ADMISSION HISTORY AND PHYSICAL
Patient Name: Jonathan Jones MR#: 44579
Attending Physician: Ajay Shah, M.D. DOB: 12/24/89
Chief Complaint: 27 yo [year old] male presents with 2 days of worsening right lower quadrant belly pain, nausea, and vomiting.
History of Present Illness (HPI): 2 days prior to admission, the patient began complaining of diffuse belly pain that initially felt like indigestion. Over the course of the day, this pain grew progressively worse, localizing in the right lower quadrant. This pain became constant and dull and radiated to the back. The evening prior to admission the patient was awakened by pain and nausea. He drank some Alka-Seltzer and attempted to return to sleep, shortly after which he began vomiting nonbloody or bilious emesis. Shortly thereafter, the patient decided to come to the ED [Emergency Department].
The patient indicates he did have a fever but did not take his temperature. He denies chills, testicular pain, blood in the stool, or recent weight change. The patient’s last bowel movement was yesterday, with some small amounts of mucus but otherwise normal. He notes a history of irritable bowel syndrome. However, he states that this pain is different than the pain he has had in the past.
Past Medical History (PMH): Irritable bowel syndrome, last exacerbation 6 months ago. The rest of the past medical history is unremarkable.
Past Surgical History (PSH): Tonsillectomy and adenoidectomy in early childhood. Umbilical hernia repair at age 4.
Social History: The patient is employed as a computer programmer. He is married and has no children. He has a 10-year pack-history (in this case, 5 years, two packs a day) of smoking. He drinks alcohol rarely.
Family History: Both parents are alive and well. One sister has a history of GERD.
Review of Systems: 12-point review of systems was performed and was negative except for those items noted in the HPI above.
General: The patient is an alert and oriented male appearing his stated age. He appears to be in moderate distress. Vital signs: blood pressure 132/78. Pulse 68 and regular. Temperature 38.56°C (101.4°F).
HEENT: Normocephalic, atraumatic. Pupils were equal, round, and reactive to light. Ears clear. Throat normal.
Neck: The neck is supple with no carotid bruits.
Lungs: The lungs are clear to auscultation and percussion.
Heart: RRR, no m/g/r.
Abdomen: Nondistended. Bowel sounds are normal. There is rebound tenderness on the left side, with discomfort and guarding upon palpation in the right lower quadrant, and positive psoas sign [pain on extension of right thigh with patient lying on left side].
Extremities: No clubbing, cyanosis, or edema, distal extremities warm and well perfused.
Laboratory Data: Hemoglobin 14.6, hematocrit 43.6, WBC 13,000, sodium 138, potassium 3.8, chloride 105, CO2 24, BUN 10, creatinine 0.9, glucose 102. Urinalysis was negative.
Diagnostic Studies: Flat plate and upright films of the abdomen revealed a diffuse small bowel distension with no evidence of free air in the abdomen. CT of the abdomen indicated a thickened cecal wall and dilated appendix.
Assessment/Impression: 27 yo male with PMH significant for irritable bowel syndrome presents with clinical signs of acute onset appendicitis.
Plan: The patient will be admitted and kept NPO, and a laparoscopic appendectomy will be performed in the morning.
Admission H and P performed and dictated by Dr. Ajay Shah for Dr. Rogers.
Discussion Questions Why is it important that the admitting doctor record information about the patient’s heart, lungs, and other body systems when the pain is in the patient’s abdomen? How would you find out what the abbreviation HEENT means? What are some of the other abbreviations used in this case study, and what do they mean? Using what you’ve learned about word parts, describe the types of surgeries listed in the patient’s past surgical history. The extremities are described as “No clubbing, cyanosis, or edema.” Edema is explained in this chapter. Look up what the other two terms mean.
Your answers need to be typed as complete sentences and be thorough and detailed for full credit.