Emergency Department Clinical Assessment Note

Final/Working Diagnosis/ICD-9 Code

Final diagnosis: Acute diverticulitis, Working diagnosis: Mild dehydration, ICD-9: 562.

Chief Complaint

The patient presents with a 3-day history of worsening left lower quadrant abdominal pain, referred by his family physician.

Past Medical History (not comprehensive)

Hypertension, hyperlipidemia, diverticulosis, and gastroesophageal reflux disease [electronic chart].

Lives at home with his wife, retired accountant.

Father had colon cancer at age 78.

Habits: Non-smoker, 2-3 beers per week, denies recreational drug use.

Medications (not comprehensive)

Amlodipine (Norvasc®) 5 mg PO daily, rosuvastatin (Crestor®) 10 mg PO daily, pantoprazole (Pantoloc®) 40 mg PO daily [ConnectingOntario].

Allergies

Penicillin (maculopapular rash).

History of Present Illness

This 62-year-old male reports constant, dull LLQ abdominal pain starting 3 days ago, progressively worsening to 6/10 severity today. Pain is aggravated by movement and mildly relieved by rest. Reports subjective low-grade fevers at home and decreased oral intake. Denies nausea, vomiting, hematochezia, melena, or dysuria. No recent travel or sick contacts.

He experienced a similar episode of LLQ pain 2 years ago, which resolved with oral antibiotics as an outpatient. He was seen at a walk-in clinic 4 months ago for routine BP check, with no hospital admissions in the past year [electronic chart].

Seen earlier today by his GP, who noted LLQ tenderness and referred him to the ED for labs and CT imaging to rule out complicated diverticulitis.

Brought in by EMS; vitals en route were stable with BP 138/84 mmHg and HR 88 bpm, and he received fentanyl 50 mcg IV with good pain relief.

Took paracetamol (acetaminophen, Tylenol®) 1,000 mg PO 6 hours ago with minimal relief. Reports mild constipation over the past 2 days, no diarrhea, no urinary frequency or urgency.

Colonoscopy 3 years ago showed sigmoid diverticulosis and no polyps [electronic chart].

Physical Examination

Alert, oriented, in mild discomfort, NAD.

Temp 37.8 °C (high), HR 92 bpm, BP 134/82 mmHg, RR 16/min, SpO2 98 % on RA.

Abdomen is soft, non-distended, with localized tenderness in the LLQ and mild voluntary guarding, but no rebound tenderness or rigidness. Bowel sounds are normoactive. CVS: S1, S2 normal, no murmurs. Resp: Clear to auscultation bilaterally.

Investigations

ECG shows normal sinus rhythm at 90 bpm, no acute ischemic changes. Urinalysis is negative for leukocytes, nitrites, and blood.

WBC 13.2 x 10^9/L (high), Hb 142 g/L, Plt 245 x 10^9/L, Na 138 mmol/L, K 4.1 mmol/L, Cr 88 µmol/L, lactate 1.1 mmol/L.

Assessment/Plan

I suspect acute uncomplicated diverticulitis given the LLQ tenderness, low-grade fever, and leukocytosis. Differential diagnosis includes colitis, epiploic appendagitis, and less likely ureterolithiasis. I will order a CT abdomen and pelvis to confirm the diagnosis and rule out abscess or perforation. We will administer IV fluids and analgesia in the ED, and if imaging confirms uncomplicated disease and he tolerates oral fluids, he can be discharged home.

Ciprofloxacin (Cipro®) 500 mg PO BID for 7 days, metronidazole (Flagyl®) 500 mg PO TID for 7 days, and paracetamol (acetaminophen, Tylenol®) 650 mg PO Q6H PRN for pain.

Maintain a clear liquid diet for the next 24-48 hours, then gradually advance to a low-residue diet as symptoms improve.

Return to the ED immediately if experiencing worsening abdominal pain, persistent fever, inability to tolerate fluids, vomiting, or rectal bleeding.

Follow up with the family physician in 3-5 days for clinical reassessment, and arrange a follow-up colonoscopy in 6-8 weeks once the acute episode resolves.

Possible Imaging

Computed Tomography of the Abdomen and Pelvis: 3-day hx LLQ pain, fever, elevated WBC; r/o acute diverticulitis, abscess, or perforation.

Course in ER

14:15: IV access established. Administered normal saline 1,000 mL IV bolus and ketorolac (Toradol®) 15 mg IV for pain. Patient sent to radiology for CT scan.

16:30: CT abdomen and pelvis results reviewed, demonstrating acute uncomplicated sigmoid diverticulitis with pericolic fat stranding, no abscess or free air. Patient reports pain has decreased to 2/10 and he is tolerating oral sips of water well. Cleared for discharge home with prescriptions.

Follow-up for Primary Care Physician

1. Clinical reassessment in 3-5 days and arrangement for routine post-diverticulitis colonoscopy in 6-8 weeks (see assessment/plan).

Final/Working Diagnosis

Final diagnosis:

Acute diverticulitis

Working diagnosis: Mild dehydration

ICD-9 Code

562

Dr. Sarah Jenkins, MD, CCFP(EM), ER Physician.

This note was prepared using AI-assisted ambient scribing. Consent for this use was obtained from the patient or guardian.