CC: RLQ pain radiating in his inguinal area

HPI: Patient came in complaining of RLQ pain for 2 days that became exaggerated by leg
movement. Level of pain 6(on pain scale 0-10 ).He states he has occasional sharp pain that
radiates in his inguinal area .Denies any fever .States he had an episode of nausea today.
PMHX: denies
PSHX: denies
ALLERGIES: none
PE: pain at palpation in the RLQ area, mild guarding noted, and abdomen tender at palpation
especially in the RLQ and inguinal on the right side. Normal bowel sounds. Positive psoas sign;
positive obturator sign.
Laboratory investigation: WBC =9.9
UA=WNL
CMP=WNL
ASSESMENT: RLQ ABDOMINAL PAIN DDX: ACUTE APPENDICITIS
PLAN: continue: Patient received 30mg of ketorolac and his pain level decreased to 5 (on a pain
scale 0-10) .He was referred to ROLE III for further evaluation regarding a possible appendicitis