H&P

History

Identifying Data:

Full Name: Z.Z

Address: N/A

Date of Birth: N/A

Date & Time: 10/13/2011, 10:00 pm

Location: NYPQ

Religion: N/A

Source of Information: Self

Reliability: Reliable

Source of Referral: Self

Mode of Transport: N/A

Chief Complaint: “I’ve been having really bad stomach pain and I threw up at 3am.”

History of Present Illness:

11 year old female with PMH of exploratory laparotomy for Meckel’s diverticulum and volvulus with a small bowel resection in Sept 2022 presenting today for abdominal pain and vomiting since 3am. Patient notes she has had about 7 episodes of non-bilious/non-bloody vomiting. Pt states pain started in the periumbilical region and moved down to bilateral lower quadrants, but worse on her right side. Pt had not taken anything for the pain and rates pain 8/10. Last bowel movement was Friday (one night ago) and denies any bloody stool. Denies any fever, cough, sore throat, ear pain, diarrhea. 

Initial DDx:

• Appendicitis
• Small bowel obstruction
• Ovarian torsion
• Gastroenteritis

Past Medical History:

Meckle’s diverticulum

Small bowel obstruction

Childhood Illnesses- N/A

Immunizations – Up to date; flu vaccine yearly, COVID vaccine (most recent 2022)

Screening test and results – N/A

Past Surgical History:

Exploratory laparotomy for Meckel’s diverticulum and volvulus with small bowel resection Sept 2022

Denies any blood transfusions.

Medications:

Not on any medications.

Denies use of herbal supplements.

Allergies:

NKDA

Family History:

Mother – Alive and well

Dad – Alive and well

Children – Alive and well

Maternal/paternal grandparents – Alive and well

Family history of cancer. Denies family h/o diabetes and myocardial infarctions.

Social History:

Miss Z.Z is in middle school and lives with her parents.

Habits – Denies tobacco use. No history of alcohol abuse, denies history of illicit substances. Denies drinking coffee.

Travel – No recent travel.

Diet – She states she has a well-balanced diet.

Exercise – Exercises during gym class.

Safety measures – Admits to wearing a seatbelt.

Sexual Hx – Pt is heterosexual.

Denies history of sexually transmitted diseases.

Review of Systems:

General –Denies recent weight loss or gain, fever or chills, night sweats, loss of appetite, or generalized weakness/fatigue.

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

Head – Denies headache, vertigo, or head trauma. 

Eyes – Denies lacrimation, pruritus, visual disturbances. Does not wear glasses. Does not recall when her last eye exam was or what his visual acuity or pressure is.

Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids. 

Nose/sinuses – Denies discharge, epistaxis, or nasal polyps.

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion 

Breast – Denies lumps, nipple discharge, or pain. 

Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes or use dentures. Does not recall when last dental exam was.

Pulmonary system – Denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND). 

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

Gastrointestinal system – Usually has regular bowel movements daily. Denies nausea, diarrhea and abdominal pain. Denies change in appetite, vomiting, intolerance to specific foods, dysphagia, pyrosis, unusual flatulence or eructations, jaundice, hemorrhoids, or constipation. 

Genitourinary system – Denies dysuria and blood in urine. Denies nocturia, urinary frequency, urgency, oliguria, polyuria, incontinence, or flank pain. 

Menstrual/Obstetrical – Has not had menarche.

Musculoskeletal system – Denies muscle/joint pain from rheumatoid arthritis. Denies deformity or swelling, or redness.

Nervous –Denies seizures, headache, ataxia, loss of strength, change in cognition / mental status / memory, or weakness. 

Peripheral vascular system – Denies peripheral edema, intermittent claudication, coldness or trophic changes, varicose veins, or color changes. 

Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, or history of DVT/PE. Denies blood transfusion.

Endocrine system – Denies polyuria, 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: Female appears clean & well-groomed, alert & oriented to time, place, and person. Also has good posture and seems like a reliable source of information. Pt appears to be in pain and guarding. Pt appears as stated age.

Vital Signs:     BP: (R) Seated 128/80                        P:  89 beats/min, regular

                               (L) Seated 125/80

                        R: 16 breaths/min, unlabored             O2 Sat: 98% Room Air

                        T: 36.8 degrees C (oral)

                        Height: 59 inches        Weight: 94.16 lbs       BMI: 19

Head, Skin, & Nails

Hair: Average quantity and distribution. Black color. Straight texture. No evidence of lice or seborrheic dermatitis.

