History and Physical - Bengamin Engelhart Essay

667 Words Sep 8th, 2012 3 Pages
HISTORY AND PHYSICAL - CASE 2

Patient: Benjamin Engelhart

Patient ID: 112592

DOB: 10/5/1966

Age: 46

Sex: Male

Date of Admission: 11/14/2012

Emergency Room Physician: Alex McClure, M.D. Admitting Diagnosis: Acute Appendicitis

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 three days of abdominal pain. It initially started three 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
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The pain is 8 out of 10.

HEENT: 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.
Heart: Regular rate and rhythm. No thrills or murmurs heard.
Lungs: Clear to auscultation bilateral.
Abdomen: Obtuse with minimal bowel sounds, slightly distended. There is RLQ (right lower quadrant) tenderness with guarding and with pinpoint rebound. Positive McBurney and obturator signs with a negative psoas sign.
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