Identifying Data:

Full Name: M. D.

DOB (Age):  16

Gender: Male

Date & Time: Aug. 3, 2020 / 6:00 PM

Location: QHC – PEDs ED

Source of information: Self and mother

Reliability: Reliable

Chief Complaint: Abdominal pain x 1 day

HPI:

16-year-old male with no significant PMhx brought by mother to the ED this evening with complaint of abdominal pain x 1 day. Patient states the pain is intermittent, sharp pain at the right lower part of abdomen without radiation.  He says the pain happened suddenly yesterday afternoon, when he walked around in his room, and it went away when he sat down. Nothing makes the pain worse. He rates the pain as 4/10. Patient has not taken any other medication. Patient denies nausea, vomiting, fever, chill, constipation, or diarrhea.

Past Medical History:

• Past medical illness – Denies
• Immunization – Up to date

Past Surgical History:

Denies surgical Hx

Home Medications:

• Pediatric multiple vit-C-FA chewable tablet

Allergies:

• No food or environmental allergies
• NKDA

Family history:

• Mother – 40s, Diabetes
• Father – 40s, Hypertension

Social History:

Patient is a high school student. Denies use of illicit drugs, alcohol, and tobacco. Denies being sexually active.

Review of systems:

General: Patient denies recent weight loss or weight gain, loss of appetite, generalized weakness, fatigue, fever, chill or night sweats

Skin, Hair, Nails: Patient denies any changes of texture, excessive dryness or sweating, discolorations, pigmentations, moles, or changes in hair condition.

Head: Patient denies headache, vertigo, head trauma, or fracture

Eyes: Patient denies visual disturbance, lacrimation, photophobia, pruritus, or last eye exam

Ears: Patient denies deafness, pain, discharge, tinnitus

Nose/Sinuses: Patient denies discharge, epistaxis, or obstruction

Mouth and throat: Patient denies bleeding gums, sore tongue, sore throat, mouth ulcers or last dental exam

Neck: Patient denies localized swelling or lumps, stiffness or decreased range of motion

Breast: Patient denies lumps, nipple discharge, pain, or last mammogram

Pulmonary System: Patient denies SOB, DOE, cough, wheezing, hemoptysis, cyanosis, orthopnea, paroxysmal nocturnal dyspnea

Cardiovascular System: Patient denies chest pain, palpitations, edema, syncope, or known heart murmur

Gastrointestinal System: Patient denies changes in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, flatulence, eructation, abdominal pain, diarrhea, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding, blood in stool or stool guaiac test or colonoscopy

Positive: abdominal pain

Genitourinary System: Patient denies changes in frequency, nocturia, urgency, oliguria, polyuria, dysuria, change in color of urine, incontinence, awakening at night to urinate, or pain. Denies hesitancy, dribbling or last prostate exam

Nervous System: Patient denies seizures, headache, loss of consciousness, sensory disturbances, numbness, paresthesia, dysesthesias, ataxia, loss of strength, change in cognition, mental status, memory, or weakness

Musculoskeletal System: Patient denies muscle or joint pain, deformity or swelling, redness, arthritis

Peripheral System: patient denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes

Hematological System: Patient denies anemia, easy bruising or bleeding, or lymph node enlargement

Endocrine System: Patient denies polyuria, polydipsia, polyphagia, heat or cold intolerance or goiter

Psychiatric: Patient denies depression, sadness, feeling of helplessness, hopelessness, lack of interest in usual activities, anxiety, obsessive or compulsive disorder, seen a mental health professional, or use medications

Physical Examination:

Vital Signs:

• BP 108/67, sitting position, left arm
• HR 100 bpm, regular
• RR 18 breaths per minute, regular
• O2 98%, room air
• T 98.5 oral
• Wt 111 lbs

General: Patient is a 16-year-old male, A&O x 3. Well-developed and good posture. Well dressed, groomed, and nourished. No apparent distress.

Skin: warm & dry, good turgor. No scar, increase or loss in pigmentation, nonicteric

Nail: no clubbing. Capillary refill < 2 seconds throughout. Nails are trim

Hair: average quantity and soft of hair, evenly distribution, no signs of lice, nits, no seborrhea.

Head: eyes and ears aligned, normocephalic, atraumatic, non-tender to palpation throughout, except left frontal area. no trauma, no specific facies.

