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HILLCREST MEDICAL CENTER

2016 Fall High Road

Anywhere, US 12000

HISTORY AND PHYSICAL EXAMINATION

PATIENT NAME: Benjamin Engelhart

PATIENT ID: 112592

DOB: 10/05/1970

AGE: 46

SEX: Male

DATE OF ADMISSION: 11/14/2015

EMERGENCY DEPTARTMENT 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, presents to the emergency department 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 RLQ. He had some nausea 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 early this morning that was not normal for him. He has not passed gas this morning. He
is voiding well. He denies fevers, 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. 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 is married.

OST 242-MEDICAL TRANSCRIPTION-DENISE HIGHTOWER-INSTRUCTOR-FALL 2015


FAMILY HISTORY: There is no history of cancer or inflammatory bowel disease in his family.

(Continued)
HISTORY AND PHYSICAL EXAMINATON

PATIENT NAME: Benjamin Engelhart


PATIENT ID: 112592
DATE OF ADMISSION: 11/14/2015
Page 2

REVIEW OF SYSTENS: A 12-point review of systems was performed and is negative except as noted above
in the history of present illness, past medical, and past surgical history. Careful attention is paid to endocrine,
cardiac, pulmonary, hepatobiliary, renal, integument, and neurologic exams.

PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 101.0, blood pressure 127/79, heart rate 129,
respirations 18, weight: 215 lb. Saturations: 96% on room air. The pain scale is 8/10. HEENT:
Normocephalic, atraumatic. PUPILS: equally round and reactive to light. EOMs: Intact. ORAL CAVITY:
Shows oropharynx clear, but slightly dry mucosal membranes. TMs: Clear. NECK: Supple. There is no
thyromegaly, no JVD. No cervical, supraclavicular, axillary, or inguinal lymphadenopathy. HEART: Regular
rate and rhythm. No thrills or murmurs heard. LUNGS: Clear to auscultation, bilaterally. ABDOMEN: Abyss
with minimal bowel sounds, slightly distended. There is RLQ tenderness with guarding and with pin-point
rebound. Positive McBurney and obturator signs with a negative source site. RECTAL EXAM: Revealed no
evidence of blood or masses. PROSTATE: WNL. EXTREMITIES: No clubbing, cyanosis, clots, or edema.
There are 1+ pedal pulses, bilaterally. NEURAL: Cranial nerves II-XII grossly intact.

DIAGNOSTIC DATA: WBC was 13.4, hemoglobin and hematocrit 15.4 and 45.8. Platelets 206 with an 89%
shift. Sodium 133, potassium 3.7, chloride 99, bicarb 24, BUM and creatinine are 18 and 1.1, respectively.
Glucose 146, albumin 4.3, total bilirubin 1.7. The remainder of the LFTs is WNL. Urinalysis reveals trace
ketones with 100 mg/dl protein and a small amount of blood. CT scan was performed, revealing evidence of
acute appendicitis with pericecal inflammation, as well as dilatation of the appendix and inflammation and
haziness in the periappendiceal fat. There is evidence of degenerative joint disease in bilateral hips on the CT
scan as well.

ASSESSMENT/PLAN: This 46-year-old, Caucasian gentleman has signs and symptoms and radiographic
findings consistent with acute appendicitis, without evidence of abscess. The plan is to take him to the operating
room for laparoscopic, possible open, appendectomy, and possible large bowel resection should the case
necessitate it. Plan was discussed with patient and his wife. Risks, benefits, and alternatives were discussed.
There were no barriers to communication and all questions were answered appropriately. The patient
understands the plan and desires to proceed. Plan was discussed with Dr. Kester of General Surgery, who agrees
and will take the patient to the operating room.

___________________________________

OST 242-MEDICAL TRANSCRIPTION-DENISE HIGHTOWER-INSTRUCTOR-FALL 2015


Alex McClure, MD

AM:lr

D:11/14/2015
T:11/14/2015

OST 242-MEDICAL TRANSCRIPTION-DENISE HIGHTOWER-INSTRUCTOR-FALL 2015

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