Discharge Summary
ER ADMMISION, HISTORY AND PHYSICAL EXAMINATION Admitting/ Attending Physician: Alex McClure M.D.
Patient name: Benjamin Engel Hart
Patient ID: 112592 DOB: 10/5 Age: 46 Sex: Male
Date of admission: 11/14/----
Emergency room physician: Alex McClure M.D.
Admitting diagnosis: Acute appendicitis.
History of present illness: This 46 year old gentlemen with past medical history significant only for the generative disease of bi-lateral hips, secondary arthritis presents to the emergency room after having had three days of abdominal pain. It initially started three days ago and was generalized big abdominal complaint. Earlier this morning the pain localized and radiated to RLQ. He has some nausea without emesis.
He was able to tolerate P.O earlier around 6 AM but he now denies having an appetite. Patient had very small bowel movements early this morning that was not normal for him. He has not passed gas this morning. He is voiding well. He denies fever, chills or night sweats. The pain is localized to the RLQ without radiation at this point. He has never had a colonoscopy.
Past Medical History: Significant for arthritis of bilateral hips, seen by Dr Harsh.
Past surgical history: Negative.
Medications: Piroxicam for the generative joint decease bi-lateral hips.
Allergies: no none drug allergies.
Social history: Patient admits to alcoholic ingestion nightly and on weekends. Denies tobacco use, denies Ellis drug use. He is married.
Family history: There is no history of cancer, or inflammatory bowel disease in his family.
Review systems: A 12 point review of systems was performed and is negative except in not at above in the history of present illness.
Past medical and past surgical history: Careful attention is paid to the Endocrine, Cardiac, Pulmonary, Hipatebelury, Renal, Integument and Neurological exam.
ER ADMMISION, HISTORY AND PHYSICAL EXAMINATION Admitting/ Attending Physician: Alex McClure M.D.
Patient name:
Patient name: Benjamin Engel Hart
Patient ID: 112592 DOB: 10/5 Age: 46 Sex: Male
Date of admission: 11/14/----
Emergency room physician: Alex McClure M.D.
Admitting diagnosis: Acute appendicitis.
History of present illness: This 46 year old gentlemen with past medical history significant only for the generative disease of bi-lateral hips, secondary arthritis presents to the emergency room after having had three days of abdominal pain. It initially started three days ago and was generalized big abdominal complaint. Earlier this morning the pain localized and radiated to RLQ. He has some nausea without emesis.
He was able to tolerate P.O earlier around 6 AM but he now denies having an appetite. Patient had very small bowel movements early this morning that was not normal for him. He has not passed gas this morning. He is voiding well. He denies fever, chills or night sweats. The pain is localized to the RLQ without radiation at this point. He has never had a colonoscopy.
Past Medical History: Significant for arthritis of bilateral hips, seen by Dr Harsh.
Past surgical history: Negative.
Medications: Piroxicam for the generative joint decease bi-lateral hips.
Allergies: no none drug allergies.
Social history: Patient admits to alcoholic ingestion nightly and on weekends. Denies tobacco use, denies Ellis drug use. He is married.
Family history: There is no history of cancer, or inflammatory bowel disease in his family.
Review systems: A 12 point review of systems was performed and is negative except in not at above in the history of present illness.
Past medical and past surgical history: Careful attention is paid to the Endocrine, Cardiac, Pulmonary, Hipatebelury, Renal, Integument and Neurological exam.
ER ADMMISION, HISTORY AND PHYSICAL EXAMINATION Admitting/ Attending Physician: Alex McClure M.D.
Patient name: