Benjarmin Engelhart

Topics: Defecation, Medical history, Bowel obstruction Pages: 5 (746 words) Published: November 3, 2014

HISTORY AND PHYSICAL EXAMINATION
OR EMERGANCY DEPARTMENT TREATMENT RECORD
Patient Name
: Benjamin Engelhart
Patient ID
: 112592
Date of Birth
: 10/05/1958
Age
: 46
Sex
: Male
Date of Admission
: 11/14/2014
Emergency Room Physician
: Alex McClure, MD
Admitting Diagnosis
: Acute Appendicitis.
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...
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