Eye: Symmetrical OU; no redness, no strabismus, exophthalmos or ptosis; sclera white; conjunctiva & cornea clear. Visual fields full OU. PERRL, EOMs full with no nystagmus.

Ears: Symmetrical, no evidence of mass, lesion, erythema, inflammation, ear canal atresia. Non tender to palpation. Auditory Acuity: whisper test, intact to whispered voice AU.

Nose/Sinuses:

Nose – Symmetrical, no evidence of mass, lesion, deformities, erythema, inflammation. Non-tender to palpation and no step-off. no evidence of nasal obstruction

Sinuses – Non tender to palpation

Mouth/Throat:

Pink and well hydrated lip, gingivae, tongue, mucosa, and palate. No masses, lesions, erythema, exudate or discharge noted. Good dentition. No obvious dental caries noted. Non-tender to palpation. Uvula pink, no edema, deviation.

Neck/Thyroid:

Trachea midline. 2+ Carotid pulses. No masses, lesions, scars, pulsations noted. No stridor, thrills, bruits noted bilaterally. No palpable adenopathy noted. Non-tender to palpation, no thyromegaly noted.

Thorax and Lungs:

Chest – Symmetrical, no deformities, no evidence trauma.   Respirations unlabored, no paradoxic respirations or use of accessory muscles noted.  Lat to AP diameter 2:1. Non-tender to palpation.

Lungs – Clear to auscultation. No adventitious sounds. No stridor, respiratory distress.

 

Cardiovascular:

Regular rate and rhythm (RRR); S1, S2 noted; No gallops, S3 or S4. No JVD. Carotid pulse 2+ bilaterally without bruits.

Abdomen:

flat, symmetrical, no evidence of scars, striae, caput medusae or abnormal pulsations. BS present in all 4 quadrants. No bruits noted over aortic/renal/iliac/femoral arteries. Tympany to percussion throughout. No evidence of organomegaly. No masses noted. Hernia confirmed negative in the ventral area.

Positive: tenderness in the right lower quadrant to deep palpation. There is guarding. No rebound tenderness. rovsing sign and obturator sign are negative. 

Male genitalia and hernia: did not perform

Anus, rectum, and prostate: did not perform

Peripheral Vascular System: Skin normal in color and warm to touch upper and lower extremities bilaterally.  No calf tenderness bilaterally. No palpable cords or varicose veins bilaterally.

Neurological:

Mental Status: Alert and oriented to person, place and time. Memory and attention intact. Receptive and expressive abilities intact. Thought coherent. No dysarthria, dysphonia or aphasia noted.

Cranial Nerves

• I – Intact no anosmia.
• II- Visual fields by confrontation full.
• III-IV-VI- PERRL, EOM intact without nystagmus.
• V- Facial sensation intact, strength good.
• VII- Facial movements symmetrical and without weakness.
• VIII- Hearing grossly intact to whispered voice bilaterally.
• IX-X-XII- Swallowing and gag reflex intact. Uvula elevates midline. Tongue movement intact.
• XI- Shoulder shrug intact.

Motor/Cerebellar: Full active/passive ROM of B/L upper and lower extremities without rigidity or spasticity. Normal muscle bulk and tone. No atrophy, tics, tremors or fasciculations. Strength equal and appropriate for age bilaterally (5/5 throughout). Coordination-finger to nose intact. Normal gait.

Sensory: For b/l upper and lower extremity, Intact to light touch, sharp/dull, point localization, extinction.

Reflexes

• Patellar : R-2+ ; L-2+

Meningeal Signs: No nuchal rigidity noted. Brudzinski’s and Kernig’s signs are negative.

Musculoskeletal: No erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. No crepitus noted throughout. No evidence of spinal deformities. FROM of all upper and lower extremities.  No evidence of spinal deformities.

Assessment

16 year old male without significant PMHx was brought to ED by mother for RLQ abdominal pain.

Differential Diagnosis:

• Appendicitis
• Cholecystitis
• Viral gastroenteritis
• Right-sided ureteric stone
• Meckel’s diverticulum

Plan:

Appendicitis

• Order Labs: CBC, CMP
• Order abdominal ultrasound to confirm appendicitis
  • If confirmed:
    • IV ceftriaxone 50 to 75 mg/kg/day divided every 12 to 24 hours; maximum daily dose: 2,000 mg/day
    • laparoscopic appendectomy