Identifying Data:

Full Name: Mrs. G

DOB (Age):  xx/xx/1983 (37 y.o.)

Gender: Female

Religion: Hindu

Date & Time: Nov. 2, 2020 / 10:30 AM

Location: QHC, Jamaica

Source of information: Self

Reliability: Reliable

Chief Complain: “I have an abdominal pain” X 2 week

HPI:

37 years old female with PMHx DM, HLD, hypothyroidism, recently diagnosed acute appendicitis (admitted from 10/18-10/19/2020) present with sharp RLQ pain since 10/18. The pain is constant without radiation, associates with nausea and loss of appetite. Patient states she only took soft food for the past few days, last eaten bread this morning without vomiting. Patient reports recently presented to ED on 10/18 with complaints of right flank pain, radiating to the groin. Of note, she underwent a CT A/P without contrast on 10/18, which found possible appendiceal dilation and surrounding stranding. She was admitted to the surgical service and treated non-operatively and discharged with ciprofloxacin and flagyl, which the patient is adherent to. Patient denies fever, chills, vomiting, cough, SOB, vaginal bleeding, vaginal discharge, or flank pain.

Past Medical History:

• Past medical illness –DM, Dyslipidemia, Acquired hypothyroidism
• Childhood illnesses – None
• Immunization – Up to date; last flu vaccine yearly

Past Surgical History:

• Cesarean Section

Home Medications:

• Empagliflozin 10 mg tablet, PO, 1 tablet daily
• Ergocalciferol 50,000 units capsule, PO, 1 capsule once per week
• Glipizide 10 mg tablet, PO, 1 tablet BID
• Insulin Detemir 100 unit/mL pen injection, inject 30 unites under the skin nightly
• Levothyroxine 100 mcg tablet, PO, 1 tablet daily
• Rosuvastatin 20 mg tablet, PO, 1 tablet daily
• sitagliptin-Metformin 50-1,000 mg tablet, PO, 2 tablets daily

Allergies:

• Pt has no known allergies

Family history:

• Mother – alive and healthy
• Father – alive with DM, HTN
• Sister – 30s, alive and healthy
• Brother – 30s, alive and healthy

Social History:

Married, living with her husband in a private house. Denies tobacco use, occasional alcohol use. Denies recent traveling history. Regular diet. Routine walking. Denies sleeping problems. Sexually active, denies any hx of STD

Review of systems:

General –No appreciable disease.  Patient denies generalized weakness, recent weight loss or weight gain, or night sweats

• Positive: loss of appetite

Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, or changes in hair distribution.

Head – Denies headaches, vertigo, head trauma, unconsciousness, coma, or fracture.

Eyes –Denies diplopia, fatigue with use of eyes, scotoma, halos, lacrimation, photophobia, pruritus. Last eye exam: none.

Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids.

Nose/sinuses – Denies discharge, epistaxis, or obstruction.

Mouth and throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes or use dentures. Last dental exam in May 2020.

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

Breast – Denies lumps, nipple discharge, or pain.

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

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

Gastrointestinal system – Regular bowel movements daily. Denies intolerance to specific foods, dysphagia, pyrosis, unusual flatulence or eructations, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.

• Positive: abdominal pain, nausea and diarrhea

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

-Sexual History: States she is currently sexually active with her husband. Denies STI

Nervous system – Denies headache, seizures, loss of consciousness, sensory disturbances, ataxia, or change in cognition/mental status/memory.

Musculoskeletal system –Denies muscle pain, or deformity.  

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

Hematologic system – Denies transfusion, easy bruising or bleeding, lymph node enlargement or history of DVT/PE

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

Psychiatric – Denies depression, sadness, anxiety, obsessive, or any experience of seeing a mental health professional.

Physical Examination:

Vital Signs:

 

BP 104/65, sitting, right arm

HR 76 bpm, RRR

O2 Sat: 97%

RR 18 breaths per minute, regular

T 97.8 oral

Ht 5’2’’    Wt 136lbs     BMI 24.9

 

General: Patient is a 37-year-old female, A&O x 3. Well-developed and good posture. Well dressed, groomed, and nourished. No apparent distress.

Skin: warm & dry, good turgor. No scar, increase or loss in pigmentation, nonicteric

Nail: no clubbing. Capillary refill < 2 seconds throughout. Nails are trim

Hair: average quantity and soft of hair, evenly distribution, no signs of lice, nits, no seborrhea.

Head: eyes and ears aligned, normocephalic, atraumatic, non-tender to palpation throughout, except left frontal area. no trauma, no specific facies.

