HISTORY OF PRESENT ILLNESS: This 46-year-old gentleman with past medical history significant only for degenerative disease of the bilateral hips, secondary to arthritis. Present to the emergency room after having had three days of abdominal pain. It initially started three days ago and was a generalized vague abdominal complaint. Earlier this morning the pain localized and radiated down to the right lower quadrant he had some nausea and without emesis. He was able to tolerate p. o. earlier around 6 a. m. , but he now denies having an appetite.
Patient had a very small bowel movement this morning that was not normal for him, he has not passed gas this morning he’s avoiding well. He denies fevers, chills or night sweats the pain is localized though the RLQ what out radiation at this point. He has never had a colonoscopy. PAST MEDICAL HISTORY: Significant for arthritis bilateral hips seen by Dr. hush. PAST MEDICAL SURGERY: Negative. MEDICATION:Piroxican, for degenerative joint disease, bilateral hips. ALLERGIES: No none drug history SOCIAL HISTORY: Patient admits alcohol in jesting on nights and weekends. Denies tobacco use, denies illicit drug use. He is married.
FAMILY HISTORY: There is no history of cancer or inflammatory bowel disease in his family. REVIEW HISOTRY: The 12 point view of systems was performed and is negative. except noted above the in the history of present illness, past medical and past surgical history. Careful attention is paid endocrine, cardiac, pulmonary, hepatobiliary, renal, integument, and neurological exams. (Continued) HISTORY AND PHYSICAL EXAMINATION Patient Name: Benjamin Engelhart Patients ID: 112592 Date of Admission: 11/14/—- Page 2 PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 101. 0 BLOOD PRESSURE: 127/79 HEART RATE: 129. RESPIRATION: 18. WEIGHT: 215 pounds.
SATURATION: 96% on room air. The pain scale is 8 out of 10. HEENT: Normocephalic, atraumatic pupils equal and round and reactive to light, extraocular motions impact. ORAL CAVITY: shows oral pharynx clear but slight dry mucosa membranes. TMs: clear. MAP: supple. There is no thyromegaly, no JVD, no cervical, supraclavicular, axillary, inguinal lymphadenopathy. HEART: regular rate and rhythm, no thrills or murmurs heard. LUNGS: clear auscultation bilateral. ABDOMEN: Obese with minimum bowel sounds slightly extended. There is RLQ tenderness with guarding and with pinpoint rebound. Positive McBurney and obturator sign with a negative source sit.
RECTAL: No evidence of blood or masses, prostate WML. EXTREMITIES: No clubbing, cyanosis or clots or edema. There are 1+ pedal pulses bilaterally. NEUROLOGIC: Cranial nerves 2 – 12 grossly intact. DIAGNOSITIC DATA: White count was 13. 4, hemoglobin and hematocrit 15. 4 and 44. 8. Platelets 206 with 89% shift. Sodium 133, potassium 3. 7, chloride 99, bicarbonate 24, BUN and creatinine I 18 and 1. 1 respectively, glucose 146. Amylase 4. 3, total bilirubin 1. 7, the remainder of the LFTs is within normal limits. Urinalysis reveals traces ketones with 100 mg per deciliter protein and a small amount of blood.
CT scan was preformed revealing evidence of acute appendicitis with par sickle inflammation, as well dilatation of appendix and inflammation and haziness in the periappendiceal fat. There is degenerate joint disease in bilateral hips on the CAT scan as well. ASSESSMENT PLAN: This 46-year-old Caucasian gentleman has signs and symptoms and the radiographic finding, consistent with acute appendicitis without evidence of abscess. The plan is to take him to the OR for Laparoscopic possible open appendectomy and possible large bowel dissection should the case necessitate.
(Continued) HISTORY AND PHYSICAL EXAMINATION Patient Name: Benjamin Engelhart Patients ID: 112592 Date of Admission: 11/14/—- Page 3 Plan was discussed with patient and wife risks benefits and alternatives were discussed. There were no barriers to communication, and all questions were answered appropriately. The patient understands the plan, desires to proceed. Plan was discussed with Dr. Kester of general surgery who’s agreed and will take the patient to operating room. _________________________ Alex McClure, MD. AM:XX D:11/15/—- T:11/16/—-.