History and Physical - Bengamin Engelhart Essay

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.

PHYSICAL EXAMINATION: Vital signs are WNL. Apparently he has had no chills, night sweats, or favors. Generalized malaise and a lack of energy have been the main concerns. HEART: Regular rate and rhythm with S1 and S2. No S3 or S4 is heard at this time. LUNGS: Bilateral rhonchi. No significant amphoric sounds are noted. ABDOMON: Soft nontender. No hepatosplenomegaly or masses are detected. RECTAL EXAM: Prostate smooth and firm. No stool is present for hemoccult test.

On later reflection I realized I could have though about interstitial cystitis, appendicitis and renal calculi. My multiple hypotheses for this patient are presented in Table 1.

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

My patient is a 64-year-old that came in for upper abdominal pain. She felt her pain was worse when she lied down flat, so she had been trying to sit up and lean forward for most of the day. As the day went on her pain got worse, so she came into Emergency Department for further evaluation. She did not have any nausea or emesis and no change in her bowel habits. No fevers or chills. No trauma to the abdomen. In the hospital, she is diagnosed with acute pancreatitis.

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

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

Breasts: no masses, no nipple retraction, no discharge. Heart: S1 and S2, no gallops, rubs, or murmurs appreciated. Abdomen is scaphoid, soft and non-tender with positive bubble sounds. Pelvic/ Rectal: deferred as patient has recently visited her GYN for a routine Pap smear. Neurologic exam reveals normal motor strength in all muscle

The patient complained of right lower quadrant pain and of feeling faint. Dr. O'Donnel documented a chief complaint, a brief history of present illness, and a systemic review of the gastrointestinal system and respiratory system. Dr. O'Donnel also documented a complete examination of all body systems, which included all required elements. Medical decision making was of moderate complexity.

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

This patient presented to the emergency department (ED) with pain in his upper right quadrant and flank. He reported experiencing abdominal distention

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

Patient N.L. was brought into the emergency room (ER) and was admitted to the medical-surgical unit on Tuesday at 1700 complaining of sudden onset of diffuse contraction-like peri-umbilical pain radiating all over her abdomen on and off for an hour after having lunch at home. Patient was a 9/10 on a pain scale with nausea and vomiting x 2. Her admitting diagnosis was small bowel obstruction and systemic inflammatory response with leukocytosis.

Mr. Franklin is a 38 yo male with a history of reactive airway disease who presents today complaining of RLQ stomach pain that started yesterday on his way home from work and progressively got worse overnight. He describes his pain as sharp when moving, dull and crampy when not moving. It does not radiate. Early this morning he had an episode of nausea and vomiting that temporarily subdued his pain. He took Aspirin about 4-5 hours ago for the pain though it didn’t help. He hasn’t had a BM in 3 days but it is not abnormal for him. He denies diarrhea or constipation. His vitals are normal with a slightly elevated temp. of 99.4. Mr. Franklin is coughing a lot today. He said that he is always coughing a little and that he is always congested. He

Head and Neck: Patient skull is of normocephalic, atraumatic and without masses. The patient 's facial expression and facial contours are normal. The parotid glands are normal. The sinuses are non-tender. Palpation of the temporal and masseter muscles reveals normal strength of muscle contraction. There is symmetry of the nasolabial folds. There is no facial droop noted. Trachea midline. Thyroid is smooth, no goiter or