Eye: Symmetrical OU; no redness, no strabismus, exophthalmos or ptosis; sclera white; conjunctiva & cornea clear. Visual fields full OU. PERRL, EOMs full with no nystagmus.

Ears: Symmetrical, no evidence of mass, lesion, erythema, inflammation, ear canal atresia. Non tender to palpation. Auditory Acuity: whisper test, intact to whispered voice AU.

Nose/Sinuses:

Nose – Symmetrical, no evidence of mass, lesion, deformities, erythema, inflammation. Non-tender to palpation and no step-off. no evidence of nasal obstruction

Sinuses – Non tender to palpation

Mouth/Throat:

Pink and well hydrated lip, gingivae, tongue, mucosa, and palate. No masses, lesions, erythema, exudate or discharge noted. Good dentition. No obvious dental caries noted. Non-tender to palpation. Uvula pink, no edema, deviation.

Neck/Thyroid:

Trachea midline. 2+ Carotid pulses. No masses, lesions, scars, pulsations noted. No stridor, thrills, bruits noted bilaterally. No palpable adenopathy noted. Non-tender to palpation, no thyromegaly noted.

Thorax and Lungs:

Chest – Symmetrical, no deformities, no evidence trauma.   Respirations unlabored, no paradoxic respirations or use of accessory muscles noted.  Lat to AP diameter 2:1. Non-tender to palpation.

Lungs – Clear to auscultation. No adventitious sounds. No stridor, respiratory distress.

 

Cardiovascular:

Regular rate and rhythm (RRR); S1, S2 noted; No gallops, S3 or S4. No JVD. Carotid pulse 2+ bilaterally without bruits.

Abdomen:

Soft, non-distended, symmetrical, no evidence of scars, striae, caput medusae or abnormal pulsations. BS present in all 4 quadrants. No bruits noted over aortic/renal/iliac/femoral arteries. Tympany to percussion throughout. No evidence of organomegaly. No masses noted. No evidence of guarding or rebound tenderness. No CVAT noted bilaterally.

• Positive: tenderness to palpation in the right lower quadrant

Genitourinary:

Vaginal normal. Cervix exhibits no motion tenderness B/L, no discharge and no friability. Adexum displays no mass, no tenderness and no fullness B/L, no bleeding in the vagina. No foreign body in the vagina. No signs of injury around the vagina. No vaginal discharge found.

Peripheral Vascular System: Skin normal in color and warm to touch upper and lower extremities bilaterally.  No calf tenderness bilaterally. No palpable cords or varicose veins bilaterally.

Neurological:

Mental Status: Alert and oriented to person, place and time. Memory and attention intact. Receptive and expressive abilities intact. Thought coherent. No dysarthria, dysphonia or aphasia noted.

Cranial Nerves

• I – Intact no anosmia.
• II- Visual fields by confrontation full.
• III-IV-VI- PERRL, EOM intact without nystagmus.
• V- Facial sensation intact, strength good.
• VII- Facial movements symmetrical and without weakness.
• VIII- Hearing grossly intact to whispered voice bilaterally.
• IX-X-XII- Swallowing and gag reflex intact. Uvula elevates midline. Tongue movement intact.
• XI- Shoulder shrug intact.

Motor/Cerebellar: Full active/passive ROM of B/L upper and lower extremities without rigidity or spasticity. Normal muscle bulk and tone. No atrophy, tics, tremors or fasciculations. Strength equal and appropriate for age bilaterally (5/5 throughout). Coordination-finger to nose intact. Normal gait.

Sensory: For b/l upper and lower extremity, Intact to light touch, sharp/dull, point localization, extinction.

Reflexes

• Patellar : R-2+ ; L-2+

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

Musculoskeletal: No erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. No crepitus noted throughout. No evidence of spinal deformities. FROM of all upper and lower extremities.  No evidence of spinal deformities.

ECG:

Normal sinus rhythm at 76 bpm with no ST elevation or depression, no T wave changes.

Labs:

Poc glucose capillary: 482

Urine HCG: negative

Assessment:

37 years old female with PMHx DM, HLD, hypothyroidism, recently diagnosed acute appendicitis presents with sharp RLQ pain for 2 weeks.

Differential Diagnosis:

Appendicitis

pyelonephritis

Nephrolithiasis

Gastroenteritis

UTI

Plan:

Labs: CBC, BMP, Lipase, LFT, UA

CT abdomen and pelvic

Keep the patient NPO and start IV Fluid

Pain management: morphine

Treat nausea: Zofran

Serum glucose management: Insulin