Identifying Data:
Full Name: Ms. AM
Address: Queens, NY
Date of Birth: 10/03/2003
Date & Time: September 28, 2020
Location: New York-Presbyterian Queens
Religion: Unknown
Source of Information: Self
Source of Referral: Self
Mode of Transport: Mother
Chief Complaint: “Stomach pain and vomiting” x 1 days.
HPI: 17-year-old female with pmhx perforated appendicitis and ovarian cyst is here due to complaints abdominal pain and vomiting. Two days ago (9/22), patient was discharged after she underwent laparoscopic appendectomy for perforated appendicitis as she was tolerating pain well, able to ambulate and tolerating regular diet. She is now re-admitted with worsening right lower abdominal pain which started last night and rates the pain a 10/10. Patient states the pain is constant and sharp which does not radiate anywhere else. She also states pain was so severe that she couldn’t even walk and lying down makes the pain more durable. She tried Tylenol for pain at home but was not helpful. Patient also complains of vomiting x1 day. She tried dinner last night but ended up vomiting everything out. Patient denies blood in stool, hematemesis, diarrhea/ constipation, fever, chills, dysuria, urinary frequency, coughing, shortness of breath, chest pain or change in appetite.
Differentials:
1) Intra-abdominal abscess after laparoscopic appendectomy
2) Peritonitis
3) Wound infection from prior laparoscopic appendectomy.
4) UTI
6) Bowel obstruction
5) Ovarian torsion (unlikely)
Past Medical History:
Past/Present medical illnesses – Perforated appendicitis, ovarian cyst
Past Surgical history/ Hospitalizations: Laparoscopic appendectomy for perforated appendicitis done at NYPQ 2020.
Immunizations- Up to date.
Screening tests and results- none.
Childhood illnesses –Denies childhood illnesses
Medications:
Zosyn (piperacillin and tazobactam) 4500mg IV q8h. post-op antibiotics
Tylenol 975mg PO
Allergies:
Denies drug, environmental or food allergies.
Family History:
Denies family history of cancer, cardiovascular diseases, or diabetes.
Mother- Alive and well. Age 42y/o
Father- Alive and well. Age 45y/o
Social History:
Ms. AM lives at home with parents and siblings. She is currently a senior in high school and as of right now she’s learning remotely online.
Denies use of alcohol, smoking or illicit drug.
Sexually active with one partner (male), uses protection, not on birth control and no past history of STD’s or HIV.
Review of Systems:
General: Denies loss of appetite, fatigue, fever, recent weight gain or night sweats.
Skin, hair, nails –Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, or changes in hair distribution.
Head – Denies vertigo or head trauma, or headaches
Eyes – Denies lacrimation, pruritis, visual disturbances, or photophobia. Last eye exam 2019 – does not know her visual acuity, normal pressure.
Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids.
Nose/sinuses – Denies discharge, obstruction, or epistaxis.
Mouth/throat –Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, jaw soreness. Last dental exam 2019.
Neck– Denies localized swelling/lumps or stiffness/decreased range of motion.
Breast – Denies lumps, nipple discharge, or pain.
Pulmonary system – Denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).
Cardiovascular system – Denies chest pain, palpitations, edema/swelling of ankles/feet, syncope, known heart murmur.
Gastrointestinal system –Complains of right lower abdominal pain that started 1 day ago and also had one episode of vomiting which was not bloody but the food she had just consumed.
Genitourinary system –Denies urinary frequency or urgency, oliguria, polyuria, dysuria, incontinence.
Nervous – Denies seizures, headaches, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition / mental status.
Musculoskeletal system –Denies other muscle/joint pain, deformity or swelling, redness or arthritis.
Peripheral vascular system – Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes.
Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, or history of DVT/PE.
Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter
Psychiatric – Denies mood changes, depression. Denies sadness, OCD.
Physical exam:
General: Patient is alert and oriented x3, responsive to commands, NAD, lying supine in bed on her phone.
