Hillcrest Medical Case 2

Satisfactory Essays
Patient Name: Benjamin Engelhart
Patient ID: 112592 DOB: 10/05/ Age: 46 Sex: M
CT Scan No: 10-790031
Ordering Physician: Alex McClure, MD
Procedure: CT scan of abdomen and pelvis without contrast.
Date of Procedure: 11/14/2012
HISTORY: RLQ pain, no previous studies.
ABDOMEN: The lung basis appeared unremarkable. The liver, spleen, gallbladder, adrenals, kidneys and pancreas and abdominal aorta appeared unremarkable. The bowels seen on the study appeared thickened. Dilated appendix seen constant with acute appendicitis. Osseous structures of the abdomen appeared unremarkable. No free air was seen.
PELVIS: Good quality, non contrasted actual CT examination of the pelvis with coronal reconstructions.
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He was able to tolerate PO earlier around 6am. but now denies having an appetite. Patient had very small bowel movement earlier this morning that was not normal for him. He has not passes has the morning. 'he is voiding well. Denies fevers, chills or night sweats. The pain is localized to the RLQ without radiation at this point. He has never had a colonoscopy.
PAST MEDICAL HISTORY: Significant for arthritis of bilateral hips seen by Dr. Hersch.
MEDICATIONS: Piroxicam for degenerative joint disease of bilateral hips
ALLERGIES: No known drug allergies
SOCIAL HISTORY: Patient admits alcohol ingestion nightly and on weekends. Denies tobacco use and illicit drug us. He is married.
FAMILY HISTORY: No history of cancer or inflammatory bowel disease in his family.
REVIEW OF SYSTEMS;;12 point ROS was preformed and is negative except noted in above HIP, PMH and PSH. Careful attention was paid to endocrine, integumentary, pulmonary, renal and neurological exam
PHYSICAL EXAMINATION: Vital Signs. TEMPERATURE: 101.0, Blood Pressure- 127/179, Heart Rate-129, Respirations- 185, Weight-215. Situations 96% on room air. Pain Scale- 8/10. HEENT-Normal cephalic, atrumatic pupils equally round and reactive to light. Extra ocular motions intact. ORAL: Shows oral pharynx clear but slightly dry mucosal membranes. TMS: Clear. NECK: Supple, No thrangegally or JVD. No cervical, subclavicular, axilarry or lingual lymphinalpathy.
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