Abdominal Pain ER Template Format #1
CHIEF COMPLAINT: Abdominal pain.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old gentleman who presents to the emergency room with abdominal pain. He states that he had hemorrhoid surgery done on Saturday and that he has not had a bowel movement since then.
He states that he has also had a difficult time passing his urine. He had passed some urine prior to the emergency room visit. He states that he has not passed enough normal. He did notice some blood and some clotted blood through the urethral meatus, and he continues to have abdominal pain and rectal pain.
PAST MEDICAL HISTORY: Hemorrhoidectomy in 2000 and 2006.
SOCIAL HISTORY: Denies alcohol, tobacco or illicit drug use.
FAMILY HISTORY: Noncontributory.
MEDICATIONS:
1. Oxycodone.
2. Colace.
3. Castor oil.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: As mentioned, otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 94/58, pulse 84, respirations 16, temperature is 98.2, O2 sat 96% on room air.
GENERAL: He is awake, alert and oriented, in no acute distress.
HEENT: Normocephalic and atraumatic. Pupils are equal, round, reactive to light and accommodation. Extraocular movements are intact.
NECK: No lymphadenopathy, no carotid bruits. Neck veins are flat.
CHEST: Good breath sounds bilaterally with no wheezes, rales or rhonchi.
HEART: Regular rate and rhythm with no murmurs, rubs or gallops.
ABDOMEN: Soft, somewhat tender to palpation in the suprapubic area.
EXTREMITIES: No clubbing, cyanosis or edema.
NEUROLOGIC: Cranial nerves are intact. Reflexes are normal. Sensation is grossly intact.
EMERGENCY DEPARTMENT COURSE: The patient and was seen and evaluated for abdominal pain. It seems as though he is having painful urination, difficult time with urination, urinary retention, and constipation. We did place the Foley catheter that drained some urine, less than 200 mL was released from the bladder. He also states that he has been able to void on his own here in the emergency room. Urinalysis was done and was positive for protein, nitrites, leukocyte esterase, bacteria. He will therefore be treated with an antibiotic. He is concerned about his bowels. We will get him Colace and laxative to take at home. Otherwise, his emergency room course was uneventful. He was stable throughout the entire emergency room course and will be discharged home in stable condition.
DISCHARGE DIAGNOSES:
1. Urinary retention.
2. Constipation.
3. Abdominal pain.
PLAN:
1. Cipro 250 twice daily for 5 days for UTI.
2. Colace twice daily and a magnesium citrate half bottle in the a.m. Repeat and use the other half if necessary.
3. Return to emergency room, any worsening of symptoms.
4. We advised him to contact his physician tomorrow for followup plans.
DISPOSITION: He was discharged home in stable condition.
Abdominal Pain ER Template Format #2
CHIEF COMPLAINT: Abdominal pain.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old gentleman seen for evaluation of abdominal pain. He has a complicated medical history. He had gastric bypass surgery done 3 years ago without complication. He has had numerous umbilical hernia repairs. He does not give exact history; it sounds like he may have had an incarcerated hernia and repair by his description.
At this time, he has abdominal pain with no accompanying symptoms. He denies nausea, vomiting, diarrhea, constipation, hematuria or rectal bleeding. He has just abdominal pain that he states is in the middle of his abdomen. It does not seem to radiate to his back. It does not seem to radiate to other quadrants. This has been persistent at this time for about 4 days, but it seems that it is an ongoing issue.
He tells me that he has been to the emergency room 4 to 5 times for similar complaints and his testing thus far is negative.
PAST MEDICAL HISTORY: As mentioned in HPI and is also significant for Parkinson’s disease.
SOCIAL HISTORY: He denies alcohol, tobacco or illicit drug use.
FAMILY HISTORY: Noncontributory.
MEDICATIONS: Include Requip, Sinemet and Celexa.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: Positive for abdominal pain, otherwise is negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 122/78, pulse 58, respirations 20, temperature 97.7, pulse ox 98% on room air.
GENERAL: He is awake, alert and oriented, and in no acute distress.
HEENT: Normocephalic and atraumatic. Pupils are equal, round, reactive to light and accommodation. Extraocular movements are intact.
NECK: No lymphadenopathy and no carotid bruits. Neck veins are flat.
CHEST: Good breath sounds bilaterally with no wheezes, rales or rhonchi.
HEART: Regular rate and rhythm with no murmurs, rubs or gallops.
ABDOMEN: Minimal tenderness to palpation in the epigastric area with some radiation into the umbilicus. There is no tenderness in either lower quadrants, some discomfort to palpation in the right upper quadrant. There is no rebound or guarding. There is no organomegaly.
EXTREMITIES: No clubbing, cyanosis or edema.
NEUROLOGIC: Cranial nerves are intact. Reflexes are normal.
EMERGENCY DEPARTMENT COURSE: The patient was seen for evaluation of abdominal pain. He does have a complicated medical history, especially as related to abdominal pain with multiple surgeries in the past. We did do some blood work. He had an electrolyte panel done that was basically normal. Sodium and potassium were normal. BUN of 15 and creatinine of 1. He had a urinalysis done that showed trace blood; otherwise, he had no evidence of any infectious process going on. CBC demonstrated white count of 4.6, H&H of 11.3 and 34.3, and platelet count was 224,000. Blood sugar was 150. Amylase and lipase were normal at 63 and 36. His liver enzymes were normal. His AST was 15, ALT was 3, bilirubin was normal. His testing was normal.
