case 2
HISTORY AND PHYSICAL EXAMINATION
Patents Name: Benjamin Engelhart
Patients ID: 112592 DOB: 10/05/---- Age: 46 Sex: M
Date of admission: 11/14/----
Emergency Room Physician: Alex McClure, MD.
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. Present 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 down to the right lower quadrant he had some nausea and without emesis. He was able to tolerate p.o. earlier around 6 a.m., but he now denies having an appetite. Patient had a very small bowel movement this morning that was not normal for him, he has not passed gas this morning he's avoiding well. He denies fevers, chills or night sweats the pain is localized though the RLQ what out radiation at this point. He has never had a colonoscopy. PAST MEDICAL HISTORY: Significant for arthritis bilateral hips seen by Dr. hush. PAST MEDICAL SURGERY: Negative. MEDICATION:Piroxican, for degenerative joint disease, bilateral hips. ALLERGIES: No none drug history SOCIAL HISTORY: Patient admits alcohol in jesting on nights and weekends. Denies tobacco use, denies illicit drug use. He is married. FAMILY HISTORY: There is no history of cancer or inflammatory bowel disease in his family. REVIEW HISOTRY: The 12 point view of systems was performed and is negative. except noted above the in the history of present illness, past medical and past surgical history. Careful attention is paid endocrine, cardiac, pulmonary, hepatobiliary, renal, integument, and neurological exams.
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HISTORY AND PHYSICAL EXAMINATION
Patient Name: Benjamin Engelhart
Patients ID: 112592
Date of Admission: 11/14/----
Page 2
PHYSICAL
Patents Name: Benjamin Engelhart
Patients ID: 112592 DOB: 10/05/---- Age: 46 Sex: M
Date of admission: 11/14/----
Emergency Room Physician: Alex McClure, MD.
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. Present 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 down to the right lower quadrant he had some nausea and without emesis. He was able to tolerate p.o. earlier around 6 a.m., but he now denies having an appetite. Patient had a very small bowel movement this morning that was not normal for him, he has not passed gas this morning he's avoiding well. He denies fevers, chills or night sweats the pain is localized though the RLQ what out radiation at this point. He has never had a colonoscopy. PAST MEDICAL HISTORY: Significant for arthritis bilateral hips seen by Dr. hush. PAST MEDICAL SURGERY: Negative. MEDICATION:Piroxican, for degenerative joint disease, bilateral hips. ALLERGIES: No none drug history SOCIAL HISTORY: Patient admits alcohol in jesting on nights and weekends. Denies tobacco use, denies illicit drug use. He is married. FAMILY HISTORY: There is no history of cancer or inflammatory bowel disease in his family. REVIEW HISOTRY: The 12 point view of systems was performed and is negative. except noted above the in the history of present illness, past medical and past surgical history. Careful attention is paid endocrine, cardiac, pulmonary, hepatobiliary, renal, integument, and neurological exams.
(Continued)
HISTORY AND PHYSICAL EXAMINATION
Patient Name: Benjamin Engelhart
Patients ID: 112592
Date of Admission: 11/14/----
Page 2
PHYSICAL