Toor Noori  

Evaluator Visit H&P

 History

 Identifying Data:

Full Name: Mr. s

Address: Astoria, Queens

Age: 55

Date & Time: 01/23/2019

Location: Statcare Medical Clinic

Religion: christian

Nationality: white

Source of Information: self

Source of Referral: Self

Chief Complaint: “ I have abdominal pain x 2 days.

HPI:

Mr. S, a 55 y/o male, PMHx of  asthma, and diverticulosis, presents to the clinic ℅ a low grade fever, constipation, and lower abdominal pain x 2 days. Pt states the pain started in the afternoon after straining to use the bathroom. Pain is crampy, 5/10, is not aggravated by anything and does not radiate . He states his highest temp was 100.1 taken orally.  Pt states he has had similar episodes in the past and was treated for acute diverticulitis at the time. He explains he passed some very hard dark brown stool x 1 day and has been constipated since then. Pt’s daily diet includes many fiber rich foods, and lots of fluids since his dx. Pt has currently been on a clear liquid diet x 8 hrs. Pt denies any N/V/D, loss of appetite, blood in the stool, flank pain, urinary symptoms, night sweats, weight loss, or back pain.

 

Past Medical History:

Present illnesses –  none

Past medical illnesses – diverticulosis, asthma, hemorrhoids

Hospitalized

Childhood illnesses –  Denies any illnesses.

Immunizations – Up to date on all vaccine; flu vaccine received 12/2018.

Screening tests: none

Past Surgical History: none

Medications:  Albuterol 90 mcg as needed (Asthma has been well controlled for over 4 months)

 Allergies:   Denies drug, environmental or food allergies.

 Family History:

Paternal Grandfather –   deceased cause and age unknown

Paternal Grandmother –  deceased cause and age unknown

Maternal Grandfather –don’t know

Maternal Grandmother – don’t know

Father –  alive and well

Mother –  alive and well

Sister–   alive and well

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

 Social Hx: Pt is a 55 year old gym teacher, who lives with his girlfriend of 5 years. Pt rides his bike to work and back everyday ( 2 mile distance). Pt has been on a fiber rich diet since his dx of diverticulosis.

Travel – denies any recent travel.

Safety measures – admits to wearing a seat belt.

ROS:

General –  Pt has had low grade fever x 2 days. Denies recent weight loss or gain, loss of appetite, generalized weakness/fatigue, chills, 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 – denies headaches, vertigo, head trauma.

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

Ears – Pt states has pain and pressure in the right ear. denies any discharge, tinnitus, deafness or use of hearing aids.

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

Mouth and throat – Denies bleeding gums, sore throat or tongue, mouth ulcers, or voice changes. Last dental exam was 6 months ago.

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

Breast – denies lumps or pain.

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

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

Gastrointestinal System – Pt ℅ abdominal pain and constipation x 2 days. denies change in appetite, intolerance to specific foods, vomiting, dysphagia, pyrosis, flatulence, eructations, diarrhea, change in bowel habit, hemorrhoids, melena.

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

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

Musculoskeletal System – denies any pain,  deformity/swelling, redness, or arthritis.

Peripheral Vascular System – denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, 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: 55 y/o male, AO x3 appears to be in no apparent distress. Patient is well developed, and well groomed. He looks his stated age.

Vital Signs: add

BP: Seated   128/80

Supine     not taken

RR: 18 breaths/min, unlabored

HR: 90 beats/min, regular

Temp: 99.8T (oral)

O2 Sat: 98%, room air

Height: 68 inches

Weight: 156 lbs

BMI: 23.7

Skin: warm & moist, good turgor. Nonicteric, no lesions noted, no scars, 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.

Mild cerumen impaction in external auditory canals AU; no discharge/foreign bodies. TM’s pearly grey without erythema, or exudates. Auditory acuity intact to whispered voice AU.

Nose: Symmetrical, no obvious masses/lesions/deformities/trauma/deviated septum . Nares patent bilaterally/Nasal mucosa pink & well hydrated. No discharge or swollen turbinates noted on anterior rhinoscopy lesions/deformities/injection/perforation. No evidence of foreign bodies.

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

Lips: Pink, dry and cracked; no evidence of cyanosis or lesions. Non-tender to palpation.

Mucosa: Pink; well hydrated. No masses; lesions noted. Non-tender to palpation. No evidence of leukoplakia.

Palate: Pink; well hydrated. Palate intact with no lesions; masses; scars. Non-tender to palpation.

