Consult note General Surgery- LC

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MCPHS University *

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PASC-800

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Nursing

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May 24, 2024

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Surgery Rotation Consult Note Lauren Cardenas Physician Assistant Student Consult note Patient Name: Jane Doe Patient Identifier: DOB: XX/XX/2004 (20 years old) Date: 03/23/2024 18:30 EDT Patient Reliability/Source: Patient Date of planned procedure: 03/24/2024 Anticipated procedure: Laparoscopic appendectomy Surgeon: Dr. Samuel Chief Concern: “Abdominal pain and nausea” History of Present Illness: Jane Doe is a 20-year-old female presenting to the emergency department via private vehicle with her aunt for abdominal pain and nausea. She states she has been having discomfort around her bellybutton for the past 3 days, along with nausea and decreased appetite. She had an annual physical exam with her primary care provider today and mentioned her abdominal pain. Jane initially thought the pain was due to her menstrual cycle as she is currently mensurating and often gets substantial cramping. She states the pain feels different than her regular menstrual cramping. She describes the pain as a deep pain in which she rated 7/10 in severity. The pain initially started around her bellybutton but has migrated to her right lower quadrant. Her PCP recommended obtaining a right lower quadrant ultrasound. The ultrasound demonstrated a 1 cm thickened tubular structure with hyperechoic fat, suggestive of acute appendicitis. Her PCP recommended she be evaluated in the ED. She has been taking Ibuprofen for the past 24 hours with little relief. The last dose was around 1400. She states she has felt “warm” but did not take her temperature at home. She denied vomiting, chills, weakness, shortness of breath, chest pain, blood in stool, black tarry stools, or painful urination. ED provider started Levofloxacin 750 mg IV, piggyback Normal Saline 0.9% bolus 1000mL, IV prophylaxis for acute appendicitis due to her penicillin allergy prior to our consult. Past Medical History

• Medical Illnesses: No prior medial history • Current Medications: Tylenol 500mg, 2 pills every 6 hours as needed for pain, Levofloxacin 750 mg IV, piggyback Normal Saline 0.9% bolus 1000mL, IV. • Allergies: Penicillin - (anaphylaxis, hives), Clindamycin (hives) • Surgical History: No prior surgical history • OBGYN: o Menarche: Regular menses monthly, normal flow, moderate amount of cramping throughout menstrual cycle o LMP: 3/20/2024 (currently menstruating) o Pap smear: Has not had a pap smear o Gravida: 0 • Immunizations/Preventative: Up to date on all childhood vaccines, Up to date on current season influenza vaccine and PNA • Psychiatric: No psychiatric diagnoses or hospitalizations Family History Mother: (47)-Alive, no prior medical history Father: (49)- Alive, Hypertension Social History • Occupation: Student in college • Diet: Decreased appetite, able to tolerate liquids and small amount of food • Safety: Feels safe at home • Substance Use: No illicit drug use • Alcohol: Consumes alcohol once a week • Smoking: Vapes daily, no nicotine use • Exposures: No recent travel, no recent sick contacts • Living Arrangements: Lives at home with mom and dad • Sexuality: Sexually active, monogamous relationship- uses contraceptive barriers • Social Support: Has aunt in the room. She plans to stay with her for her stay. Mom is currently out of state. Lives at home with mom and dad. Review of Systems • General: See HPI. Denies chills, weakness, fatigue, or weight changes. • Skin: Denies rashes, sores or lumps. • Hematopoietic: Denies easy bruising or enlarged lymph nodes. • Head: Denies headaches, dizziness, or fainting. • Eyes: Denies changes in vision, eye pain, redness or drainage.

