Sakeenah Case Study

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

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.

Her hematocrit levels could be low, along with her red blood cells being pale and immature because she isn’t getting the proper nutrition, and her over

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.

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,

Diagnostic Studies: Flat plate and upright films of the abdomen revealed a localized abnormal gas pattern in the right lower quadrant with no evidence of free air.

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

Mindy Perkins is 48 year old woman who presents to the ED with 10- 15 loose, liquid stools daily for the past 2 days. She completed a course of oral Amoxicillin seven days ago for a dental infection. In addition to loose stools, she complains of lower abdominal pain that began 2 days ago as well. She has not noted any blood in the stool. She denies vomiting, fever, or chills. She is on Prednisone for Crohn’s disease as well as Pantoprazole (Protonix) for severe GERD.

B.S. is an 81 year old Caucasian female presenting with abdominal pain, diarrhea, nausea and vomiting in the emergency room on February 3, 2013. B.S. has a history of glaucoma, hypothyroidism, degenerative arthritis and diverticulosis. She has allergies to iodine and vicodin. B.S. is admitted for diverticulitis with possible partial bowel obstruction and hydronephrosis. B.S. was admitted on February 3, 2013 here at Verdugo Hills Hospital.

Physical examination today reveals a weight of 6.8 kg, between the 15th and 50th percentile, a length of 64.5 cm, between the 15th and 50th percentile, and a head circumference of 41.7 cm, between the 15th and 50th percentile. Heart sounds were normal and the chest was clear. The remainder of the general physical examination was unremarkable. Neurologically, tone and deep tendon reflexes were

No known allergies, no sinus, tenderness, no epistaxis, no bleeding gums, patient has partial dentures, one dental carrier noted, tongue is slightly coated, no swelling, lumps or tenderness noted in throat,

Blue or patchy (mottled) skin color, rapid heart rate, rapid breathing (signs of immature lungs or heart failure)

This condition is distinguished by a mass of glandular tissue that measures approximately 0.5 cm in diameter with glandular