Reference no: EM133846028

Question

Directions Retype the following data into correct H and P form. The patient is J. J. "Kip" Siegler. The physician is Felix Rios, MD. Use today's date and the format of your choice. Please indicate which format you have selected for your assignment by writing the name of the format on the top of your page. The chief complaint is right-sided, abdominal pain, eight hours duration. The present illness is as follows: this is the first Brookside Hospital admission for this twenty-four year old unemployed carpenter who was in his usual state of excellent health until approximately eight hours prior to admission when he developed some high, transverse midepigastric abdominal pain following completion of a Chinese meal. The pain became progressively more intense and gradually, over the following four hours, localized in the right lower quadrant. One hour prior to admission, while preparing to come to the hospital, the patient had one episode of emesis. The patient denies any subsequent nausea and diarrhea but has been "constipated" for the past two days. The past medical history: Serious injuries: None. Surgery: None. Illnesses: None. Allergies: Assorted pollens, undetermined. Medications: None. Smoke: None. Alcohol: Very infrequently. Immunizations: None in the past four years. The father is deceased, age twenty-one, apparent suicide. The mother is living and well, age forty-one. One sister, age twenty-two, living and well. The patient is married and has one child and has been unemployed for the past six months. He spends most of his time refurbishing an old sailboat. Systemic review is unremarkable. On physical examination there is an alert, oriented Caucasian male in very mild abdominal distress, lying supine with his right hip flexed. His temperature is one hundred one point two degrees, pulse is eighty eight, respirations twenty, blood pressure is one hundred thirty over seventy eight. The skin is warm and moist without pallor, icterus, or cyanosis. There are no acute lesions or petechiae. Tympanic membranes are clear. Pupils are equal and reactive to light. Conjunctivae are mildly injected. Nares, likewise mildly injected. Pharynx and mouth, likewise, very minimally injected, without evidence of purulent debris. The neck is supple, without cervical adenopathy. The lungs are clear to auscultation and percussion. The heart rhythm is regular without murmurs or enlargement. The abdomen is somewhat protuberant with absent bowel sounds, with moderate tenderness and guarding in the right lower quadrant without rebound. There is also very mild tenderness in the right "See vee a" area. There are no apparent herniae determined in the supine position. Rectal: Prostate is normal. There is moderate to exquisite tenderness in the right quadrant. Stool is brown, and HemeSelect is negative. Genitalia: Patient is circumcised. Testicles are bilaterally descended, appear normal in size and shape. Extremities: No deformities or edema. Neurologic: Deep tendon reflexes are two plus bilaterally. Diagnosis: Acute appendicitis.