| Name: P.S | Date: 5/4/2017 | Time: |
| Age: 32 | Sex: Female | |
| SUBJECTIVE | ||
| CC: P.S arrived at the hospital complaining of increased abdominal pain. She says, “I am having too much pain in my stomach even to stand straight. It is increasing when I bend to the right, and it has not stopped since it started.” | ||
| HPI: P.S was well until three days ago when she started to experience some slight pain in the abdomen. The pain was generalized, and she sent her husband to get paracetamol because she believed it could alleviate the pain. The husband brought the medicine, which the pharmacist had prescribed to be taken as 1 gram by mouth every eight hours. However, the pain increased that evening when she went to sleep. P.S indicates that in the past 24 hours, the pain has been increasing despite the intake of the drug. Today morning, the pain was intense, and she could not walk, bend, or stand straight. The pain further became localized in the lower right quadrant and led to increased discomfort, which has prompted her to seek immediate medical attention. | ||
| Medications: Paracetamol 1g by mouth every eight hours | ||
| PMH
Allergies: P.S has no known drug allergies. No food allergies identified on further questioning. Medication Intolerances: No history of drug intolerance. Chronic Illnesses/Major traumas: No history of major traumas or chronic illnesses. Hospitalizations/Surgeries: P.S was hospitalized once when she had a cesarean section with her first daughter. It was the only surgery she has had in her lifetime. |
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| Family History: P.S is the third born in a family of five. Her two other younger siblings, both boys, are in college. Her father has diabetes type two, and he is overweight. Her mother is in a satisfactory state of health. No other members of the immediate or extended family have a chronic illness. | ||
| Social History: P.S has a bachelor’s degree in electrical engineering. However, she has never been formally employed because she runs a family business. She lives with her husband and her first-born daughter. She neither drinks, smokes, nor uses any illicit drug. Currently, P.S indicates that she has several friends with whom she attends a gym together. She also likes to spend time with her family despite her busy schedule and the need to attend to the business issues. | ||
| ROS | ||
| General: Positive for fever and body malaise. Denies weight gain, chills, night sweats, and fatigue. | Cardiovascular: Denies edema of any part of the body, claudication, palpitations, chest pain, or orthopnea. | |
| Skin: Denies any history of bruising, rashes, pruritus, changes in skin lesions, or bleeding. | Respiratory: Denies wheezing, any recent history of coughing, hemoptysis, or dyspnea. Also denies TB or pneumonia. | |
| Eyes: Denies the use of any visual aids, eye discharges, or any visual changes. | Gastrointestinal: Positive for loss of appetite, nausea, and vomiting. Also positive for lower abdominal pain with increased pain in the right lower abdomen. Denies hemorrhoid, hepatitis, ulcers, or constipation. | |
| Ears: Denies any ear discharges, hearing loss, ear pain, or tinnitus. | Genitourinary/Gynecological: Positive for dysuria. No urinal urgency. Also denies increased frequency of urination and urine discoloration.
