History:

Date & time: 11/15/22 9:00 am

Full Name: LK

DOB: 05/14/1993

Address: Jamaica, NY

Age: 29 y/o

Sex: Male

Race: Asian

Religion: Christian

Source: Pt. himself

Transportation: Self 

Reliability: Reliable

Location: Flushing, NY

Chief Complaint: “My stomach hurts” x  4 days

History of Present Illness:

     29 y/o male with no PMH other than an ED visit 3 months ago with a diagnosis of appendicitis and abx treatment, presents to the ED ℅ abdominal pain for 3 days. Pt. states the onset of his pain was sudden and is predominantly localized to his right lower quadrant. He describes the duration as consistent and characterizes the pain as dull. He states that nothing alleviates or aggravates the pain and that it does not radiate anywhere else. The pt. denies any specific timing and reports the severity as a 3/10. Pt. denies fever, diarrhea, nausea, vomiting, testicular pain, flank pain, swelling of testicles, and blood in stool.

Past Medical History:

• Immunizations up to date; flu vaccine yearly (unknown date); Covid vaccines and booster up to date (unknown dates).

Past Surgical History:

• Right elbow surgery in 2012, no complications.
• Pt. denies past blood transfusions.

Medications:

• Pt. states that he is not any medications.
• Denies use of herbal supplements.

Allergies:

• NKDA
• Denies seasonal, food, and animal allergies.

Family History:

• Mother – alive age 60 h/o DM2
• Father – age 64 alive and well
• Maternal/paternal grandparents – deceased at unknown age & unknown reasons

Social History:

• Habits- Pt. denies h/o of smoking or tobacco use along with illicit drug use. Pt. also denies alcohol and caffeine use. 
• Travel- Pt. denies any recent travel.
• Marital history- Married to wife for 3 years.
• Occupational history- tattoo artist.
• Home situation- Lives with wife.
• Diet- Pt. states that his diet consists mainly of vegetables, protein, and rice.
• Exercise- Pt. states he exercises for at least an hour every day.
• Sexual Hx- Heterosexual. Denies h/o sexually transmitted diseases.
• Safety measures– Admits to seat belt use.

Review of Systems:

General – Denies fever, night sweats, weight loss or gain, generalized fatigue, chills, changes in appetite.

Skin, hair, nails – Denies changes in texture, excessive dryness, pigmentations, moles/rashes, pruritus, excessive sweating, or changes in hair distribution,

Head – Denies headaches, vertigo, or head trauma, dizziness

Eyes – Denies glasses or contact usage, Last eye exam 2021 visual acuity unknown. Denies glasses or contact usage, visual disturbances, photophobia, lacrimation, or pruritus.

Ears – Denies deafness, pain, discharge, tinnitus.

Nose/sinuses –Denies discharge obstruction, or epistaxis.

Mouth/throat – Last dental exam February 2022. Denies sore throat, bleeding gums, sore tongue, mouth ulcers, or voice changes.

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion

Breast – Denies lumps, nipple discharge, or pain.

Pulmonary system – Denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).

Cardiovascular system – Denies palpitations, chest pain, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur

Gastrointestinal system – Pt. reports abdominal pain. Has regular bowel movements daily. Denies change in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructation, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.

Genitourinary system – Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, incontinence, awakening at night to urinate or flank pain.

Nervous –Denies seizures, loss of consciousness, migraines, sensory disturbances, ataxia, loss of strength, changes in cognition / mental status / memory, or weakness.

Musculoskeletal system –Denies muscle/joint pain, deformity or swelling, or redness.

Peripheral vascular system – Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes.

Hematological system –Denies anemia, lymph node enlargement, blood transfusions, or history of DVT/PE.

Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter

Psychiatric – Denies anxiety, OCD or ever seeing a mental health professional. Pt. has h/o of depression.

Physical:

General: Medium sized male, neatly groomed, looks older than her stated age of 35 years

Vital Signs: BP:                             R                                                       L

                  Seated                        123/79                                               121/74

                  R: 16/min, unlabored                                               P: 85 beats/min, regular

                  T: 97.6 degrees F (oral)                                         O2 Sat: 99% Room air

                  Height: 72-inches              Weight: 175 lbs                  BMI: 23.7

Skin: warm & moist, good turgor. Nonicteric, no lesions noted, no scars.

Hair: average quantity and distribution. 

Nails: no clubbing, capillary refill <2 seconds throughout.

Head: normocephalic, atraumatic, non-tender to palpation throughout

Nose: Symmetrical / no masses / lesions / deformities / trauma / discharge. Nares patent bilaterally / Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions / deformities / injection / perforation. No foreign bodies.

Sinuses: Non tender to palpation and percussion over bilateral frontal, ethmoid, and maxillary sinuses.

Ears: Symmetrical and appropriate in size. No lesions/masses / trauma on external ears. No discharge / foreign bodies in external auditory canals AU. TM pearly grey / intact with light reflex in good position AU. Auditory acuity intact to whispered voice AU. Weber midline / Rinne reveals AC>BC AU.

Lips –   Pink, moist; no cyanosis or lesions.

Mucosa – Pink; well hydrated. No masses: lesions noted. No leukoplakia.

Palate – Pink; well hydrated. Palate intact with no lesions; masses; scars. 

Teeth – Good dentition / no obvious dental caries noted.

Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge.

Tongue – Pink; well papillated; no masses, lesions, or deviation.

Oropharynx – Well hydrated; no injection, exudates, masses, lesions, or foreign bodies.

