Emergency Medicine Clerking template

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