HISTORY AND PHYSICAL EXAMINATION
Patient Name: Benjamin Engelhart
Patient ID: 112592 DOB: Oct 5 Age: 46 Sex: Male
Date of Admission/Date of Arrival: 11/14
Admitting/Attending 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 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, hepatobiliary, renal, integument, and neurologic exams.
(Continued)
Review of Systems: A 12-point ROS was performed and is negative except
as noted above in the history of present illness, past medical, and past
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Patient Name: Benjamin Engelhart
Patient ID: 112592
surgical history. Careful attention is paid to endocrine, cardiac, pulmonary,
hepatobiliary, renal, integument, and neurologic exams.
Physical Examination: Vital Signs: Temperature: 101
Blood Pressure: 127/79
Heart rate: 129
Respirations: 18
Weight: 215 lb
Saturation 96% on room air
The pain scale is 8 out of 10.
HEENT: Normocephalic, atraumatic. Pupils equally round and reactive to
light. Extra ocular motions intact. Oral cavity shows oropharynx clear, but
slightly dried 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: Obese 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 psoas sign. Rectal exam revealed no
evidence of blood or masses.
Prostate: WNL.
Extremities: No clubbing, cyanosis, clots, or edema. There are 1+ pedal
pulses bilaterally.
Neuro: Cranial nerves 2 through 12 grossly intact.
Diagnostic Data: White count 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, BUN and creatinine are 18 and 1.1 respectively,
glucose 146, albumin 4.3, total Bilirubin 1.7. The remainder of the LFTs is
within normal limits. 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
(Continued)
appendix and inflammation and haziness in the periappendiceal fat. There is
evidence of degenerative joint disease in bilateral hips on the CAT scan as
well.
2 | Page
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Patient Name: Benjamin Engelhart
Patient ID: 112592
Assessment Plan: This 46-year-old, Caucasian gentleman has signs and
symptoms and radiographic findings consisting of acute appendicitis without
evidence of abscess. The plan is to take him to the O.R. for laparoscopic,
possible open appendectomy and possible large bowel dissection should the
case necessitate it. Plan was discussed with the 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.
Cester of General Surgery, who agrees and will take the patient to the
Operating Room.
RAB
D:
T: 09/15/16
3 | Page
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