Positive for the use of contraceptives but denies low libido. Also denies any recent history of any STDS. Menarche occurred at 11 years old. The menstrual cycle is regular. It lasts twenty-eight days, while menstruation lasts five days. Has never done a breast exam before. |
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| Nose/Mouth/Throat: Denies any bleeding in the gums, rhinorrhea, sinusitis, a sore throat, or epistaxis. | Musculoskeletal: Positive for body malaise and fatigue. Denies any joint pains, back pains, fractures, or muscle stiffness. | |
| Breast: No breast tenderness, rashes, lumps, or lesions. | Neurological: Denies history of seizures, transient paralysis, weakness, or paresthesia. | |
| Heme/Lymph/Endo: Denies any positive test for HIV. Also denies swollen glands, any history of blood transfusion, polyphagia, night sweats, polydipsia, or heat intolerance. | Psychiatric: Positive for slight depression and anxiety. Denies any recent history of insomnia or suicidal ideations. | |
| OBJECTIVE | ||
| Weight: 132lbs BMI :21.6 | Temp: 100.4F | BP: 122/78mmHg |
| Height: 5’5” | Pulse: 80bpm | Resp: 23bpm |
| General Appearance: A middle-aged female who looks sick and appears anxious. She is oriented to time and place. Responds to questions well. | ||
| Skin: Intact, dry, warm, and clean skin without rashes. No bruising noted to extremities or the trunk | ||
| HEENT
Head: Normocephalic, without lesions. An evenly distributed long hair on the head noted. Eyes: Intact visual acuity, conjunctiva pink, sclera clear. Ears: Ears do not have lesions. Normal auditory canal noted. Visible ear landmarks identified. Nose: Midline nasal septum, mucosa pink, normal turbinates. Neck: Full ROM noted on neck examination, no cervical lymphadenopathy. Mouth and Throat: No thyromegaly noted on inspection. Oral mucosa pink. Pharynx without any erythema and exudate, 32 teeth. |
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| Cardiovascular: Does not have edema and has 3+ pulses. Regular hearts sound with no murmurs, rubs, or clicks. Capillary refill time is 2 seconds. | ||
| Respiratory: Chest wall is symmetric with regular respirations. Auscultation reveals no rhonchi or crackles. | ||
| Gastrointestinal: Active bowel sounds in all the four quadrants. Has pain, which is 10/10. Abdominal swelling. Has no hepatosplenomegaly. Abdomen tender in the right lower quadrant. | ||
| Breast: No tenderness or masses on breast palpation. Also, no dimpling or discharge upon observation. The consistency of the skin color of the breast noted. | ||
| Genitourinary: Bladder not distended but feels uncomfortable when palpating the pubic region. No blood noted in the external genitalia. Coarse pubic hair is present on mons veneris and has a normal distribution. No lesions, rashes, or bruising noted on the labia minora and labia majora.
Anteverted uterus, which lies behind the bladder. Non-palpable ovaries. |
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| Musculoskeletal: Has full ROM of the upper extremities, but abdominal pain limits the movement of the lower extremities. | ||
| Neurological: Has clear speech, but the abdominal pain has caused a waddling gait. | ||
| Psychiatric: Oriented to place and time, despite the expression of anxiety. Dressed appropriately and maintains eye contact. Answers questions as asked. | ||
| Lab Tests: CBC to check for elevated leukocytes to confirm infection (?ahbaz et al., 2014). | ||
| Special Tests
Abdominal ultrasound results are available and show an inflamed appendix. |
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| Diagnosis | ||
| Differential Diagnoses (Drake & Flum, 2013).
· 1- Pelvic Inflammatory Disease · 2- Ovarian Cyst · 3- Pancreatitis Diagnosis · Acute appendicitis. According to Drake and Flu (2013), ultrasound results showing an inflamed appendix in a slightly swollen and tender abdomen indicate acute appendicitis.
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| Plan/Therapeutics | ||
| Plan
Further testing: Further testing using X-ray is necessary to rule out the possibility of pelvic inflammatory disease and perforation of the appendix (Drake & Flu, 2013). Medication: Although pain-relieving medications are essential, Gomes et al. (2015) indicate that they are not necessary at first. However, Cefoxitin 2 grams intravenously TDS may be necessary after appendectomy as a prophylactic measure to prevent infection (Abbas, Omer, & Ali, 2015). Non-medication treatments: Drake and Flu (2013) advocate appendectomy as the most appropriate approach to treating appendicitis. Education: Reassure P.S and tell her that the disease is manageable to alleviate her anxiety. Additionally, since intravenous medications are necessary after an appendectomy, tell her that she would need an admission to monitor her status until she recovers. Finally, advise her on the importance of the appendectomy procedure before she signs the informed consent to surgery. |
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| Evaluation of encounter with P.S: P.S is anxious, and the facial expression indicates increased discomfort. However, her consent to surgery shows she has accepted the interventions. However, her curiosity about the outcome of the surgery signifies the need for more education. |
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