Appendicitis

WESTWARD HOSPITAL

591 Chester Road

Masters, FL 33955

PATIENT: HARRINGTON, ROSA

DATE OF ADMISSION: 01/15/22

DATE OF DISCHARGE: 01/17/22

DIAGNOSIS: Appendicitis

Attending Physician: Dennis Beckham, MD

HISTORY OF PRESENT ILLNESS: This is a 39-year-old previously healthy female. She awoke this morning with pain in her abdomen. Her pain continued, periumbilical, and apparently now has traversed to the right lower quadrant. On a 1 to 10 pain scale she states a 7 for pain. She has had some nausea and vomiting. No history of inflammatory bowel disease, colon cancer, abdominal operations, or bleeding. No urinary tract symptomatology.

PAST MEDICAL HISTORY: Noncontributory.

MEDICATIONS: None.

ALLERGIES: None.

SOCIAL HISTORY: No smoking.

FAMILY HISTORY: Unremarkable.

REVIEW OF SYSTEMS: As per ER intake chart.

PHYSICAL EXAMINATION:

HEENT: No scleral icterus.

NECK: Unremarkable.

HEART: No findings.

LUNGS: No findings.

ABDOMEN: Exquisite right lower quadrant tenderness. Positive focal rebound. No masses.

RECTAL: Unremarkable.

EXTREMITIES: Unremarkable.

LABORATORY AND DIAGNOSTIC STUDIES: White blood count is 25, otherwise unremarkable. An ultrasound of the appendix was performed. The patient has clear-cut possible retrocecal appendicitis.

RECOMMENDATIONS/PLAN: The patient has received antibiotics. The patient has consented to a laparoscopic, possible open, appendectomy. She was counseled concerning the benefits and risks of the surgery, including but not limited to bleeding, infection, death, and injury. All questions were answered and she agreed to the procedure. We will place bilateral sequential compression devices and call the operating room to have her scheduled as soon as possible.

Dennis Beckham, MD

556839/mt98328: 01/17/22 09:50:16 T: 01/17/22 12:55:01

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Determine the most accurate ICD-10-PCS code(s) for the ultrasonography.