The patient is a 56-year-old Caucasian female presenting with a chief complaint of severe abdominal pain and tenderness in the right lower quadrant of the abdomen

QUESTION

HPI: 56-year old Caucasian female with complaint of severe abdominal pain and tenderness to the right lower quadrant of the abdomen and sometimes radiating to the right side of shoulder and back. Describes pain to be sharp and worsening over couple of hours. Says she feels more pain with deep breath and when she eats. Vomited x 2 today. Explained that pain started few weeks ago, subsided and resumed again. Describes pain to be at 10/10. Expressed feeling of relief without food and not relieved with Tylenol. Denied any diarrhea, constipation and change in bowel pattern. Denies shortness of breath, chest pain or fever.

1. Write a detailed soap note using the above information

2. Document detailed abdominal exam PE findings including all the abnormal abdominal findings.

ANSWER

Subjective

The patient is a 56-year-old Caucasian female presenting with a chief complaint of severe abdominal pain and tenderness in the right lower quadrant of the abdomen. The pain is described as sharp and has been worsening over the past couple of hours. The patient reports that the pain sometimes radiates to the right side of the shoulder and back. She mentions feeling increased pain with deep breaths and when eating. The patient also reports vomiting twice today. She states that the pain initially started a few weeks ago, subsided for a period, and then resumed. She rates her pain intensity as 10 out of 10. The patient expresses temporary relief when fasting, but the pain is not alleviated by taking Tylenol. The patient denies any symptoms of diarrhea, constipation, or changes in bowel patterns. Additionally, she denies experiencing shortness of breath, chest pain, or fever.

Objective

Vital Signs:
Blood pressure: 130/80 mmHg
Heart rate: 88 beats per minute
Respiratory rate: 16 breaths per minute
Temperature: 98.6°F (36.9°C)
Oxygen saturation: 98% on room air

General

The patient appears uncomfortable and is holding her abdomen. She is alert and oriented to person, place, and time. She is cooperative and responds appropriately to questions.

Abdominal Examination:
Inspection:
The abdomen is distended and slightly asymmetrical.
There are no visible masses, hernias, or prominent veins.
Skin appears intact without any visible lesions or discoloration.

Auscultation

Bowel sounds are present in all four quadrants, although hypoactive.

Palpation:
Light palpation reveals tenderness and guarding in the right lower quadrant of the abdomen.
Deep palpation exacerbates the pain and elicits involuntary guarding.
No palpable masses or organomegaly detected.
McBurney’s point is tender upon palpation.

Percussion

Tympanic percussion notes are elicited over the entire abdomen.
No dullness or shifting dullness is appreciated.

Special Tests

Rebound tenderness is positive in the right lower quadrant.
Rovsing’s sign is positive, with pain being felt in the right lower quadrant when pressure is applied to the left lower quadrant.
Obturator sign and psoas sign are negative.

Assessment

Based on the patient’s history and physical examination findings, the following assessments are made:
Acute appendicitis: The patient’s severe abdominal pain, tenderness in the right lower quadrant, rebound tenderness, positive McBurney’s sign, and positive Rovsing’s sign are consistent with acute appendicitis.
Vomiting: The patient’s vomiting episodes may be attributed to the underlying abdominal pain.

Plan

Consultation with general surgery: Urgent referral to the general surgery department for further evaluation and consideration of appendectomy.
NPO (nothing by mouth): The patient should remain fasting to alleviate symptoms until surgical evaluation.
Intravenous access: Establish intravenous access for hydration and potential administration of analgesics.
Pain management: Administer appropriate analgesics to alleviate the patient’s severe pain.
Continuous monitoring: Monitor vital signs, including blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation.
Provide emotional support: Offer reassurance, answer questions, and address any concerns the patient may have.

Follow-up

The patient will be closely monitored by the surgical team and further management will be determined based on the surgical evaluation. Post-operative care instructions will be provided if appendectomy is performed.