Emergency Department Acute Care Encounter

Chief Complaint: Right lower quadrant abdominal pain for 12 hours.

History of Presenting Illness: 34-year-old male (MRN: 849-201-74) arrived via private vehicle at 14:15 CST on 14/05/2024 with acute onset RLQ pain starting at 02:00 today. Pain initially periumbilical, dull, migrating to RLQ over 6 hours, now sharp, constant, and rated 7/10. Aggravated by movement and coughing; no relieving factors. Associated with anorexia, mild nausea, and one episode of non-bilious emesis at 09:00. Patient took paracetamol (acetaminophen, Tylenol®) 500 mg PO at 08:00 with minimal relief. Last normal baseline was yesterday evening at 22:00. Denies fever, chills, diarrhea, constipation, dysuria, or hematuria. No prior similar episodes, no recent illnesses, no recent hospital admissions, and no recent medication changes.

Past Medical History: Mild intermittent asthma, childhood tonsillectomy (1998).

Medication History: Salbutamol (albuterol, ProAir HFA®) 90 mcg/actuation INH 2 puffs Q4H PRN for wheezing. Allergies: Penicillin (hives).

Social History: Never smoker. Alcohol: 2-3 beers on weekends. Denies illicit drug use.

Family History: Father with HTN; mother with T2DM.

Review of Systems

• Constitutional symptoms: Positive for anorexia. Negative for fever, chills, fatigue, or weight change.
• Eyes: Negative for vision changes, pain, or redness.
• Ears, Nose, Mouth, Throat: Negative for sore throat, rhinorrhea, or ear pain.
• Cardiovascular: Negative for chest pain, palpitations, or edema.
• Respiratory: Negative for cough, SOB, or wheezing.
• Gastrointestinal: Positive for RLQ abdominal pain, nausea, and vomiting. Negative for diarrhea, constipation, melena, or hematochezia.
• Genitourinary: Negative for dysuria, frequency, urgency, hematuria, or flank pain.
• Musculoskeletal: Negative for back pain, myalgias, or arthralgias.
• Integumentary (Skin): Negative for rash, pruritus, or lesions.
• Neurological: Negative for headache, dizziness, syncope, or focal weakness.
• Psychiatric: Negative for anxiety, depression, or SI/HI.
• Endocrine: Negative for polyuria, polydipsia, or temperature intolerance.
• Hematologic/Lymphatic: Negative for easy bruising, bleeding, or lymphadenopathy.
• Allergic/Immunologic: History of penicillin allergy; no active allergic symptoms.

Objective

• Vitals: BP 128/82 mmHg, HR 94 bpm, Temp 37.8 °C, RR 18 breaths/min, SpO2 99 % on RA.
• General: Alert, oriented x3, lying still on gurney in moderate discomfort.
• Abdo: Soft, non-distended. Marked tenderness to palpation in RLQ at McBurney's point with localized guarding and positive rebound tenderness. Positive Rovsing's and psoas signs. Bowel sounds hypoactive. No CVA tenderness.
• CVS: Regular rate and rhythm, normal S1/S2, no murmurs, rubs, or gallops.
• Resp: Lungs clear to auscultation bilaterally, no wheezes or rales.

Investigations

• Bloods: WBC 14,200 /mcL (neutrophils 82 %), Hb 15.1 g/dL, Plt 245,000 /mcL. BMP: Na 138 mmol/L, K 4.1 mmol/L, Cl 102 mmol/L, HCO3 24 mmol/L, BUN 14 mg/dL, Cr 0.9 mg/dL, Glucose 98 mg/dL. Lipase 32 U/L. CRP 45 mg/L.
• Imaging: CT Abdomen/Pelvis with IV contrast shows a dilated, fluid-filled appendix measuring 11 mm in diameter with periappendiceal fat stranding and a small appendicolith; no abscess or free air.
• Other: Urinalysis: SG 1.020, pH 6.0, negative for leukocyte esterase, nitrites, blood, protein, and glucose. ECG: Normal sinus rhythm at 92 bpm, no acute ST-T wave changes.

Assessment

• Primary Diagnosis: Acute appendicitis without perforation or gangrene (ICD-10: K35.80).
• Differential Diagnosis: Nephrolithiasis (ICD-10: N20.0) excluded by negative hematuria on UA and absence of renal calculi on CT; Acute gastroenteritis (ICD-10: A09) less likely given focal peritoneal signs, absence of diarrhea, and confirmatory CT findings; Mesenteric adenitis (ICD-10: I88.0) excluded by visualization of inflamed appendix on CT.

Plan

• Immediate Management: NPO. IV 0.9% NaCl 1,000 mL bolus infused over 1 hour, then maintenance at 125 mL/hr. Ondansetron (Zofran®) 4 mg IV once for nausea. Morphine 4 mg IV Q4H PRN for pain. Ciprofloxacin (Cipro®) 400 mg IV Q12H and metronidazole (Flagyl®) 500 mg IV Q8H initiated given penicillin allergy.
• Investigations Planned: Pre-operative type and screen, PT/INR.
• Referrals: General Surgery consulted at 16:00 CST. Case discussed with Dr. R. Vance, who reviewed CT images, evaluated the patient at bedside, and agreed with the diagnosis of acute uncomplicated appendicitis; patient accepted for laparoscopic appendectomy this evening.
• Discharge Criteria: Admit to General Surgery service for operative management. Discharge home post-operatively once tolerating oral intake, pain is controlled on oral analgesics, voiding spontaneously, and ambulating independently.
• Follow-up: Lab and CT results showing acute appendicitis were reviewed with the patient, and the pathophysiology of appendiceal obstruction and inflammation was explained. Once discharged post-operatively, follow up with the General Surgery clinic in 1-2 weeks for wound check and with primary care provider as needed; utilize supportive home care including rest, keeping incisions clean and dry, avoiding heavy lifting (> 5 kg) for 2 weeks, and returning to the ED for fever, worsening abdominal pain, persistent vomiting, or wound purulence. Thank you for entrusting us with your care today.