Date of Visit

January 12, 2026

Facility

Riverside Valley Medical Center – Emergency Department
Austin, Texas

Doctors

Dr. Michael Reynolds – Emergency Medicine Physician
Sarah Mitchell, RN – Registered Nurse

Complaints

Patient presented with complaints of severe abdominal pain, nausea, and persistent vomiting lasting approximately two days.

Symptoms

Lower right abdominal pain

Fever (101.8°F)

Loss of appetite

Nausea and vomiting

Difficulty walking due to abdominal discomfort

Assessment

Patient appeared uncomfortable but was alert and oriented. Physical examination revealed abdominal tenderness. The physician considered multiple possible causes, including gastrointestinal infection, ovarian pathology, and possible appendicitis. A CT abdomen/pelvis was performed, which showed findings suggestive of possible early appendiceal inflammation.

Diagnosis

Suspected viral gastroenteritis. CT findings indicated possible early-stage appendiceal inflammation requiring clinical correlation.

Recommendations

IV fluids administered

Pain medication provided

Anti-nausea medication prescribed

Patient discharged with instructions to monitor symptoms and seek follow-up care if symptoms worsened

Link to Pages in Master PDF

Pages 1–6
Includes emergency department intake notes, physician evaluation, nursing documentation, laboratory results, CT imaging report, and discharge instructions.

January 12, 2026

Facility

Riverside Valley Medical Center – Emergency Department
Austin, Texas

Doctors

Dr. Michael Reynolds – Emergency Medicine Physician
Sarah Mitchell, RN – Registered Nurse

Complaints

Patient presented with complaints of severe abdominal pain, nausea, and persistent vomiting lasting approximately two days.

Symptoms

Lower right abdominal pain

Fever (101.8°F)

Loss of appetite

Nausea and vomiting

Difficulty walking due to abdominal discomfort

Assessment

Patient appeared uncomfortable but was alert and oriented. Physical examination revealed abdominal tenderness. The physician considered multiple possible causes, including gastrointestinal infection, ovarian pathology, and possible appendicitis. A CT abdomen/pelvis was performed, which showed findings suggestive of possible early appendiceal inflammation.

Diagnosis

Suspected viral gastroenteritis. CT findings indicated possible early-stage appendiceal inflammation requiring clinical correlation.

Recommendations

IV fluids administered

Pain medication provided

Anti-nausea medication prescribed

Patient discharged with instructions to monitor symptoms and seek follow-up care if symptoms worsened

Link to Pages in Master PDF

Pages 1–6
Includes emergency department intake notes, physician evaluation, nursing documentation, laboratory results, CT imaging report, and discharge instructions.