Hillcrest Medical Case 2

Date of Procedure: 11/14/---- HISTORY: Right lower quadrant pain. No previous studies. Abdomen: The lipases appeared unremarkable. The liver, spleen, gallbladder adrenals, kidneys, pancreas and abdominal aorta appeared unremarkable. The bowels seen on the study appeared thickened. Dilated appendix seemed consistent with acute appendicitis. All the structures of the abdomen appeared unremarkable. No free air was seen.

history of urinary and bowel incontinence. The patient is confused, afebrile, and hypotensive with a blood pressure of 82/44 mm Hg. His respiratory rate is 28 breaths/min

SURGICAL HISTORY History of Present Illness: The patient is a 27-year-old male complaining of right lower-quadrant abdominal pain, nausea, and

Pulmonary- clear to procession and occultation bilaterally. Cardiovascular- no murmurs or gallops noted. Abdomen- soft, none tender, protuberate, no organomegaly, and positive bells sounds. (Continued) HISTORY AND PHYSICAL EXAMINATION Patient Name: Adela Torres Patient ID: 132463 RM #: 541 Date of Admission: 06/22/---- Page: 3 Neurologic examine- cranial nerves 2-12 are grossly intact, diffuse hyporeflexia. Musculoskeletal- erosive destructive changes in the elbows, wrist, and hands consistent with rheumatoid arthritis, has bilateral total knee replacements with stovepipe legs and perimalleolar pitting edema 1+. I feel no pluses distally in either leg.

Case Study 43 Choledocholithiasis Scenario T.B. is a 65-year-old retiree who is admitted to your unit from the emergency department (ED). On arrival you note that he is trembling and nearly doubled over with severe abdominal pain. T.B. indicates that he has severe pain in the right upper quadrant (RUQ) of his abdomen that radiates through to his mid-back as a deep, sharp boring pain. He is more comfortable walking or sitting bent forward rather than lying flat in bed. He admits to having had several similar bouts of abdominal pain in the last month, but “none as bad as this.” He feels nauseated but has not vomited, although he did vomit a week ago with a similar episode. T.B. experienced an acute onset of pain after eating fish and chips

Rectal exam: Revealed no evidence of blood or masses. Prostate, WNL (within normal limits). Extremities: No clubbing, cyanosis, clots, or edema. There are 1+ pedal pulses bilaterally. Neural: Cranial nerves 2-12 grossly intact. DIAGNOSTIC DATA: White count was 13.4, hemoglobin and hematocrit 15.4 and 45.8, platelets 206, with an 89% shift. Sodium 133, potassium 3.7, chloride 99, bicarb 24, BUN and creatinine are 18 and 1.1, respectively. Glucose 146, albumin 4.3, total bilirubin 1.7. The remainder of the LFTs is within normal limits. Urinalysis reveals trace ketones with 100mg per decilitre protein and a small amount of blood. CT scan was performed revealing evidence of acute appendicitis with pericecal inflammation, as well as, dilatation of the appendix and

Patient was in the ER room when first seen. PT was with her family members and family states that she speaks little English and that she has had abdominal pain for the past day along with bloody stools. Family states that she is on calcium supplements and no other medications.

Cardiovascular Assessment: No visible pulsations, no heaves or lifts. Apical pulse present in the fifth intercostal space at the left midclavicular line. Auscultation of apical rate 62 beats per minute, normal rhythm regular S1 - S2 heart sounds present. Pulsations present when supine and disappear at a 45 degree angle position. Extremities are brown color without redness, cyanosis, lesions or varicosities bilaterally. Temperature warm bilaterally, Allen test was negative. Homan’s sign negative. Carotids: +2 and present bilaterally. Right Radial +2, left radial +1 , Right Brachial: +2

She's married with no children. On Exam:  BP today was 140/86. Head and neck exam was all clear. She had no oral or nasal ulcers. She had no lymphadenopathy or bruits. Heart sounds were normal and the chest seemed clear, as did the abdominal exam. Musculoskeletal exam disclosed widespread Heberden's and Bouchard's nodes. She had no swelling or stress pain at the MCPs. She was not tender at the CMC joints. She had no swelling in the wrist, elbows or shoulders. She had no soft tissue tender points. She has bilateral knee crepitus but only slight instability and no effusions. She had actually good range of movement of both hips. She was tender in the lumber spine and has a scar at the lower lumbar spine from her previous operations. Her feet are somewhat flat with tenderness across the

Substance Use History: The patient denies any drug or substance use except for Alcohol and Marijuana; started using in high school and everyday use.

Generally, this is a well-developed man sitting comfortably in no acute distress. Skin is warm and dry. HEENT: Head is normocephalic, atraumatic. Pupils equal, reactive to light and accommodation. Sclerae are anicteric. Oral mucosa is moist without lesions. No JVD. No thyromegaly. Lymphatics: No cervical, supraclavicular, axillary, or inguinal adenopathy appreciated. Respiratory: Lungs are clear to auscultation bilaterally. Heart: Regular rate and rhythm. Abdomen: Soft, nontender. Positive bowel sounds. Liver and spleen not palpable. Strength is 5/5 throughout. Neurological exam is

On assessment today, blood pressure is 140/66, pulse 78, weight 249 pounds, down 2 pounds from previous. The neck is supple. Short stature without adenopathy, (thyromegaly), nodules, tenderness.

ROS: General—the patient reports lethargy, decreased appetite, and recent bloating; he relates that his pants are tighter in the waist than usual

The patient is a 70-year-old female that presents to the ED complaining of right upper quadrant pain and nausea with sudden onset. The patient is known to be diabetic, fibromyalgia, has morbid obesity, and sleep apnea. She also is complaining of some chest pain and on presentation initial troponins were 0.032. She therefore is seen in consultation by Dr. Atul Prakash and the patient undergoes a stress test approximately 3 weeks ago after having presented to the ED with a similar complaints. Stress test was interpreted as normal. It is to be noted she has CO2 retention having PCO2 of 51. She is dehydrated having a urine specific gravity greater than 1030. On ultrasound she is noted to have cholelithiasis, fatty liver and mesenteric panniculitis.

Samantha Parker is a twenty-four-year-old female who went to the emergency department with complains of stomach pain in the Right Lower Quadrant. She stated that the pain started around 9am today while she was at work and the pain is progressively getting worse. Samantha stated that she has the urge to throw up, but does not. Samantha reports diaphoresis (sweating) and irregularity in her bowel habit. She does not have a fever, shortness of breath, headache, dizziness, cough, sore throat, urinary problems, chest pain, or rash. Samantha has never experienced this pain before. She rated the pain 8/10 in severity. Samantha informed her doctor of her previous surgeries and she had cholecystectomy surgery (removal of gallbladder and gallstones).