Identification Data
Initials: B. K
Caucasian is the nationality.
Age: eighteen
Information’s source
Patient Sex: Male
Chief culture/religion: n/a Complain: lower abdominal distress
His medical history: He was healthy until two days ago when he started feeling discomfort in his lower abdomen (Rating: 8.10). The pain flared up at night. The discomfort can be relieved by taking analgesics. The discomfort is not related to any other gastrointestinal symptoms.
Start Date: Two days ago
Lower abdomen
Period: Intermittent; mainly at night
Being piercing
Aggravating factors include abdominal movements and exercise.
Administration of analgesics and Rest
Tylenol is currently being used to relieve pain
He has no medical history. He is not aware of any known allergies to food or medications.
Previous surgical history: No prior procedures.
His social background is that he lives with his parents. He’s a student at a nearby college who refuses to use alcohol or other recreational drugs. Condoms may be used as protection for someone sexually active. His travel record is not known.
He is a healthy child with his parents. He is the second of three children in his family.
ROS Gastrointestinal: Reports of right lower abdomen discomfort, appetite loss and gastrointestinal symptoms are available.
The Physical Examination Results: T = 37.4, HR=96, RR=16, BP=108/70, O2sat= 98%. RA
General Aesthetic
Patients are well-groomed, aware of place and time.
HEENT. Red reflex present. The optic disc is clearly defined, the macula has no lesions and the trachea is center. The pink oropharynx, which is moist and free of disease, is healthy.
Neuro: Excellent orienting
Respiratory: There is no evidence of nodules within normal limits. The Trachea is well positioned. Without extraneous noises, the lungs sound audible clear both bilaterally and anteriorly.
The rhythm and heart beat are all normal with no murmurs.
Abdomen: soft, active x 4 bowel noises. When palpated, there is no soreness in the abdomen. No bilateral CVP pain on percussion.
GI GU: Soft abdomen, active bowel noises x 4. Palpable tenderness or recurrence. Strikes can cause pain. Psoas sign is visible.
Excessive tiredness, myalgia are both musculoskeletal disorders.
Behavioral health: A focus on time, place, and the individual
List of symptoms include fever, nocturnal chills, decreased appetite, muscle pain, fatigue, nausea, vomiting, and increased tiredness.
Differential diagnosis
Appendicitis
Irritable bowel syndrome
Idiopathic colitis
Gastroenteritis
Plan/management
Diagnostics
Ultrasound may reveal an increase in pelvic fluid, noncompressible tubular structure > 6 mm in diameter (Antakia et al., 2021).
A complete blood count is required to confirm the absence or presence of leukocytosis.
MRI exams to assess the severity of perforation
Medication
Injectable antibiotics
Antipyretics for fever management
Pain relief with nonsteroidal anti-inflammatory medication
Laparoscopic Appendectomy after Diagnostic Confirmation (Snyder and al. 2018, 2018).
Referrals
In the case of severe peritonitis, you should seek advanced treatment
Education
Keep a low-calorie diet, and watch for changes in your health.
To alleviate anxiety, inform the patient of treatment options and testing results.
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