• Ear: Denies hearing loss, pain or discharge. • Nose: Denies loss of smell, or drainage. • Mouth and throat: Denies sore throat, difficulty swallowing, or mouth sores. • Neck: Denies stiffness, pain, or reduced range of motion. • Cardiac and Pulmonary: Denies cough, shortness of breath, chest pain, or fluttering in chest. • Vascular: Denies leg pain or swelling in extremities. • Musculoskeletal: Denies muscle weakness, cramping or reduced range of motion. • Gastrointestinal: See HPI. • Urinary: See HPI. Blood in urine, or burning urination. • Neuropsychiatric: Denies depression, anxiety, loss of memory, poor balance, excessive sleep, numbness, or decreased sensation. • Endocrine : Denies excessive thirst, hair loss, dry skin, or heat or cold intolerance. • Female Genitalia: See HPI. Denies vaginal discharge, itching, painful intercourse, bleeding between menses, or pregnancies. VITAL SIGNS: • Temperature: 37* C • Pulse: 92 beats per minute • Respirations: 18 breaths per minute • Blood pressure: 122/85 mmHg right arm • Oxygen: 97% room air • Height: 65” • Weight: 163 lbs • Body Mass Index: 26.3 • Pain Scale: 7/10 Physical Exam GENERAL APPEARANCE: Awake, alert, and oriented and in no acute distress. Non-toxic appearing but looks uncomfortable and reluctant to move around. SKIN/NAILS: Skin is warm, dry and intact without rashes or lesions. Nailbeds are pink without cyanosis or clubbing. No jaundice. HEAD/NECK: Head is normocephalic and atraumatic without lesions or masses. Hair is evenly distributed. Neck is symmetric without lesions, scars, or lumps. Trachea is midline.

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EARS: External ear and ear canal are non-tender without erythema or swelling. Tympanic membrane is translucent without perforations bilaterally. The cone of light is in the correct anatomical position bilaterally. Hearing grossly intact. NOSE: No visible deformity, masses or lesion on external surface of the nose. Mucosa is pink without epistaxis. Septum is midline without perforations. Nares are patent bilaterally. MOUTH/THROAT: Oral mucosa is pink with good dentition. No ulcerations, masses, or lesions noted. Uvula is midline. Tongue is symmetric. Equal rise and fall of pharynx noted without swelling or erythema. Tonsils are symmetric without swelling or exudate. EYES: Eyelids are visualized bilaterally without erythema, crusting, lesions or masses. Conjunctiva clear, no sclera icterus , PERRLA. Extraocular movements intact, no signs of nystagmus. RESPIRATORY: Lungs clear to auscultation bilaterally. No crackles, wheezing, or increased work of breathing. CARDAIC: Regular rate and rhythm normal S1 and S2, there are no murmurs no rubs no gallops, no heaves or thrills. PERIPHERAL VASCULAR: Upper and lower extremities are symmetric bilaterally without edema. Distal pulses are 2+ bilaterally. LYMPH: No cervical, axillary, or inguinal lymphadenopathy bilaterally. MUSKULOSKELETAL: Upper and lower extremities are atraumatic in appearance without deformity. Full passive ROM of upper and lower extremities noted. Muscle strength is 5/5 bilaterally in upper and lower extremities. NEURO: Patient is awake and oriented to person, place, and time with normal speech. Cranial nerves 2-12 are intact. Gait is steady without swaying or unsteadiness. Memory is intact with rational thought process. ABDOMEN: Abdomen is flat without lesions, rashes or scars. Umbilicus is midline. Bowel signs are present and normoactive in all four quadrants. Tympany to percussion in all four quadrants. Abdomen is symmetric, non-distended and soft. Tender to palpation in RLQ with guarding. Positive McBurney's point. No masses, hepatomegaly, or splenomegaly. FEMALE GU: Patient denied vaginal exam. No CVA tenderness. DIAGNOSTIC TESTING Abdominal ultrasound

Results- ultrasound of the right lower quadrant shows a tubular blind-ending structure measuring up to 1 cm in diameter, with thickened walls and surrounding hypoechoic fat. This is concerning for an inflamed enlarged appendix. The patient was tender to scanning over this area. IMPRESSION: 1.Findings concerning for acute appendicitis. Patient was advised to go to the ED. 2.Normal appearance of remaining abdominal ultrasound. Complete Blood Count w/ Differential WBC 9.1 x10(3)/mcL RBC 4.78 million/mcL Hct 41.4 % MCV 87 fL MCH 29 pg MCHC 33 g/dL RDW 40.1 fL RDW-SD 40 RDW-CV 13 % Platelet Count 300 x10(3)/mcL MPV 9.2 fL NRBC Auto Abs 0.00 x10(3)/mcL NRBC Auto Rel 0 % Neutrophil Rel 70 %

