Patient case details

Case: Raj — OPD to Admission for Minor Surgery

Patient name: Raj (M, 35) Doctor: Dr. Deep Bhatt (General Surgery) Presenting complaint: "Sharp pain in stomach" (onset 14 hours; started peri-umbilical, now right lower quadrant), nausea, low-grade fever. Allergies: None known Medications/PMH: No anticoagulants; no DM/HTN; no prior abdominal surgery; non-smoker

OPD Findings

• Vitals: HR 102 bpm, BP 128/78 mmHg, RR 18/min, Temp 37.9 °C, SpO₂ 99% RA
• Exam: RLQ tenderness with guarding; rebound tenderness; Rovsing's sign positive; no jaundice, no Murphy sign
• Labs (today): WBC 14.8 ×10⁹/L (N 82%), CRP 38 mg/L, Creatinine 0.9 mg/dL, LFTs & electrolytes within normal limits
• Imaging (USG Abdomen): Noncompressible blind-ending tubular structure in RLQ, diameter 7.8 mm, wall thickening, peri-appendiceal fat stranding; no abscess/free air

Impression

Uncomplicated acute appendicitis (likely). Risk of progression to perforation/abscess if delayed.

Doctor's Recommendation (OPD Note Summary)

• Admit today for monitoring and treatment
• NPO now, start IV fluids, analgesia, and IV antibiotics (e.g., ceftriaxone + metronidazole)
• Pre-anesthesia check; plan laparoscopic appendectomy within 6–12 hours
• Expected recovery: ~2 days under observation post-op if uncomplicated

Red-Flag Deterioration (if still at home)

Worsening generalized abdominal pain/rigidity, persistent vomiting, fever >38.5 °C, syncope, or signs of sepsis → present to ER immediately