Jonathan Jones 44579 Ajay Shah, M.D. 12/24/89 27 yo [ ] male presents with 2 days of worsening right lower quadrant belly pain, nausea, and vomiting. 2 days prior to admission, the patient began complaining of diffuse belly pain that initially felt like indigestion. Over the course of the day, this pain grew progressively worse, localizing in the right lower quadrant. This pain became constant and dull and radiated to the back. The evening prior to admission the patient was awakened by pain and nausea. He drank some Alka-Seltzer and attempted to return to sleep, shortly after which he began vomiting nonbloody or bilious emesis. Shortly thereafter, the patient decided to come to the ED [ ]. The patient indicates he did have a fever but did not take his temperature. He denies chills, testicular pain, blood in the stool, or recent weight change. The patient’s last bowel movement was yesterday, with some small amounts of mucus but otherwise normal. He notes a history of irritable bowel syndrome. However, he states that this pain is different than the pain he has had in the past. Irritable bowel syndrome, last exacerbation 6 months ago. The rest of the past medical history is unremarkable. Tonsillectomy and adenoidectomy in early childhood. Umbilical hernia repair at age 4. None. NKDA The patient is employed as a computer programmer. He is married and has no children. He has a 10-year pack-history (in this case, 5 years, two packs a day) of smoking. He drin
ks alcohol rarely. Both parents are alive and well. One sister has a history of GERD. 12-point review of systems was performed and was negative except for those items noted in the HPI above. Physical Examination The patient is an alert and 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). Normocephalic, atraumatic. Pupils were equal, round, and reactive to light. Ears clear. Throat normal. The neck is supple with no carotid bruits. The lungs are clear to auscultation and percussion. RRR, no m/g/r. Nondistended. Bowel sounds are normal. There is rebound tenderness on the left side, with discomfort and guarding upon palpation in the right lower quadrant, and positive psoas sign [ ]. No clubbing, cyanosis, or edema, distal extremities warm and well perfused. Hemoglobin 14.6, hematocrit 43.6, WBC 13,000, sodium 138, potassium 3.8, chloride 105, CO2 24, BUN 10, creatinine 0.9, glucose 102. Urinalysis was negative. Flat plate and upright films of the abdomen revealed a diffuse small bowel distension with no evidence of free air in the abdomen. CT of the abdomen indicated a thickened cecal wall and dilated appendix. 27 yo male with PMH significant for irritable bowel syndrome presents with clinical signs of acute onset appendicitis. The patient will be admitted and kept NPO, and a laparoscopic appendectomy will be performed in the morning. . .