HISTORY OF PRESENT ILLNESS: This 46-year-old gentle man, with past medical history, significant only fo r degenerative disease of the bilateral hips, seconda ry to arthritis, presents to the emergency room aft er having had three days of abdominal pain. It initially star ted three days ago and was a generalized, vague abd ominal complaint. Earlier this morning the pain localized and radiated to the right lower quadrant. He had so me nausea 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 e arly this morning that was not normal for him.
He h as not passed gas this morning. He is voiding well. He denies fevers, chills, or night sweats. The pain i s localized to the RLQ without radiation at this point. He has nev er had a colonoscopy. PAST MEDICAL HISTORY: Significant for arthritis of bilateral hips, seen by Dr. Hirsch. PAST SURGICAL HISTORY: Negative. MEDICATIONS: Piroxicam for degenerative joint disea se, bilateral hips. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Patient admits to alcohol ingestion nightly and on weekends. Denies tobacco use, denie s illicit drug use. He is married. FAMILY HISTORY: There is no history of cancer or in flammatory bowel disease in his family.
(Continued) HISTORY AND PHYSICAL EXAMINATION OR EMERGANCY DEPARTMENT TREATMENT RECORD Patient Name: Benjamin Engelhart Patient ID: 112592 Date of Admission: 11/14/2014 Page 2 REVIEW OF SYSTEMS: A 12-point ROS was performed and is negative except as noted above in the history o f present illness, past medical, and past surgical hi story. Careful attention is paid to endocrine, card iac, pulmonary, hepatobiliary, renal, integument, and ne urologic exams. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature: 101 .0; Blood Pressure: 127/79; Heart rate: 129;
Respirations: 18; Weight: 215 lb; Saturation 96% on room air. The pain scale is 8 out of 10. HEENT: Normocephalic, atraumatic. Pupils equally round and reactive to light. Extra ocular motions intact. Or al cavity shows oropharynx clear, but slightly dried mucosal membranes. TMs clear. Neck: Supple. There is no thyromegaly, no JVD. No cervical, supraclavicular, axillary, or inguinal lymphadenopathy. HEART: Regul ar rate and rhythm. No thrills or murmurs heard. LUNGS: Cle ar to auscultation bilaterally. ABDOMEN: Obese with minimal bowel sounds, slightly distended. There is RLQ tenderness with guarding and with pin-point reb ound.
Positive McBurney and obturator signs with a negati ve psoas sign. Rectal exam revealed no evidence of blood or masses. PROSTATE: WNL. EXTREMITIES: No clubbing , cyanosis, clots, or edema. There are 1+ pedal pul ses bilaterally. NEURO: Cranial nerves II through XII grossly intact. DIAGNOSITIC DATA: White count was 13. 4, hemoglobin and hematocrit 15. 4 and 45. 8, platelets 206, with a n 89% shift. Sodium 133, potassium 3. 7, chloride 99, bicarb 24, BUN and creatinine are 18 and 1. 1 respec tively, glucose 146, albumin 4. 3, total Bilirubin 1. 7.
The remainder of the LFTs is within normal limits. Urin alysis reveals trace ketones with 100 mg/dl protein and a small amount of blood. CT scan was performed, revealing evidence of acute appendicitis with pericecal inflammation, as well a s dilatation of the appendix and inflammation and haz iness in the periappendiceal fat. There is evidence of degenerative joint disease in bilateral hips on the CAT scan as well. (Continued) HISTORY AND PHYSICAL EXAMINATION OR EMERGANCY DEPARTMENT TREATMENT RECORD Patient Name:
Benjamin Engelhart Patient ID: 112592 Date of Admission: 11/14/2014 Page 3 ASSESSMENT PLAN: This 46-year-old Caucasian gentlem en has signs and symptoms and radiographic findings consistent with acute appendicitis without evidence of abscess. The plan is to take him to the OR for laparoscopic, possible open appendectomy and possib le large bowel deception, should the case necessita te it. Plan was discussed with patient and his wife.
Risk, benefits, and alternatives were discussed. There w ere no barriers of communication, and all questions were a nswered appropriately. The patient understands the plan and desires to proceed. Plan was discussed with Dr. Kester of General Surgery, who agrees and will tak e the patient to the operating room. _________________________ Alex McClure, MD AM:XX D:10/14/2014 T:10/15/2014.