History

Identifying Data:

Full Name: TS

Address: Jamaica, NY

Age: 40

Date & Time: 6//2019

Location: Woodhull Mental and Medical Health Center  (Surgery Dept)

Religion: Unknown

Nationality: Hispanic

Source of Information: self

Source of Referral: Self

 

Chief Complaint:

“I have belly pain” x 5 days

HPI:

Mr. TS is a 40 y/o obese Hispanic M with no PMHx , who presents to the ED with RLQ abdominal pain x 5 days. The pain is 6/10, sharp, non-radiating, and is worse with movement. Patient took over the counter pain med with no relief. Patient states he has never had similar symptoms in the past and is concerned it may be appendicitis, so he came to the ER to get evaluated. Patient is also reporting subjective fevers and chills and one episode of diarrhea yesterday. Patient denies any N/V, blood in the stool, CP, SOB, trauma to the abdomen, recent travel, loss of appetite, sudden wt loss, night sweats, constipation, urinary symptoms, blood in the urine.

 Past Medical History:  

none

Hospitalization: none

Childhood illnesses – none

Immunizations – Up to date on all vaccines

Past Surgical History:

Surgery of the left shoulder

Medications:

None

Allergies:  none

Denies environmental or food allergies.

Family History: none

Pt denies family h/o heart disease, respiratory disease, CVD,  allergies,  gastrointestinal disease, or psychiatric disorders.

Social Hx:

Travel – denies any recent travel.

Does not smoke or drink alcohol

Exercise: does not exercise much

Sexually active with one partner (female)

ROS: General –  c/o subjective fevers, chills denies change in appetite, recent weight loss or gain, generalized weakness/fatigue, or night sweats.

Skin, hair and nails – denies change in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution.

Head – Pt denies H/A,  vertigo or head trauma.

Eyes – Pt denies problems with vision, visual disturbance, lacrimation, photophobia, pruritus.

Ears – Pt. denies any discharge, tinnitus, deafness or use of hearing aids.

Nose/Sinuses – Pt denies discharge , nasal congestion, sinus pressure,  epistaxis or obstruction.

Mouth and throat – Pt denies any bleeding gums, sore throat or tongue, mouth ulcers, or voice changes.

Neck – Pt denies localized swelling/lumps, stiffness/decreased range of motion.

Breast – Pt denies lumps or pain.

Pulmonary System – Pt denies SOB, DOE,  cough, wheezing, hemoptysis, cyanosis, orthopnea or PND.

Cardiovascular System –  denies edema, chest pain, palpitations, irregular heartbeat, syncope or known heart murmur.

Gastrointestinal System – Pt is experiencing  RLQ pain x 5 days and one episode of diarrhea yesterday.  Pt denies any nausea/vomiting, intolerance foods and drinks dysphagia, pyrosis, flatulence, eructations, diarrhea, or constipation, hemorrhoids, melena.

Genitourinary System –denies any urinary urgency, urinary frequency and nocturia; denies flank pain, oliguria, polyuria, dysuria, or hesitancy.

Nervous System – denies loss of consciousness, sensory disturbances, ataxia, change in cognition/mental status/memory, weakness.

Musculoskeletal System – no pain,  deformity/swelling, redness, or arthritis.

Peripheral Vascular System –  denies peripheral edema, intermittent claudication, coldness or trophic changes, varicose veins, color change.

Hematologic System –; denies blood transfusions,  anemia, easy bruising or bleeding, lymph node enlargement, or history of DVT/PE.

Endocrine System – denies polyuria/polydipsia/polyphagia, heat or cold intolerance, goiter, excessive sweating, hirsutism.

Psychiatric – denies depression/sadness, anxiety, obsessive/compulsive disorder, seeing a mental health professional, taking psychiatric medications.

 

Physical 

General:  40 y/o obese Hispanic, male,  AO x3 ( person,  place, date) well dressed, and groomed looks his stated age and appears to be in moderate distress.

Vital Signs:

BP:	132/78
Pulse:	92
Resp:	20
Temp:	(!) 102.2 °F (39 °C)** Oral
SpO2:	100%
Weight:	98.9 kg (218 lb)
Height:	1.52 m (4′ 11.84″)

BMI: 44 (obese)

Physical Exam:

Skin:  warm & moist, good turgor. Non-icteric, no lesions noted, no scars,  no tattoos.

Hair: average quantity and distribution.

Nails: no clubbing, capillary refill <2 seconds throughout.

Head: normocephalic, atraumatic, non-tender to palpation throughout.

