Chief Complaint: Severe abdominal pain lasting for 3 days.
Past Medical History (not comprehensive):
- Hypertension
- Social history: Lives alone, works as a teacher
- Family history: Father had coronary artery disease
- Social history including smoking, alcohol consumption, and drug use habits: Smokes 10 cigarettes a day, occasional alcohol use
Medications (not comprehensive):
- Lisinopril 10mg daily; information from electronic record
Allergies:
- Penicillin - causes rash
History of Present Illness:
The patient presents with severe abdominal pain that started 3 days ago, located in the lower abdomen, and described as sharp and constant. No previous occurrences of similar pain. The patient reports nausea but no vomiting, and denies any changes in bowel habits. No recent hospital admissions. The patient took over-the-counter ibuprofen with minimal relief. No associated fever or chills.
Review of Systems:
- Constitutional: No weight change, no fever, no chills, no night sweats, fatigue present
- Gastrointestinal: Nausea, no vomiting, no diarrhea, no constipation, abdominal pain present, no heartburn, no dysphagia, no hematochezia, no melena, no jaundice
Physical Examination:
- General appearance: Appears in mild distress due to pain
- Vital signs: Temperature 98.6°F, blood pressure 140/90 mmHg, heart rate 88 bpm, respiratory rate 18 breaths/min, oxygen saturation 98% on room air
- Abdominal: Tenderness in the lower abdomen, no rebound tenderness, no guarding
Investigations:
- Basic blood work: Elevated white blood cell count
- Imaging: Abdominal ultrasound shows possible appendicitis
- ECG findings: Normal sinus rhythm
Assessment/Plan:
- Most likely diagnosis: Appendicitis; differential diagnoses include ovarian cyst, diverticulitis
- Plan: Surgical consultation for possible appendectomy, IV fluids, and pain management with morphine
- General patient care advice: Rest and avoid solid foods until further notice
- Danger signs: Return to the emergency department if fever, increased pain, or vomiting occurs
- Follow-up recommendations: Follow-up with primary care physician in 1 week post-discharge
Follow-up for Primary Care Physician:
- Monitor blood pressure control
- Review surgical outcomes and recovery
Final/Working Diagnosis:
- Working diagnosis: Appendicitis
- Primary diagnosis: Appendicitis
Chief Complaint:
[Description of the primary reason for the consultation, including duration, in one sentence]
Past Medical History (not comprehensive):
- [List of past medical conditions]
- [Social history]
- [Family history]
- [Social history including smoking, alcohol consumption, and drug use habits]
Medications (not comprehensive):
- [Current medications; include source of information, especially if from electronic record or Connecting Ontario]
Allergies:
- [Any allergies and associated reactions]
History of Present Illness:
[Provide a detailed narrative of symptoms and relevant history, including pertinent negatives, risk factors, and exposure]
[Describe any previous occurrences of current symptoms or issues, including recent visits, assessments, hospital admissions in the last year]
[Describe related visits, investigations, management, and any diagnoses]
[Include medications taken and the patient’s response]
[Associated symptoms]
[Other relevant history]
Review of Systems:
- Constitutional: [Weight change, Fever, Chills, Night sweats, Fatigue, Malaise]
- Eyes: [Eye pain, Swelling, Redness, Foreign body sensation, Discharge, Vision changes]
- Ears, Nose, Mouth, Throat: [Hearing changes, Ear pain, Nasal congestion, Sinus pain, Hoarseness, Sore throat, Rhinorrhea, Swallowing difficulty]
- Cardiovascular: [Chest pain, SOB, PND, Dyspnea on exertion, Orthopnea, Claudication, Edema, Palpitations]
- Respiratory: [Cough, Sputum production, Wheezing, Smoke exposure, Dyspnea]
- Gastrointestinal: [Nausea, Vomiting, Diarrhea, Constipation, Abdominal pain, Heartburn, Dysphagia, Hematochezia, Melena, Jaundice]
- Genitourinary: [Dysuria, Urinary frequency, Hematuria, Urinary incontinence, Flank pain, Changes in urinary flow]
- Musculoskeletal: [Arthralgias, Myalgias, Joint swelling, Back pain, Neck pain]
- Integumentary: [Skin lesions, Pruritis, Hair changes, Nipple discharge]
- Neurological: [Weakness, Numbness, Paresthesias, Syncope, Dizziness, Headache]
- Psychiatric: [Anxiety, Depression, Insomnia, Delusions, Suicidal ideation, Hallucinations]
- Endocrine: [Polyuria, Polydipsia, Temperature intolerance]
- Hematologic/Lymphatic: [Bruising, Bleeding, Transfusion history, Lymphadenopathy]
- Allergic/Immunologic: [Allergic reactions, Auto-immune disorders]
(Do not include any section above if not mentioned.)
Physical Examination:
- General appearance: [Brief description of general appearance]
- Vital signs: [Record temperature, blood pressure, heart rate, respiratory rate, glucose levels, oxygen saturation, and any other vital signs mentioned]
- HEENT: [Findings related to head, eyes, ears, nose, and throat]
- Respiratory: [Findings related to the respiratory system, such as air entry, crackles, or wheezes]
- Cardiac: [Findings related to the cardiovascular system, such as heart sounds, murmurs]
- Abdominal: [Findings from palpation, tenderness]
- Skin: [Findings related to skin, including rashes]
- Other: [Any other physical exam findings, if mentioned]
Investigations:
- [Results of basic blood work]
- [Results of any imaging]
- [ECG findings]
Assessment/Plan:
- [Most likely diagnosis and differential diagnoses suggested by the physician, as well as the overall plan for further assessment, diagnosis, and management in the emergency department and post-discharge]
- [Recommended medications and dosage]
- [General patient care advice]
- [Danger signs that would prompt a return to the emergency department]
- [Follow-up recommendations]
Follow-up for Primary Care Physician:
- [List any elements specifically identified by the physician for follow-up by the patient's usual primary care provider, in point form]
Final/Working Diagnosis:
- [Differentiate whether it is a final diagnosis or working diagnosis]
- [Primary diagnosis]
(Never come up with your own patient details, assessment, diagnosis, interventions, evaluation or plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank)