Vital Signs: BP: 110/75
R: 20/min unlabored P: 75, regular
T: 98.42 degrees F (oral) O2 Sat: 97% Room air
Height 61.4 inches Weight 120 lbs. BMI: 22.4 (normal)
Skin: warm to the touch & moist, good turgor. Nonicteric, no lesions noted, no scars, no tattoos.
Head: Head is normocephalic, atraumatic.
Ears: Symmetrical and normal size. EOMs intact, PERRLA. No conjunctival injection. No scleral icterus.
Nose – Symmetrical / no obvious masses / lesions / deformities / trauma / discharge. Nasal mucosa pink & appears dehydrated.
Oropharynx –no evidence of injection; exudate; masses; lesions; foreign bodies. Tonsils present with no evidence of injection or exudate. Uvula pinkish, no edema, lesions.
Neck – Trachea midline. No masses; lesions; scars; pulsations noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally.
Thyroid –Non-tender; no palpable masses; no bruits noted.
Chest/Lungs:
Symmetrical without deformity or signs of trauma. Respiration unlabored and without use of accessory muscles. Non-tender to palpation. Clear to auscultation bilaterally with no adventitious lung sounds.
Heart: Regular rate and rhythm (RRR); S1 and S2 are normal. There are no murmurs, S3, S4, splitting of heart sounds, friction rubs or other extra sounds.
Abdomen: Soft and slightly distended in the right lower quadrant. Dressing clean, dry, and intact with no signs of erythema. Tenderness to palpation on the right lower quadrant. No rebound or guarding No caput medusae or abnormal pulsations. No masses noted.
Peripheral Vascular:
The extremities are normal in color, size, and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis or edema noted bilaterally. No ulcerations noted.
Upper & Lower Extremities:
No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM of all upper and lower extremities bilaterally. No evidence of spinal deformities.
Labs:
Human Chorionic Gonadotropin Qualitative: Negative
CBC
-WBC: 12.77 (4.80-10.80)
-HGB: 13.3 (11.7-15.3)
-HCT: 40 (35.0- 45.0)
-MCV: 86.7 (78-100.0)
-PLT: 274 (150-400)
-Neutrophil: 66 (37.0-80)
Urinalysis:
-Urine appearance: Clear
-Urine bacteria: Negative
-Urine bilirubin: Negative
-Urine Leukocytes Esterase: Trace
-Urine Nitrite: Negative
-Urine Protein: Negative
Imaging:
Pelvic/Transvaginal U/S (9/26): 2.1 cm left ovarian cyst. No evidence of ovarian torsion.
CT abdomen/Pelvis (9/26): Status post appendectomy with post-surgical changes. Non-specific 2.6 x 2.5 x 5.3 cm fluid collection in right lower quadrant adjacent to the surgical clips. Abscess cannot be excluded.
Assessment: Ms. AM is a 17-year-old female with pmhx of perforated appendicitis and ovarian cyst. Two days ago, she underwent laparoscopic appendectomy for perforated appendicitis and was doing well, however today she is re-admitted for worsening right lower abdominal pain and vomiting. CT of the abdomen suggested abscess formation in right lower quadrant adjacent to the surgical clips. Pt is hemodynamically stable.
Plan:
Attempt CT guided pelvis abscess drainage.
Repeat UA, CBC and see if there’s still signs of infections.
Closely monitor vital signs and continue pain management. If pain is not controlled with Tylenol, start her on Toradol.
Continue antibiotic (Zosyn)
Place patient on NPO.
Continue to monitor for bowel movements and vomiting.
Encourage to ambulate to prevent potential DVTs
Repeat U/S in 8 months to re-evaluate left ovarian cyst.
Side note:
She was placed on Oxycodone/Paracetamol for the pain and CT guided pelvic abscess drainage was done the same day. Patient remained NPO until after the procedure. (CT drainage (9/28): Attempted aspiration of small collection which yielded no significant fluid. No drain placed at this time.)
September 30, 2020, patient doing better. Her pain is well controlled. She felt nausea and received Zofran. No episodes of vomiting, no fever and is able to tolerate diet well. She is ambulating and able to pass gas, voiding and positive bowel movements (3-4 loose stools).
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