ER Note

History

• 42-year-old female
• Presents to ER with 12-hour history of periumbilical pain migrating to the RLQ. Associated with anorexia, nausea, and 1 episode of non-bilious emesis. Denies fever, chills, diarrhea, dysuria, or vaginal bleeding. LMP 2 weeks ago, regular.
• PMHx: Mild intermittent asthma, GERD. PSHx: C-section (2018).
• Salbutamol (Ventolin®) 100 mcg INH PRN, omeprazole (Losec®) 20 mg PO daily, St. John's Wort 300 mg PO daily.
• Non-smoker, social EtOH (2 drinks/week), denies recreational drug use. Lives with spouse and two children; works as an accountant.
• Penicillin (rash)

Physical

• Temp 37.8 °C, HR 96 bpm, BP 124/78 mmHg, RR 18 /min, SpO2 99 % on RA.
• General: Alert, oriented, in mild distress secondary to abdominal pain. CVS: S1, S2 normal, no murmurs. Resp: Clear to auscultation bilaterally. Abd: Soft, non-distended, marked tenderness to palpation at McBurney's point with localized guarding and positive Rovsing's sign. Psoas sign positive. Bowel sounds hypoactive.

Initial Impression / Plan

• Acute appendicitis. Differential includes ovarian torsion, ruptured ovarian cyst, and PID.
• Keep NPO. Start IV normal saline at 125 mL/h. Administer morphine 4 mg IV q4h PRN for pain and ondansetron (Zofran®) 4 mg IV q8h PRN for nausea. Order CBC, electrolytes, Cr, lipase, beta-hCG, urinalysis, and CT abdomen/pelvis with IV contrast. Consult General Surgery once imaging is complete.