The patient is a 27-year-old male complaining of right lower quadrant abdominal pain, nausea, and vomiting. The initial onset of the pain was about 48 hours prior to the presentation. The pa
Below is a sample medical report. Review and answer the case questions at the end.
Physical Examination Report: Appendicitis
Patient Name: Jonathan Jones MR#: 44579
Attending Physician: Ajay Shah, M.D. ROOM #: 527-A
Chief Complaint: Abdominal pain.
History of Present Illness: The patient is a 27-year-old male complaining of right lower quadrant abdominal pain, nausea, and vomiting. The initial onset of the pain was about 48 hours prior to the presentation. The pain was progressive in nature and began radiating to the back. Late yesterday, the patient drank some Alka-Seltzer and went to bed. He was awakened during the night by the pain and began vomiting. The patient states the pain is constant and has localized to the right lower quadrant. His last bowel movement was yesterday afternoon and was normal. He does have a history of irritable bowel syndrome. However, he states that this pain is different from the pain he has had in the past.
Past Medical History: Irritable bowel syndrome, last exacerbation six months ago. The rest of the past medical history is unremarkable.
Past Surgical History: Tonsillectomy and adenoidectomy in early childhood. Umbilical hernia repair at age four.
Medications: None.
Allergies: No known drug allergies.
Social History: The patient is employed as a computer programmer. He is married and has no children. He has smoked a half pack of cigarettes daily for the last ten years. He drinks alcohol rarely.
Family History: Both parents are alive and well. One sister has Down syndrome.
Review Of Systems: Negative except for complaint of pain in the right lower quadrant.
Physical Examination:General: The patient is an alert, oriented male appearing his stated age. He appears to be in moderate distress. Vital signs: blood pressure 132/78. Pulse 68 and regular. Temperature 38.56? C. (101.4 ? F.)
HEENT: Normocephalic, atraumatic. Pupils were equal, round, reactive to light. Ears clear. Throat normal.
Neck: The neck is supple with no carotid bruits.
Lungs: The lungs are clear to auscultation and percussion.
Heart: Regular rate and rhythm.
Abdomen: Bowel sounds are normal. There is rebound tenderness, with maximal discomfort on palpation in the right lower quadrant.
Extremities: No clubbing, cyanosis, or edema.
Laboratory Data: Hemoglobin 14.6, hematocrit 43.6, WBC 13,000. Sodium 138, potassium 3.8, chloride 105, C02 24, BUN 10, creatinine 0.9, glucose 102. Urinalysis was negative.
Diagnostic Studies: Flat plate and upright films of the abdomen revealed a localized abnormal gas pattern in the right lower quadrant with no evidence of free air.
Impression: Appendicitis.
Plan: The patient will be admitted, kept NPO, and an appendectomy will be performed by Dr. Rogers in the morning.
Ajay Shah, M.D.
Case Study Questions :
1. Why is it important that the doctor record information about the patient’s heart, lungs and other body systems when the pain is in the patient’s abdomen?
2. How would you find out what the abbreviation HEENT means? What are some of the other abbreviations used, and what do they mean?
3. Using what you’ve learned about word parts, describe the types of surgeries listed in the patient’s past surgical history.
4. The extremities are described as “No clubbing, cyanosis, or edema.” What do each of these terms mean?
5. What does NPO stand for?
6. Why is the patient’s past history important?
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