1. Chief Complaint:
"Severe abdominal pain and nausea."
2. History of Presenting Complaint:
The patient reports a sudden onset of severe abdominal pain that began approximately 6 hours ago. The pain is described as sharp and constant, located in the lower right quadrant. The patient also reports nausea and has vomited twice since the onset of pain.
3. Associated Symptoms:
- Nausea
- Vomiting
- Loss of appetite
4. Past Medical History:
Chronic Conditions: Hypertension
Previous Surgeries: Appendectomy 5 years ago
Previous Episodes: None related to current complaint
5. Medication History:
Current Medications: Lisinopril 10 mg once daily
Allergies: Penicillin (rash)
6. Social History:
Smoking: Non-smoker
Alcohol Use: Occasional, 1-2 drinks per week
Drug Use: Denies any illicit drug use
Living Situation: Lives alone, independent in daily activities
7. Review of Systems:
General: No recent weight loss, fever, or fatigue
Cardiovascular: No chest pain or palpitations
Respiratory: No cough or shortness of breath
Gastrointestinal: Nausea, vomiting, no diarrhea
Neurological: No headaches or dizziness
Musculoskeletal: No joint pain or swelling
Skin: No rashes or lesions
8. Examination Findings:
Vital Signs:
- Temperature: 37.8°C
- Heart Rate: 98 bpm
- Respiratory Rate: 18 breaths/min
- Blood Pressure: 130/85 mmHg
- Oxygen Saturation: 98%
General Appearance: Patient appears in mild distress due to pain
Head and Neck: No abnormalities noted
Chest/Lungs: Clear to auscultation bilaterally
Heart: Regular rate and rhythm, no murmurs
Abdomen: Tenderness in the lower right quadrant, no distension, normal bowel sounds
Extremities: No edema, pulses intact
Neurological: Alert and oriented, no focal deficits
9. Investigations:
Laboratory Tests: Elevated white blood cell count
Imaging Studies: Abdominal ultrasound shows possible gallstones
ECG Findings: Normal sinus rhythm
10. Impression and Differential Diagnosis:
Clinical impression suggests possible cholecystitis. Differential diagnoses include pancreatitis and peptic ulcer disease.
11. Plan:
Immediate Management: Administered IV fluids and analgesics
Further Investigations: CT scan of the abdomen to confirm diagnosis
Consultations: Referral to general surgery for further evaluation
Discharge Instructions: Advised to avoid fatty foods, prescribed antiemetics, and instructed to return if symptoms worsen
Follow-Up: Follow-up with primary care physician in 3 days
