Diagnosis:
- Acute appendicitis
Results:
- CT scan of the abdomen showed an inflamed appendix with peri-appendiceal fluid collection.
Treatment:
- Administered intravenous antibiotics and performed an appendectomy.
Prescribed Medications:
- Amoxicillin 500 mg, take one tablet every 8 hours for 7 days. Common side effects include nausea and diarrhea. Take with food to minimize stomach upset.
- Acetaminophen 500 mg, take one tablet every 6 hours as needed for pain. Do not exceed 4 grams in 24 hours.
Return Precautions:
Return to the Emergency Department if you experience any of the following:
- Severe abdominal pain
- Fever over 101Β°F
- Persistent vomiting
- Signs of infection at the surgical site, such as redness or pus
Patient Education:
- Avoid heavy lifting and strenuous activities for at least 2 weeks post-surgery.
- Maintain a balanced diet and stay hydrated to aid recovery.
Follow-Up Care:
- Follow up with your primary care provider in 1 week for a post-operative check-up.
- Referral to a dietitian for nutritional guidance if needed.
Diagnosis:
- [describe diagnosis and/or clinical impression] (only include if explicitly mentioned in the transcript, additions, contextual notes or clinical note, otherwise leave blank.)
Results:
- [describe test results, imaging findings, lab results, etc.] (only include if explicitly mentioned in the transcript, additions, contextual notes or clinical note, otherwise leave blank.)
Treatment:
- [describe treatment provided in the ED, including medications administered, procedures performed, etc.] (only include if explicitly mentioned in the transcript, additions, contextual notes or clinical note, otherwise leave blank.)
Prescribed Medications:
- [list all medications prescribed during discharge, include the dosage and administration frequency, list pertinent and/or common side effects to look out for, list recommendations for medication administration such as eat with a meal, or take on an empty stomach, or drink plenty of water, etc.] (you may offer suggestions based off patients diagnosis if not already explicitly mentioned in the transcript, additions, contextual notes or clinical note.)
Return Precautions:
Return to the Emergency Department if you experience any of the following:
- [list specific symptoms or signs that warrant a return visit based off of the patients diagnosis and/or clinical impression.]
Patient Education:
- [provide patient education related to the diagnosis, including lifestyle modifications, medication instructions, etc.]
Follow-Up Care:
- Follow up with your primary care provider or specialist as recommended.
- [specify follow-up care instructions, including appointments, referrals, and any additional tests or treatments needed] (only include if explicitly mentioned in the transcript, additions, contextual notes or clinical note, otherwise leave blank.)