Lymphocyte Rel 21 % (Low) Monocyte Rel 6 % Eosinophil Rel 2 % Basophil Rel 0 % Imm Gran Rel 0 % Neutrophil Abs 6.3 x10(3)/mcL Lymphocyte Abs 1.9 x10(3)/mcL Monocyte Abs 0.6 x10(3)/mcL Eosinophil Abs 0.22 x10(3)/mcL Basophil Abs 0.02 x10(3)/mcL Imm Gran Abs 0 10^3/uL Complete Metabolic Panel Sodium Lvl 136 mEq/L Potassium Lvl 3.7 mEq/L Chloride Lvl 101 mEq/L CO2 25 mEq/L AGAP 10.0 Calcium Lvl 9.3 mg/dL BUN 12 mg/dL

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Creatinine Lvl 0.61 mg/dL BUN/Creat 20 Albumin Lvl 4.5 g/dL Globulin 2.9 g/dL ALT 15 U/L AST 18 U/L Osmolality Calc 282 mmol/kg eGFR CKD-EPI >90 mL/min/1.73m2 Bili Total 0.4 mg/dL Glucose Level 101 mg/dL (High) Lipase Lvl 34 U/L Magnesium Lvl 1.9 mg/dL Calcium Corrctd 9 mg/dL HcG pregnancy test HCG By Nursing Negative Urinalysis UA Color Light-Yellow UA Appear Clear

UA Spec Grav 1.013 UA pH 6.5 UA Protein Negative UA Leuk Est Negative UA Nitrite Negative UA Glucose Negative; UA Ketones Negative UA Bili Negative UA Urobilinogen Normal IRis UA Blood Large; (Abnormal) UA WBC 0-10 UA RBC 3-5 (Abnormal) UA Bacteria Few (Abnormal) UA Squam Epith Few (Abnormal) UA Mucus Few (Abnormal) Assessment Jane Doe is a 20-year-old female presenting today with her aunt for right lower quadrant abdominal pain, nausea and anorexia. PCP ordered an RLQ abdominal ultrasound after evaluating the patient in the office. Ultrasound was concerning for appendicitis and the patient was recommended to go to the ED. Miss Doe denied emesis, hematemesis, diarrhea, hematochezia, black tarry stools, dysuria, hematuria, fever or chills. The physical exam revealed an uncomfortable female with tenderness to palpation in the right lower quadrant with guarding and a positive McBurney's point, the rest of the exam was unremarkable. Miss Doe’s

presentation is most consistent with uncomplicated acute appendicitis due to her acute presentation of RLQ abdominal pain, nausea, anorexia, positive McBurney's point on physical exam, and the RLQ abdominal ultrasound revealing an inflamed, enlarged appendix. Complicated appendicitis is less likely due to absence of abdominal ridgity, fever, and leukocytosis on CBC. Ectopic pregnancy was considered due to her being sexually active, acute abdominal pain in the RLQ and vaginal bleeding, however, she had a negative pregnancy test and there was an absence of a palpable mass on physical exam or abdominal ultrasound. Cystitis was also considered due to unilateral acute abdominal pain, however, Miss Doe denied dysuria, hematuria, there was no CVA tenderness on physical exam, and urinalysis had absences of leukocytes, nitrates, and blood. Plan Acute Appendicitis 1. Given the most likely diagnosis, a Laparoscopic appendectomy was recommended. After risks and benefits of the procedure and anesthesia were discussed, the patient was agreeable to move forward with the appendectomy. Discussed plan with surgery resident. OR was unavailable for the evening, the appendectomy was scheduled for the next day. She will be admitted tonight with the plan to move forward with the surgery tomorrow. Miss Doe and aunt understood and agreed with the plan. 2. Admit to General Surgery for management 3. Clear liquid diet 4. NPO after midnight 5. Intake and Output recorded 6. Routine Pulse Ox Spot Check Nursing 7. Routine Vital Signs 8. Sequential Compression Device Application 9. heparin 5,000 Unit(s) = 1 mL, Subcut, Q8hr 10. Metronidazole (Flagyl) 500 mg = 100 mL, IV Piggyback, Q8H-int, Indication: GI/Intra- abdominal infection 11. Continuous: (1) Lactated Ringers 1,000 mL 1,000 mL, IV, 125 mL/hr 12. PRN: (2) acetaminophen, 650 mg = 2 tab, Oral, Q4hr, PRN, For: Temp over 100 F Oxycodone, 5 mg = 1 tab, Tab, Oral, Q4hr, PRN, For: Pain Moderate SIGNATURE Lauren Cardenas PA-S2 transcribed 3/23/2024 @ 20:00 EDT

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