Teeth: Good dentition, no obvious dental caries noted.

Gingivae: Pink; moist. No evidence of hyperplasia; masses; lesions; erythema or discharge. Non-tender to palpation.

Tongue: Pink; well papillated; no masses, lesions or deviation noted. Non-tender to palpation.

Oropharynx: Mildly Injected oropharynx; 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 paradoxic respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non-tender to palpation.

Lungs – Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. No adventitious sounds.

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

Abdominal-  Flat / 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. Tender to deep palpation in  left  lower quadrant.  Neg rovsings, or  psoas sign, no rebound tenderness No evidence of organomegaly. No masses noted.  Mild  guarding,  No CVAT noted bilaterally.

 Assessment: Mr. S, a 55 y/o male, PMHx of diverticulosis, presents to the clinic ℅ a low grade fever, constipation, and lower abdominal pain x 2 days. Pt hx and clinical presentation are indicative of diverticulitis, however other dx should be ruled out to have a more confident dx.

Plan:

Labs:

Urinalysis in-house- WNL ( looking for signs of infection)

Imaging: Ultrasound-  pending ( not required for outpatient dx but is a great cheaper tool for  quick confirmation while reducing pt exposure to radiation – if neg will order CT)

Medications: Tx due to clinical presentation: Ciprofloxacin (500 mg every 12 hours) plus metronidazole (500 mg every 8 hours)

Diet: Clear liquid diet until follow up in 2-3 days ( if no improvement then may need inpatient treatment)

Sitz bath to help with constipation and hemorrhoids.

Differentials:

diverticulitis- most likely

cystitis- no urinary symptoms so less likely

appendicitis-  Abdominal pain and low grade fever, no psoas sign, rovsigns sign, rebound tenderness , N/V or anorexia.

IBS- symptoms have been going on only for 2 days and the pts PMHx points toward diverticulitis.

nephrolithiasis – abdominal pain and low grade fever but no blood in the urine, no leukocytes, no urinary symptoms

 Educate the patient on the following

Diet: clear liquid diet until F/U in 2-3 days by this time symptoms should have resolved

What to do if Symptoms do not resolve: If persistent abdominal pain, fever, or inability to tolerate oral fluids despite two to three days of outpatient antibiotic therapy you should be admitted for inpatient treatment.

Can provide them with this when discharged:

Patient education: Patient education: Diverticulitis (The Basics)

 What is diverticulitis? — Diverticulitis is a disorder that can cause belly pain, fever, and problems with bowel movements.

The food we eat travels from the stomach through a long tube called the intestine. The last part of that tube is the colon . The colon sometimes has small pouches in its walls. These pouches are called “diverticula.” Many people who have these pouches have no symptoms. Diverticulitis happens when these pouches develop a small tear also known as a “microperforation,” which then become infected and cause symptoms.

What are the symptoms of diverticulitis? — The most common symptom of diverticulitis is pain, which is usually in the lower part of the belly. Other symptoms can include:

• Fever
• Constipation
• Diarrhea
• Nausea and vomiting

Is there a test for diverticulitis? — Yes. There are a few tests your doctor or nurse can do to find out if you have diverticulitis. But tests are not always needed. Your doctor or nurse might be able to diagnose you without them. If you do have a test, you might have a:

• CT scan – A CT scan is a kind of imaging test. Imaging tests create pictures of the inside of your body.
• Abdominal ultrasound – This test uses sound waves to create pictures of your intestines.

How is diverticulitis treated? — That depends on how bad your symptoms are. If you have mild symptoms, your doctor or nurse will put you on antibiotics and might put you on a clear liquid diet for a short time. That might be all the treatment you need.

But if you have severe symptoms, or if you get a fever, you might need to stay in the hospital. There, you can get fluids and antibiotics through a thin tube that goes into your vein, called an “IV.” That way you can stop eating and drinking until you get better.

If you have a serious infection, the doctor might put a tube into your belly to drain the infection. In very bad cases, people need surgery to remove the part of the colon that is affected.

A few months after your infection has been treated, your doctor might recommend that you have a procedure called a colonoscopy. During a colonoscopy, the doctor can look directly inside your colon to get an idea of the number of diverticula in your colon and to find out where they are. At the same time, he or she can check for signs of cancer.

Diet: include a lot of fiber. Good sources of fiber include fruits, oats, beans, peas, and green leafy vegetables. If you do not already eat fiber-rich foods, wait until after your symptoms get better to start.

You do not need to avoid seeds, nuts, popcorn, or other similar foods.