Hillcrest Medical Case 2

Normocephalic atraumatic. Pupils equally round and reactive to light, extraocular motions intact. Oral cavity shows oropharynx clear but slightly dried mucosal membranes. TM (tympanic membranes) clear. Neck, supple. There is no thyromegaly, no JVD. No cervical supraclavicular, axillary, or inguinal lymphadenopathy.

hypotensive with a blood pressure of 82/44 mm Hg. His respiratory rate is 28 breaths/min

HISTORY OF PRESENT ILLNESS: This 46-year old gentleman with past medical history significant only for degenerative disease of the bilateral hips, secondary to arthritis presents to the emergency room after having had 3 days of abdominal pain. It initially started 3 days ago and was a generalized vague abdominal complaint. Earlier this morning the pain localized and radiated to the right lower quadrant. He had some nausea without emesis. He was able to tolerate p.o earlier around 6am, but he now

Physical Examination: General: The patient is an alert, oriented male appearing his stated age. He appears to be in moderate distress. Vital signs: blood pressure 132/78 and pulse 68 and regular. Temperature is 38.56 oC (101.4 oF). HEENT:Normocephalic, atraumatic. Pupils were equal, round, and reactive to light. Ears are clear. Throat is normal. Neck: The neck is supple with no carotid bruits. Lungs: The lungs are clear to auscultation and percussion. Heart: Regular rate and rhythm. Abdomen:Bowel sounds are normal. There is rebound tenderness with maximal discomfort on palpation in the right lower quadrant. Extremities: No clubbing, cyanosis, or edema.

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

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

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

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. Last oral intake is 24 hours ago. Family states no known past medical history. Pt is in the hospital bed in the fetal position and towards the right side. Patient's airway is clear and breathing is normal. Skin is warm and dry. Patent is AAOx4. Assessment of head, neck, and chest show no signs of deformities. Abdominal area not assessed due to severe pain. Back is without deformity. The upper extremity shows no sign of deformities or trauma. The lower extremity shows

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.

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

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

No history of skin disease. Skin is pink, dry, and void of bruising, rashes, or lesions. No recent hair loss; head is normocephalic. Pupils equally reactive to light; no history of glaucoma or cataracts. Ears are in normal alignment; no history of chronic infections, hearing loss, tinnitus, or discharge. Nose and sinus history includes clear nasal discharge “since last October”, and occasional nose bleeds; states she use to get nose bleeds often as a child. Mouth and throat are absent of lesions; no bleeding gums, sore throat, dysphagia, hoarseness, or altered taste. Neck is void of pain, swelling,

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.

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

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).