Abdominal Pain (RLQ)

Reviewed triage note:
HPI (on my evaluation of patient):
_ nb/nb vomiting
_ no hx of abd surgeries – additionally asked specifically no hx of appendectomy
Review Of Systems:
Constitutional: no recent fever
Integument: no rashes
Eye: no acute vision changes
ENT: no current rhinorrhea/sore throat
CV: no chest pain, no syncope
Resp: no SOB, no new productive cough
GI: as detailed above in HPI
GU: no dysuria
MSK: no recent trauma/fall to any extremity
Neuro: no focal weakness
Psych: no confusion
PMH/PSH: as noted in HPI
FH: reviewed, non-contributory to patient’s current complaint
Physical Examination:
General: NAD, Alert,
Skin: No rash, warm, dry
Eye: PEERL, EOM intact
CV: RRR, no r/m/g
Resp: Lungs CBTA, respirations non-labored
GI: Abd soft, TTP in RLQ
GU: No testicular pain on palpation, normal lie
LEs:No LE swelling, palpable pulses
Neuro: Alert and oriented, normal mentation, no focal motor/sensory deficit
Psych: Normal speech, linear
MSK: No deformitites, normal ROM
 cbc (to eval for luekocytosis or significant anemia)
 bmp (to eval for electrolyte derangements)
 LFT’s, lipase (to eval for labratorial evidence of hepato-biliary pathology)
 UA (to eval for atypical presentation of UTI/pyelo)
_ upreg
_ CT (indications: suspicion for acute surgical abdominal processes: appendicitis, SBO, complicated diverticulitis, perforated viscus, AAA)
_ Pelvic US (indications: suspected GYN pathology more likely than GI pathology based upon hx and exam, as such pelvic US optimal imaging modality with concurrently minimizing potentially significant unnecessary radiation (which would put patient at risk for radiation associated malignancy). Given that patient is stable, non-toxic I believe an US would be in the best interest of the patient’s well-being at this time. Patient amenable to plan.
-Concern for appendicitis and given RLQ pain and hx, exam. Benefits of prompt diagnosis of acute emergent pathology and requisite treatment outweigh radiation risks of CT.
     _ imaging concerning for appendicitis (>6mm appendicitis) with periappendiceal fat stranding
DIAGNOSIS: appendicitis
-antibiotics (ceftriaxone 1g IV, metronidozole 500mg IV)
-pre-op labs (type/screen, coags)
-IVF, analgesia, anti-emetics PRN
-admit to acute care surgery
DISPOSITION: Admitted to acute care surgery, transfer of care of patient to surgery service
COUNSELLING: Patient/family educated on diagnostics, assessment, treatment plan. Patient/family amendable and in agreement with proposed plan. All questions and concerns answered and addressed.
SUPERVISION: Discussed and obtained approval/confirmation of evaluation (history/exam/diagnostics) and plan (assessment/interventions/disposition) with ED attending physician
Interval Update: CT negative for appendicitis
_Given CT negative for appendicitis, widen differential considered:
-Considered gastritis (infectious or ulcerative). Pt advised to f/u with PMD and if sx persist, to request GI referral for endocscopy for definitive diagnosis. Given possibility of gastritis/ulcer and relatively benign side effect profile, pt offered to start empiric trial of famotidine (OTC).
-Doubt bleeding ulcer given no hx of BRBPR/melena, no signs of anemia on exam nor significant anemia on cbc.
-Doubt perforated viscus/diverticulitis/incarcerated hernia given CT as above.
-Doubt cholecystitis given CT shows no radiographic e/o cholecystitis and labs not c/w for cholecystitis. Pt advised if worsening of symptoms to return given possibility of interval development of cholecystitis.
-Doubt cholelithiasis given US shows no gall stones. Pt advised of return precautions given inability to achieve 100% sensitivity on imaging.
-Doubt pancreatitis given lipase wnl.
-Doubt atypical presentation for nephrolithiasis given no stone seen on CT, CVA tenderness, no hematuria on UA.
-Doubt pyleonephritis given no CVA tenderness, non-infectious UA systemically well.
-Doubt pregnancy related complications (e.g. ectopic, abruption, etc) given upreg neg. Pt advised upreg not 100% sensitive.
-Doubt PID given no CMT/adnexal TTP on pelvic exam.
-Doubt ovarian torsion given hx atypical for torsion and CT has decent sensitivity for sequelae for torsion.
-Doubt DKA given no elevated glucose with anion gap.
-Doubt AAA given CT does not show AAA as above.

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