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History and Physical: A.P is a 45 year old male
PMH: Diabetes type II, MRSA
Past surgical history: traumatic right hand injury
HPI: Abdominal pain, acute appendicitis, status post op day 3
Allergies: Penicillin
References:
Appendicitis. (2019, May 24). Retrieved November 12, 2020, from https://www.mayoclinic.org/diseases-conditions/appendicitis/symptoms-causes/syc-20369543
Pearson Nursing: Concept-Based Approach (pg. 682-687)
Definition: Appendicitis occurs when there is an obstruction to at the opening of the appendix that would lead to inflammation and build up of bacteria. This is a projection off the cecum of the large intestine.
McBurney point
Look for signs and symptoms:
Because inflammation can go to perforation very quickly, time is key. Obtain vitals, abdominal assessment and any diagnostic tests and labs.
White Blood Cell (WBC) count:
Normal range: 4,000-10,000
Patient result: 16,000
This shows that the patient could have presence of inflammation or infection.
CT scan would be how to determine if the source of pain and confirm if it is appendicitis. An abnormal CT scan would show the appendix to be enlarged and inflamed.
Cephalexin: Written order:
Dose/Frequency: 1000 mg 3x Daily
Duration: 7
Route: Oral
2 tabs of 500 mg given three times a day for 7 days.
Often used when patients have allergies to penicillin, this is used to treat infection and prevent post op infection
Oxycodone Hydrochloride
Written order
Dose/Frequency: 5 mg Every 4 Hours PRN
Route: Oral