Abdominal pain right lower quadrant
 
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 
Allergies: 
morphine
 
Attending: ___.
 
Chief Complaint:
abdominal pain
 
Major Surgical or Invasive Procedure:
none

 
History of Present Illness:
This patient is a ___ year old male who complains of RIGHT
SIDED ABDOMINAL PAIN. Patient presents with 2 days of right
lower quadrant pain. Patient states noticed it while
walking. Patient's noticed intermittent pain worsens.
Patient had no relief with Pepto-Bismol. Patient denies
fevers or chills. Patient reports some anorexia.
 

 
Past Medical History:
none
 
Social History:
___
Family History:
NC
 
Physical Exam:
PHYSICAL EXAMINATION:  upon admission: ___ 
 
Temp: 97.8 HR: 90 BP: 124/86 Resp: 14 O(2)Sat: 100
 
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Right lower quadrant pain without Rovsing sign
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Speech fluent

 
Pertinent Results:
___ 06:10AM BLOOD WBC-8.9 RBC-5.59 Hgb-12.5* Hct-42.0 
MCV-75* MCH-22.4* MCHC-29.8* RDW-14.2 Plt ___
___ 10:43PM BLOOD WBC-6.6 RBC-5.71 Hgb-12.9* Hct-42.3 
MCV-74* MCH-22.7* MCHC-30.6* RDW-14.3 Plt ___
___ 06:10AM BLOOD Plt ___
___ 10:43PM BLOOD Glucose-99 UreaN-13 Creat-1.0 Na-137 
K-4.0 Cl-103 HCO3-22 AnGap-16

___:  US of appendix:

ReportFINDINGS: Non-visualization of a normal or abnormal 
appendix. Several loops 
Preliminary Reportof peristalsing bowel are noted.

___:  cat scan of abdomen and pelvis:

 Appendix demonstrates dilation of the midportion to 8 mm with 
tapering distally.  No adjacent fat stranding, but air is not 
seen distal to the focal dilation.  Acute appendicitis is 
improbable with these findings.   
  
 

 
Brief Hospital Course:
The patient was admitted to the hospital with abdominal pain.  
Upon admission, he was made NPO, given intravenous fluids and 
underwent imaging.  Cat scan imaging showed a large appendix 
with a maximum diameter of 8 mm and a small amount of fat
stranding.  The patient underwent serial abdominal examinations 
and his white blood cell count was closely monitored.  As the 
patient's abdominal pain resolved, he was introduced to clear 
liquids and advanced to a regular diet.  There was no recurrence 
of pain, nausea or vomiting. The patient's vital signs remained 
stable and he was afebrile.  The patient was discharged home on 
HD #1 in stable condition.  An appointment for follow-up was 
made with his primary care provider.  
 
Medications on Admission:
none
 
Discharge Medications:
none
 
Discharge Disposition:
Home
 
Discharge Diagnosis:
abdominal pain

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 
Discharge Instructions:
You were admitted to the hospital with right sided abdominal 
pain.  You were placed on bowel rest.  Your abdominal pain has 
slowly resolved.  You are now preparing for discharge home with 
the following instructions:

Please call your doctor or return to the emergency room if you 
have any of the following:
 

 * You experience new chest pain, pressure, squeezing or 
 tightness.
 
* New or worsening cough or wheezing.
 
* If you are vomiting and cannot keep in fluids or your 
 medications.
 
* You are getting dehydrated due to continued vomiting, 
 diarrhea or other reasons. Signs of dehydration include dry 
 mouth, rapid heartbeat or feeling dizzy or faint when standing.
 
* You see blood or dark/black material when you vomit or have a 
 bowel movement.
 

* You have shaking chills, or a fever greater than 101.5 (F) 
 degrees or 38(C) degrees.
 
* Any serious change in your symptoms, or any new symptoms that 
 concern you. 
 
* Please resume all regular home medications and take any new 
meds 
 as ordered.  

  
 
Followup Instructions:
___

{'abdominal pain': ['Abdominal pain', 'right lower quadrant'], 'intermittent pain': ['Abdominal pain', 'right lower quadrant'], 'anorexia': ['Abdominal pain', 'right lower quadrant']}