Emergency Medicine Initial Assessment

Chief Complaint

45-year-old male presents with acute-onset RLQ abdominal pain for 14 hours.

Past Medical History (not comprehensive)

• HTN, hyperlipidemia, seasonal allergic rhinitis. No prior abdominal surgeries.
• Lives with spouse and two children; works as an accountant.
• Father with T2DM and CAD; mother with hypothyroidism. No family history of IBD or GI malignancy.
• Non-smoker, social alcohol (2–3 beers/week), denies illicit drug use.

Medications (not comprehensive)

• lisinopril (Prinivil®) 10 mg PO daily (verified via EMR)
• atorvastatin (Lipitor®) 20 mg PO QHS (verified via EMR)

Allergies

• Penicillin: maculopapular rash

History of Present Illness

Pt awoke at 04:00 on 14/05/2026 with dull periumbilical pain that migrated to the RLQ over 6 hours. Pain is now sharp, constant, 7/10, and worsened by movement and coughing. Denies sick contacts, recent travel, or dietary changes.

No prior episodes of similar pain. No ED visits or hospitalizations in the past year.

No prior abdominal imaging or endoscopies.

Took paracetamol (acetaminophen, Tylenol®) 500 mg PO at 08:00 with minimal relief.

Associated with anorexia, mild nausea, and one episode of non-bilious, non-bloody emesis at 10:00. Denies diarrhea, constipation, hematochezia, melena, or dysuria.

Last meal was 13/05/2026 at 19:30.

Review of Systems

• Constitutional: Low-grade subjective fever, malaise. Denies weight loss or night sweats.
• Cardiovascular: Denies chest pain, SOB, palpitations, or edema.
• Respiratory: Denies cough, wheezing, or dyspnea.
• Gastrointestinal: Positive for RLQ pain, anorexia, nausea, and single emesis. Negative for diarrhea, constipation, melena, or jaundice.
• Genitourinary: Denies dysuria, frequency, hematuria, or flank pain.
• Musculoskeletal: Denies back pain or arthralgias.
• Neurological: Denies dizziness, headache, or syncope.

Physical Examination

• General appearance: Alert, oriented x3, lying still on stretcher in mild distress due to pain.
• Vital signs: T 37.8 °C, BP 134/84 mmHg, HR 96 bpm, RR 18/min, BG 5.8 mmol/L, SpO2 98% on RA (recorded at 18:15 America/Chicago).
• HEENT: Normocephalic, atraumatic. Mucous membranes slightly dry. Oropharynx clear.
• Respiratory: Good air entry bilaterally. Clear to auscultation, no crackles or wheezes.
• Cardiac: S1, S2 normal. Regular rate and rhythm, no murmurs, rubs, or gallops.
• Abdominal: Soft, non-distended. Normoactive bowel sounds. Marked tenderness to palpation at McBurney's point with localized guarding and positive rebound. Positive Rovsing's and psoas signs. No Murphy's sign, no CVA tenderness.
• Skin: Warm, dry, intact. No rashes or jaundice.
• Other: Neurological exam grossly intact. Normal gait prior to lying down, though guarded.

Investigations

• WBC 14,200 /µL (neutrophils 82%), Hb 14.8 g/dL, Plt 245,000 /µL. Na 138 mmol/L, K 4.1 mmol/L, Cr 0.9 mg/dL, Lipase 28 U/L, Lactate 1.1 mmol/L. Urinalysis negative for leukocytes, nitrites, and blood.
• CT Abdomen/Pelvis with IV contrast: Dilated, fluid-filled appendix measuring 11 mm with periappendiceal fat stranding and a small appendicolith. No free air or abscess.
• ECG: Normal sinus rhythm at 94 bpm, normal axis, no acute ST-T wave changes.

Assessment/Plan

• Acute uncomplicated appendicitis. Differential initially included nephrolithiasis, acute gastroenteritis, and diverticulitis, now ruled out via CT. Plan: NPO, IV fluid resuscitation with 0.9% NaCl 1,000 mL bolus then 125 mL/h, analgesia, and surgical consultation for laparoscopic appendectomy. General surgery paged at 19:45; patient accepted for admission and OR.
• morphine 4 mg IV q4h PRN pain; ondansetron (Zofran®) 4 mg IV q8h PRN nausea; ceftriaxone (Rocephin®) 2 g IV once; metronidazole (Flagyl®) 500 mg IV q8h (given penicillin allergy).
• Remain NPO prior to surgery. Rest in bed, call nursing staff for assistance with ambulation due to IV medications.
• Post-discharge (if applicable post-op): Return to ED for high fever, worsening severe abdominal pain, persistent vomiting, purulent wound drainage, or syncope.
• Inpatient admission under General Surgery service. Post-discharge follow-up in General Surgery clinic in 2 weeks.

Follow-up for Primary Care Physician

• Post-operative wound check and staple/suture removal in 7–10 days if not performed by surgery clinic.
• Re-evaluate home blood pressure regimen post-recovery.

Final/Working Diagnosis

• Final diagnosis
• Acute non-perforated appendicitis