Benjarmin Engelhart
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
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