Eyes: symmetrical OU; no evidence of strabismus, exophthalmos or ptosis; sclera white; conjunctiva & cornea clear.

Visual fields full OU. PERRLA,  EOMs full with no nystagmus. Visual acuity test not performed.

Ears: Symmetrical and normal size. No evidence of lesions/masses/trauma on external ears. no discharge/foreign bodies. TM’s clear, no erythema, or exudates. Auditory acuity intact to whispered voice AU.

Nose:  No discharge noted, no swollen turbinates noted on anterior rhinoscopy. nose Symmetrical, no obvious masses. No evidence of foreign bodies.

Sinuses: Non-tender to  palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.

Oropharynx: no erythema; well hydrated; no evidence of exudate; masses; lesions; foreign bodies. Tonsils present with no evidence of injection or exudate. Uvula pink and midline, no edema, lesions.

Neck: Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to palpation. FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no palpable adenopathy noted.

Thyroid: Non-tender; no palpable masses; no thyromegaly; no bruits noted.

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

Lungs – Lungs are CTA no wheezing/ rhonchi noted.

Heart: Carotid pulses are 2+ bilaterally without bruits. S1 and S2 are normal. There are no murmurs or extra heart sounds.

Abdominal–  soft nondistended with tenderness to deep palpation in RLQ and periumbilical region, non-tender in the LLQ,  no rebound tenderness or guarding noted. BS present in all 4 quadrants. No bruits noted over aortic/renal/iliac/femoral arteries. Tympany to percussion throughout.

No masses noted. No CVAT noted bilaterally.

Rectal (patient refused to have rectal exam performed)

Extremities :

Upper extr: FROM,   5/5 b/l muscle strength, radial pulses 2+ b/l.

Lower extr: FROM ,  5/5 b/l muscle strength,  DP and PT pulses 2+, no edema noted, non-tender on palpation, and no change in color noted.

Nervous system: cranial nerves intact. reflexes are 2+ and symmetric at the biceps, triceps, knees, and ankles. Light touch, pinprick, position sense, and vibration sense are intact in fingers and toes. Rapid alternating movements and fine finger movements are intact. Able to perform finger to nose

Labs:

Lab Results:
138| 101| 13
——————–< 100 Ca: 8.6
3.8| ?? | .97

WBC: 15 (H)/ Hb: 13.8/ Hct: 42.1  / Plt: 294
ALT: 31, AST: 23, Total bilirubin: 1.9

Lipase: 19, Lactate: 0.7, PT: 29.7 INR: 1.05

Imaging: CT pelvis and abdomen

Impression: Perforated sigmoid diverticulitis with phlegmonous changes, focus in the right lower quadrant area adjacent to and abutting a noninflamed appearing appendix.

DDX:

• Diverticulitis
• Cholecystitis
• Acute cholangitis
• Biliary Colic
• Nephrolithiasis

Assessment:

Mr. TR  is a 40  y/o obese Hispanic, male with no PMHx, presents to the ED with RLQ abdominal pain, subjective fevers, x 5 days along with one episode of diarrhea yesterday. His symptoms, labs (wbc 15), vitals (high fever 102.2) and CT imaging results indicate acute diverticulitis with possible phlegmon formation.

Patient wells score for DVT is 2.

PLAN: Uncomplicated diverticulitis micro perforation or phlegmon

– Admit patient to surgery for diverticulitis management

– pain meds (tordal PRN)

– NPO, IVF, advance to clear liquid diet when symptoms resolve

– IV antibiotics — Piperacillin/Tazobactam (Zosyn) 3.375 g IV every 6 hours

– repeat labs in the am

– colonoscopy 6-8 weeks after resolution

 

Patient education:

-You have been diagnosed with diverticulitis, when small pouches form in your colon aka large intestines and become inflamed or infected.

-You will need to get a colonoscopy done 6-8 weeks after the resolution of your symptoms

Diet

Increase fiber; fruits and vegetables are a good source.

Decrease intake of fat and red meat

Do not have to avoid nuts, seeds, or corn

Inability to tolerate fluids

Complications

Watch for any changes in your bowel movements such as constipation to diarrhea, bloody or dark maroon stools

Increase in abdominal pain, distention, or tenderness

Avoid intra-abdominal pressure (may precipitate attacks), straining with stool, vomiting, bending, lifting, and wearing tight restrictive clothing

Monitor for fever >37.8C (100.4F)

Complete all medications as instructed

Increase activity as tolerated

Weight reduction