History
Identifying Data:
Full Name: Ms. M
Address: Jamaica, NY
Date of Birth: June 5, 1996
Date & Time: October 17, 2022 (12:10 pm)
Location: Dr. Devicka Persaud, Queens, NY
Religion: Muslim
Source of Information: Self
Reliability: Reliable
Source of Referral: Self
Mode of Transport: Friend drove patient to facility
Chief Complaint: “I am having abdominal pain”
History of Present Illness:
23 year old female with a PMHx of Asthma, Hypothyroidism on Levothyroxine presents with a complaint of bilateral lower abdominal pain x 2 days. Patient states the pain is progressively worsening, rates it 6/10 currently and is non-radiating. Describes the pain as constantly dull but intermittently becomes sharp. Reports associated nausea and decreased appetite but denied vomiting. Her last meal was at 3pm yesterday. Since then, she has been drinking fluids to keep herself hydrated but reports does not feel like eating. Last bowel movement was last night, which was normal and did not visualize any blood or mucus. Reports she did not check her temperature but felt that she had a fever. States that she took OTC Tylenol 500 mg with mild relief. Pain is aggravated when she coughs or ambulates. Reports that she is not sexually active. Denies trying new foods, flank pain, hematuria, dysuria, urgency, frequency, vomiting, diarrhea, constipation, chest pain, palpitations, SOB, recent traveling and sick contacts. LMP: October 1, 2022.
Past Medical History:
Hypothyroidism x 12 years, on Levothyroxine 50 mcg daily
Asthma x 21 years, Ventolin HFA 2 Puffs PRN
Immunizations – requires the Influenza shot, up to date otherwise
Screening tests and results – Denies
Past Surgical History:
Denies past surgical history
Medications:
Levothyroxine 50 mcg daily
Denies use of herbal supplements and high risk medications like anticholinergics, tricyclics and benzodiazepines.
Allergies: Denies food, drug, latex, environmental allergies.
Family History:
Mother: alive and well, HTN, Hypothyroidism
Father: alive and well, DM II
Social History:
23 year old female lives with her parents and siblings. She is currently a student at college and has a part time job at a retail store.
Habits – Denies cigarette smoking. Denies history of substance abuse and history of illicit substance use.
Travel – Denies recent travels.
Diet – Home cooked food, avoid carbohydrates, fast food and dine out.
Exercise – Exercises at the gym at least 3 times a week.
Sexual Hx – Never been sexually active
Review of Systems:
General – Reports loss of appetite. Denies weakness and fatigue, weight gain/loss, or night sweats.
Skin, hair, nails – Denies changes in texture of skin, pigmentations, and changes in hair distribution in the extremities.
Denies excessive dryness or sweating.
Head – Denies headaches, vertigo, unconsciousness, or head trauma.
Eyes – States wearing glasses. Denies visual disturbances, or photophobia. Last eye exam – January 2022.
Ears – Denies hearing issues, pain, discharge, or tinnitus.
Nose/sinuses – Denies discharge, obstruction, or epistaxis.
Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes. Last dental
Exam- March 2021
Neck – Denies localized swelling/lumps or stiffness/decreased range of motion.
Breast – Denies lumps, nipple discharge, or pain.
Pulmonary system – Denies dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or
paroxysmal nocturnal dyspnea (PND).
Cardiovascular system – Denies arrhythmia, chest pain, edema/swelling of ankles, syncope or known
heart murmur.
Gastrointestinal system – Reports lower abdominal pain, nausea and decreased appetite. Denies flatulence, constipation, rectal bleeding, vomiting, dysphagia, pyrosis, diarrhea, jaundice, hemorrhoids.
Genitourinary system – Denies nocturia, polyuria, oliguria, hematuria, dysuria, or flank pain.
Sexual Hx – Not sexually active
Nervous – Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength,
or change in cognition / mental status / memory.
Musculoskeletal system – Denies any pain, inflammation, abrasions or redness.
Peripheral vascular system – Denies peripheral edema, color changes, intermittent claudication, coldness
or trophic changes or varicose veins.
Hematological system – Denies bruising, blood transfusion, and lymph node enlargement.
Endocrine system – Denies polydipsia, polyphagia, heat or cold intolerance, excessive sweating,
hirsutism, or goiter.
Psychiatric – Denies depression/sadness, anxiety, OCD or ever seeing a mental health professional.
Physical
General : A&O x 3, neatly groomed, well nourished, in mild distress due to pain
Vital Signs :
BP: Seated, Left arm 135/83
RR: 18/min, unlabored HR: 105, regular
T: 99.9 degrees F (oral) O2 Sat: 99% Room air
Height: 5 Feet 6 inches Weight: 124 lbs. BMI: 19
Skin: Nails with no clubbing/splinter hemorrhages, and capillary refill <2 seconds.
HEENT: Atraumatic, normocephalic, well hydrated with no masses or lesions.
Pulmonary: Clear to auscultation in all fields bilaterally. Chest expansion and diaphragmatic excursion
symmetrical. Respirations unlabored/no paradoxical respirations or use of accessory muscles noted.
Cardiovascular: 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: Not pertinent
Abdominal: Abdomen is soft.
RLQ: moderate tenderness with guarding and rebound tenderness.
LLQ: mild tenderness but greeted on RLQ. No guarding, rebound tenderness
RUQ and LUQ: No tenderness, guarding or rebound tenderness
Positive Mcburney’s sign. Negative for Psoas sign, Rovsing sign or Obturator sign. No rigidity, CVA tenderness
Rectal: Not pertinent
Musculoskeletal: No ecchymosis, edema, deformities. Full ROM in all four extremities. Strength- 5/5 both upper and lower
extremities bilaterally.
Peripheral Vascular: Warm to touch bilaterally. 2+ pulses in all extremities. No ulcerations or edema. No
calf tenderness bilaterally, equal in circumference. No palpable cords bilaterally.
Neurological: A&O x person/place/time. Able to follow commands. No gross sensory and motor deficits. Normal gait.
Psychiatric: Appropriate appearance, speech/language, mood, thought process/content.
Labs and results:
Urinalysis
Leukocyte esterase: negative
Nitrates : positive
Uro: 0.2 mg/dl
Protein: negative
pH: 6.0
Blood: negative
SH: 1.010
Ketones: negative
Bilirubin: negative
Glucose: negative
Urine Culture ordered.
Differential: UTI, Appendicitis, Diverticulitis, Inflammatory Bowel Disease
Assessment/Plan
23 year old female presents with no PSHx and a PMHx of hypothyroidism and asthma presents with ℅ bilateral lower abdominal pain x 2 days that is progressively worsening. Denies ever being sexually active and any bladder or bowel changes. Vital signs are remarkable for tachycardia. On the physical exam, the patient has RLQ tenderness, rebound and guarding but no rigidity with the presence of Mcburney’s signs. UA negative for signs of UTI but urine Culture ordered.
- Appendicitis
Based on history, UA and physical exam, the patient most likely has appendicitis. Given the patient’s acute condition with progressively worsening of pain and decreased appetite, patient was sent to the ER to rule out appendicitis. I educated patient on the importance of following up in the ER. Patient understands and states will go to the hospital. Based on the work up in the ER, advised the patient to follow up in the primary care office and to bring discharge paperwork.
- Hypothyroidism
Annual physical and lab work done June 2022. Thyroid panel was within normal limits. Condition well controlled on Levothyroxine. Continue taking levothyroxine as prescribed.
