Feel Free to either copy and paste the template below into your EHR, or you can download a copy of the template below.
Please let me know how/if this template has made your life easier or things that can be done to improve it in your professional opinion.
**Start of Template**
Assessment
The patient presents with left lower quadrant abdominal pain, fever, and changes in bowel habits, consistent with acute diverticulitis. There are no signs of perforation, abscess, or peritonitis on examination. Differential diagnosis includes irritable bowel syndrome, colorectal cancer, and ischemic colitis.
Plan:
Prescribe oral antibiotics (e.g., ciprofloxacin and metronidazole or amoxicillin-clavulanate) for uncomplicated diverticulitis. Advise the patient to follow a clear liquid diet initially, with a gradual return to a low-fiber diet as symptoms improve. Recommend NSAIDs or acetaminophen for pain control. Educate the patient about avoiding seeds, nuts, or popcorn during recovery, though this is controversial. Follow up in 2-3 days to monitor improvement. If symptoms worsen or fail to improve, consider CT imaging to evaluate for complications such as abscess or perforation, and refer to surgery if necessary.
** End of Template**