Tonsils grade 1 present with no injection or exudates. Uvula pink, no edema or lesions.

Neck – Trachea midline. No masses; lesions; scars; pulsations noted.   Supple; non-tender to palpation. FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no cervical adenopathy noted.

Thyroid – Non-tender; no palpable masses; no thyromegaly; no bruits noted.

Eyes: Symmetrical OU. No strabismus, exophthalmos, or ptosis. Sclera white, cornea clear, conjunctiva pink. Visual acuity uncorrected – 20/20 OS, 20/20 OD, 20/20 OU
Visual fields full OU. PERRLA, EOMs intact with no nystagmus 
Fundoscopy – Red reflex intact OU. Cup to disk ratio< 0.5 OU. No AV nicking, hemorrhages, exudates, or neovascularization OU.

Chest: Symmetrical, no deformities, no trauma. Respirations unlabored / no paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1. non-tender to palpation throughout.

Lungs: Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout. No adventitious sounds.

Heart: JVP is 2.5 cm above the sternal angle with the head of the bed at 30°. PMI in 5^th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.

Breasts: Symmetric, no dimpling, no masses to palpation, nipples symmetric without discharge or lesions.  No axillary nodes palpable

Abdomen: Abdomen flat and symmetric with no scars, striae or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Tender to palpation in the right lower quadrant and positive for McBurney point tenderness. Psoas, Obturator, Rovsing, and Murphy’s signs were negative. Non-tender to palpation and tympanic in other three quadrants, no guarding or rebound noted. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness appreciated.

Male Genetalia and Hernias: Circumcised male. No penile discharge or lesions. No scrotal swelling or discoloration. Testes Descended bilaterally, smooth and without masses. Epididymis nontender. No inguinal or femoral hernias noted.

Anus, Rectum, and Prostate: No perirectal lesions or fissures. External sphincter tone intact. Rectal vault without masses. Prostate smooth and non-tender with palpable median sulcus Stool brown.

Motor/Cerebellar : Full active/passive ROM of all extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Strength 5/5 throughout.  Rhomberg negative, no pronator drift noted. Gait steady with no ataxia. Tandem walking and hopping show balance intact. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis

Mental Status: A&O x 3, cooperative, thoughts & speech coherent.

Cranial Nerves: II-XII intact

Sensory: Intact to light touch, sharp/dull, and vibratory sense throughout.   Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally

Reflexes: 2+ throughout, negative Babinski, no clonus appreciated

Meningeal Signs:No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative

Peripheral Vascular: The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis or edema noted bilaterally (no C/C/E B/L) No stasis changes or ulcerations noted.

Differential diagnosis:

1. Appendicitis- Pt. ℅ right lower quadrant pain and elicited McBurney point tenderness on physical. Would order a non-contrast CT scan to view appendicitis. Would also order CBC to monitor WBC count, as well as CMP to evaluate any electrolyte abnormalities. Would also order PT and PTT to check bleeding time and assess any coagulopathies as well as a type and screen. After confirmation of appendicitis would assess the need for surgery seeing that this occurred 3 months prior. If elected for surgery would make pt. NPO, administer normal saline fluids, supportive care as needed with antiemetics, and analgesics determined on the level of pain the pt. is experiencing. Would also give antibiotics either Cefoxitin 2 grams IV or Metronidazole 500 mg IV with Cipro 400 mg IV.
2. Testicular torsion- Pt. ℅ right lower abd pain. Would order doppler ultrasound and look for decreased blood flow to confirm diagnosis. Would also give anti-emetics such as Zofran and analgesics determined on the level of pain the pt. Would then prepare for emergent surgery for detorsion and orchiopexy.
3. Inguinal Hernia- Pt. ℅ of right lower quadrant pain. Would order CT to determine whether the hernia is incarcerated or strangulated. Would also order CBC, CMP, and lactic acid to aid in the assessment of strangulation. If hernia is not incarcerated and little suspicion for strangulation would then attempt to reduce the hernia. If there is high suspicion for incarceration or strangulation would opt for emergent surgery and prep pt. by making him NPO, giving cefoxitin 2 grams IV, providing fluids with normal saline, and giving pain control and antiemetics as needed.
4. Nephrolithiasis- Pt. ℅ abdominal pain. Would order CBC to monitor wbc to assess for infection. Would also order CMP to monitor and electrolyte abnormalities and assess kidney function with BUN and creatinine. I would collect a UA on the patient along with a reflex culture to check for bleeding and infection. Would order CT to confirm diagnosis as well as the size of the stone. If the stone is over 5 mm, opt for surgery. If stone is under 5 mm would give the pt. ketorolac 15 mg IV, aggressive hydration with normal saline, antiemetics such as metoclopramide as needed, and abx if the stone is infected such as Cipro 400 mg IV q12h or Ceftriaxone 1gm IV q24h.

Assessment: 29 y/o male with no PMH other than ED visit 3 months ago for appendicitis that was treated medically ℅ right lower quadrant pain for the past 3 days.

Plan:

CBC: to monitor H and H and to assess for possible infection. If normal, order a second one in 12 hours.

UA: to assess for infection or bleeding.

CMP: to monitor for electrolyte abnormalities and kidney functioning.

Non-contrast CT of abdomen and pelvis: to rule in/out appendicitis, hernia, or kidney stones.

Medication: Metoclopramide 10 mg IV every 6 hours as needed, and Morphine 2 mg IV every 2 hours as needed.