History and Physical - Bengamin Engelhart
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 6am, but he now denies having an appetite. Patient had a very small bowel movement earlier this morning that was not normal for him. He has not passed gas this morning. He's voiding well. He denies fever, chills, or night sweats. The pain has localized to the RLQ (right lower quadrant) without radiation at this point. He has never had a colonoscopy.
PAST MEDICAL HISTORY: Significant for arthritis of bilateral hips, seen by Dr. Hirsch.
PAST SURGICAL HISTORY: Negative.
MEDICATIONS: Piroxicam for degenerative joint disease; bilateral hips.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Patient admits to alcohol ingestion nightly and on weekends. Denies tobacco use. Denies illicit drug use. He's married.
FAMILY HISTORY: There is no history of cancer or inflammatory bowel disease in his family.
REVIEW OF SYSTEMS: A 12 point review of systems was performed and is negative, except it's noted above in the history of present illness, past medical, and past surgical history. Careful attention is paid to endocrine, cardio, pulmonary, hepatobilliary, renal, integument, and neurologic exams.
(continued)
History and Physical - Case 2
Patient: Benjamin Engelhart
Patient ID: 112592
Page 2
PHYSICAL
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 6am, but he now denies having an appetite. Patient had a very small bowel movement earlier this morning that was not normal for him. He has not passed gas this morning. He's voiding well. He denies fever, chills, or night sweats. The pain has localized to the RLQ (right lower quadrant) without radiation at this point. He has never had a colonoscopy.
PAST MEDICAL HISTORY: Significant for arthritis of bilateral hips, seen by Dr. Hirsch.
PAST SURGICAL HISTORY: Negative.
MEDICATIONS: Piroxicam for degenerative joint disease; bilateral hips.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Patient admits to alcohol ingestion nightly and on weekends. Denies tobacco use. Denies illicit drug use. He's married.
FAMILY HISTORY: There is no history of cancer or inflammatory bowel disease in his family.
REVIEW OF SYSTEMS: A 12 point review of systems was performed and is negative, except it's noted above in the history of present illness, past medical, and past surgical history. Careful attention is paid to endocrine, cardio, pulmonary, hepatobilliary, renal, integument, and neurologic exams.
(continued)
History and Physical - Case 2
Patient: Benjamin Engelhart
Patient ID: 112592
Page 2
PHYSICAL