He did have some improvement in the emergency room itself without having any medications. He is concerned that he may have a muscle strain. He does see his primary care physician rather regularly. We advised him to discuss this further with his primary care physician. At this time, there is no evidence of any emergent condition, and he is stable to be discharged home.
DIAGNOSIS: Abdominal pain.
PLAN: He should followup with his primary care physician. He, in fact, has an appointment already. He is advised to keep this. He can take over-the-counter Tylenol as needed for mild abdominal discomfort. He should return to the emergency room if pain worsens or if he has any worsening or if he has symptoms otherwise related to abdominal pain.
DISPOSITION: He was discharged home in stable condition.
Abdominal Pain ER Template Format #3
CHIEF COMPLAINT: Abdominal pain.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female with long history of pain problems, which included a kidney abscess. Most recently, she was diagnosed with osteomyelitis of her pubic symphysis and has been placed on ampicillin IV therapy, which she has been compliant with. She has a PICC line and she is here for abdominal pain.
She has been seen in the ED in the last couple of days for the same thing; it is a chronic suprapubic pain. She reports she had a washout about 2 weeks ago. She has no vomiting or diarrhea. No fevers. The pain is constant, nothing seems to make it worse. It is better with morphine. It does not radiate. It is not associated with dysuria and bleeding or discharge. Furthermore, the patient reports she has no other problems at this time.
PAST MEDICAL HISTORY:
1. Diabetes.
2. Hypertension.
3. Chronic osteo.
ALLERGIES: See nurse’s notes.
MEDICATIONS: See nurse’s notes.
SOCIAL HISTORY: No alcohol, drugs, smoking reported to me.
REVIEW OF SYSTEMS: CARDIOVASCULAR: No chest pain. PULMONARY: No shortness of breath. GI: Positive for abdominal pain. All other systems reviewed and otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: See nurse’s note.
GENERAL: The patient appeared well.
HEENT: TMs are clear. Oropharynx is clear.
NECK: Nontender to palpation.
PULMONARY: Lungs are clear to auscultation bilaterally.
CARDIOVASCULAR: S1, S2. Regular rate and rhythm.
ABDOMEN: Soft, nontender. No rebound or guarding.
SKIN: The patient had an incision in her suprapubic region. It was clean, dry and intact.
EXTREMITIES: Nontender.
EMERGENCY DEPARTMENT COURSE: The patient was seen and evaluated, treated with morphine and Phenergan with relief of symptoms. Laboratory significant for a renal panel with bicarbonate of 25.
MEDICAL DECISION MAKING: This is a female with a history of abdominal pain. It seems to be chronic. She is to get antibiotics to treat. The patient at this time is stable to be discharged to home.
CLINICAL IMPRESSION: Abdominal pain.
Abdominal Pain ER Template Format #4
CHIEF COMPLAINT: Abdominal pain.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old, typically healthy young lady, who states that over the last 2 days she has had dysuria, urinary frequency and hesitancy. She denies fevers or chills, nausea or vomiting, any abdominal pain. She just has a burning sensation when she urinates. No unusual vaginal bleeding or discharge. Her last menstrual period was 2 weeks ago and was normal for her. She denies pregnancy at this time. She denies any back pain.
REVIEW OF SYSTEMS: As above or is otherwise negative.
PAST MEDICAL HISTORY:
1. Asthma.
2. Sleep apnea.
MEDICATIONS: Albuterol.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Noncontributory.
PHYSICAL EXAMINATION:
VITAL SIGNS: On admission to the ER today, temperature is 98.4, blood pressure 124/86, pulse 98, respiratory rate 16, O2 saturations 99% on room air.
GENERAL: This is a (XX)-year-old well-developed, well-nourished black female in no acute distress. She is awake, alert, and oriented x3. She is pleasant and cooperative with exam. She is well appearing.
HEENT: Head is normocephalic, atraumatic.
NECK: Supple, nontender, without lymphadenopathy.
HEART: Regular rate and rhythm.
EXTREMITIES: Pulses are symmetric and intact.
LUNGS: Clear. She is breathing easily.
ABDOMEN: Soft, nondistended, minimally tender to palpation to the suprapubic region without guarding, rebound or peritoneal signs. Good bowel sounds throughout. No CVA tenderness bilaterally.
SKIN: Intact without rash or petechia.
NEUROLOGIC: She has no focal neurologic deficits.
EMERGENCY DEPARTMENT COURSE: Here in the emergency department, her nursing notes are reviewed. Urinalysis is positive for nitrites, positive for blood, positive for leukocyte esterase. Urine hCG is negative for pregnancy. She was given her first dose of Cipro here.
ASSESSMENT: Urinary tract infection.
PLAN:
1. The patient will be discharged home.
2. She is started on Cipro and Pyridium. She is warned against wearing contacts while on Pyridium and that it will turn her pee and tears orange.
3. She is to push clear fluids and cranberry juice.
4. She is to return for worsening or persistent symptoms.
5. Follow up with her doctor.
She understands and agrees with the plan.
DISPOSITION: Home in stable condition.
