ER Note

History: - 45-year-old male - The patient presented with severe abdominal pain and nausea, which started suddenly 3 hours ago. He reports no recent trauma or similar episodes in the past. - Past medical history includes hypertension and type 2 diabetes. Previous surgeries include an appendectomy 10 years ago. - Current medications include Metformin and Lisinopril. No herbal supplements reported. - The patient is a non-smoker and consumes alcohol occasionally. - Allergies: Penicillin Physical: - Vital signs: Blood pressure 150/95 mmHg, heart rate 110 bpm, respiratory rate 22 breaths per minute, temperature 37.8°C. - Physical examination revealed tenderness in the right lower quadrant of the abdomen with guarding and rebound tenderness. Initial Impression / Plan: - Initial impression is acute appendicitis. - Plan includes ordering a CT scan of the abdomen to confirm diagnosis, administering IV fluids, and consulting with the surgical team for potential appendectomy. Follow-up in the ER for monitoring vital signs and pain management.