hematochezia, no melena, no jaundice Physical Examination: - General appearance: Appears in mild distress due to pain - Vital signs: Temperature 98.6°F, blood pressure 140/90 mmHg, heart rate 88 bpm, respiratory rate 18 breaths/min, oxygen saturation 98% on room air - Abdominal: Tenderness in the lower abdomen, no rebound tenderness, no guarding Investigations: - Basic blood work: Elevated white blood cell count - Imaging: Abdominal ultrasound shows possible appendicitis - ECG findings: Normal sinus rhythm Assessment/Plan: - Most likely diagnosis: Appendicitis; differential diagnoses include ovarian cyst, diverticulitis - Plan: Surgical consultation for possible appendectomy, IV fluids, and pain management with morphine - General patient care advice: Rest and avoid solid foods until further notice - Danger signs: Return to the emergency department if fever, increased pain, or vomiting occurs - Follow-up recommendations: Follow-up with primary care physician in 1 week post-discharge Follow-up for Primary Care Physician: - Monitor blood pressure control - Review surgical outcomes and recovery Final/Working Diagnosis: - Working diagnosis: Appendicitis - Primary diagnosis: Appendicitis