Pediatric Surgery Design Doctor Note

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Patient Information

• Patient Name: Emma Johnson

• Date of Birth: 05/15/2055

• Patient ID: PJ123456

Date of Consultation: 10/03/2090
Referring Physician: Dr.[Your Name], M.D
Contact Number: (555) 123-4567
Practice Location: Green Valley Pediatric Clinic

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Reason for Consultation

Emma was referred for evaluation of recurrent abdominal pain, specifically in the right lower quadrant. The referring physician suspects acute appendicitis due to the severity and frequency of the pain, which has been intermittent over the past week and worsened over the last 24 hours.

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Medical History

1. Past Medical History:

   • Healthy, with no chronic illnesses.

   • The previous hospitalization for mild dehydration secondary to viral gastroenteritis in 2019, was managed with IV fluids.

   • Immunizations are up to date, with the last routine vaccinations administered on April 2089.

2. Medications:

   • Currently not taking any medications.

   • Previously treated with acetaminophen for fever and pain as needed.

3. Allergies:

   • No known drug allergies (NKDA).

   • Allergic to penicillin (causes rash).

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Family History

• Family history of appendicitis in maternal uncle, who underwent surgery at age 15. No history of gastrointestinal diseases or hereditary conditions in the family.

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Social History

• Emma is a first-grade student and is active in sports, including soccer and swimming. She lives at home with both parents and has no history of smoking or substance use. There are no pets in the household, and her diet is balanced, with no known food intolerances.

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Physical Examination

1. Vital Signs:

   • Blood Pressure: 102/65 mmHg

   • Heart Rate: 88 bpm

   • Respiratory Rate: 20 breaths per minute

   • Temperature: 98.6°F

   • Weight: 18 kg (40 lbs)

   • Height: 110 cm (43 in)

2. General Appearance:

   • Alert, cooperative, and well-nourished, but appears in mild to moderate discomfort, favoring the right side during examination.

3. Examination Findings:

   • Cardiovascular: Regular rate and rhythm, no murmurs or gallops. Peripheral pulses intact.

   • Respiratory: Clear to auscultation bilaterally, no wheezing, and no signs of respiratory distress.

   • Abdomen: Soft, with mild tenderness in the right lower quadrant; no rebound tenderness or guarding. Bowel sounds are present and active. No palpable masses.

   • Neurological: Alert and oriented, with normal reflexes, strength, and tone appropriate for age.

   • Musculoskeletal: Full range of motion in all extremities, no deformities noted.

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Laboratory and Imaging Studies

1. Laboratory tests ordered:

   • Complete Blood Count (CBC): To assess for leukocytosis indicating possible infection.

   • Basic Metabolic Panel: To evaluate electrolyte levels and kidney function.

2. Imaging:

   • Abdominal ultrasound scheduled to evaluate for appendicitis, scheduled for 10/04/2090.

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Impression/Diagnosis

• Primary Diagnosis: Suspected acute appendicitis, considering clinical presentation and examination findings.

• Secondary Consideration: Rule out mesenteric adenitis or other gastrointestinal pathologies.

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Plan

1. Immediate Actions:

   • Schedule abdominal ultrasound for further evaluation.

   • Administer IV fluids if needed, and consider pain management as required.

2. Preoperative Preparation (if necessary):

   • Informed consent will be obtained before any surgical intervention.

   • Discussed the potential need for surgical consultation with the surgical team.

3. Parental Guidance:

   • Parents educated on signs of worsening condition, including fever above 101°F, increased pain intensity, vomiting, or changes in bowel habits.

   • Provided educational materials regarding appendicitis and postoperative care expectations if surgery is required.

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Follow-Up

• Schedule a follow-up appointment for 10/05/2024 to review the ultrasound results and discuss further management. If surgery is indicated, preoperative preparations will be discussed.

Sincerely,

Dr.[Your Name], M.D

Pediatric Surgeon

[Your Email]
Medical License no: 123456789

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