Skin: Warm and moist, smooth texture, good turgor. 

Nails: No clubbing, capillary refill <2 seconds in upper and lower extremities

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

Eye Exam

Eyes – Symmetrical OU. No strabismus, exophthalmos or ptosis.  Sclera white, cornea clear, conjunctiva pink. Visual acuity uncorrected – 20/20 OS, 20/20 OD,  20/20 OU. Visual fields full OU.  PERRLA, EOMs intact with no nystagmus.

Fundoscopy – Red reflex intact OU. Cup to disk ratio< 0.5 OU.  No AV nicking, hemorrhages, exudates or neovascularization OU.

Ear Exam

Symmetrical and appropriate in size. No lesions/masses/trauma on external ears. No discharge/foreign bodies in external auditory canals AU. TM’s pearly white/infarct with light reflex in good position AU. Auditory acuity intact to whispered voice AU. Weber midlines/Rhinne reveals AC>BC AU.

Nose & Sinuses Exam

Nose – Symmetrical/no masses/lesions/deformities/trauma/discharge. Nares patent bilaterally/nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions/deformities/injection/perforation. No foreign bodies.

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

Mouth & Pharynx

Lips –   Pink, moist; no cyanosis or lesions. Non-tender to palpation.

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

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

            Palpation; continuity intact. 

Teeth – Good dentition / no obvious dental caries noted. 

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

Tongue – Pink; well papillated; no masses, lesions or deviation. Non-tender to palpation.
Oropharynx – Well hydrated; no injection; exudate; masses; lesions; foreign bodies. 

Tonsils present with no injection or exudate. Uvula pink, no edema, lesions

Neck Exam

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 cervical adenopathy noted.

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

Thorax & Lungs:

Chest – Symmetrical, no deformities, no trauma, Respirations unlabored/no paradoxic respirations or use of accessory muscles noted. Lat to Ap diameter 2:1. Non-tender to palpation throughout.

Lungs –Clear to percussion & auscultation bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout.

Cardiac Exam

Heart: JVP is 2.5cm above sternal angle with the head of the bed at 30 degrees. PMI in 5^th ICS in midclavicular line.Carotid pulses are 2+ bilaterally without bruits. Irregular rate & rhythm. S1 & S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. 

Abdominal Exam: Abdomen flat and symmetric with 3-inch vertical surgical scar extending from below the umbilicus, but no striae, or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/iliac or femoral bruits. Pt is tender to palpation in periumbilical region and bilateral lower quadrants and guarding. (-) obturators sign, (+) psoas signs, (+) rebound tenderness. No hepatosplenomegaly to palpation, no CVA tenderness appreciated.

Breast Exam: Breast symmetric and smooth without masses. Nipples without discharge. 

Pelvic Exam:

Genitalia: External genitalia without erythema or lesions. Vaginal mucosa pink without inflammation, erythema or discharge. Cervix parous, pink, and without lesions or discharge. No cervical motion tenderness. Uterus anterior, midline, smooth, non-tender and not enlarged. No adnexal tenderness or masses noted. No inguinal adenopathy.

Rectal: Rectovaginal wall intact. No external hemorrhoids, skin tags, ulcers, sinus tracts, anal fissures, inflammation or excoriations. Good anal sphincter tone. No masses or tenderness. Trace brown stool present in vault. 

Neurologic: Mental status: Patient is alert and oriented to person, place and time. Cranial nerves II-XII intact. Recent and remote memory is intact, attention, abstract thinking, and new learning ability are intact. Pt has good muscle bulk and tone with strength 5/5, no fasciculations. Cerebellar: Rapid alternative movements, finger to nose intact. Gait including normal stride, on toes, on heels, and tandem walking intact. Negative Romberg and Pronator Drift. Sensory: Pinprick, light touch, graphesthesia, stereognosis, position and vibration intact bilaterally. 

Reflexes:

	Biceps	Triceps	Brachioradialis	Patellar	Ankle/Achilles	Babinski
Right	2+	2+	2+	2+	2+	absent
Left	2+	2+	2+	2+	2+	absent

Peripheral Vascular: The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis or edema noted bilaterally. No stasis changes or ulcerations noted.

Musculoskeletal (Upper Extremity): No soft tissue swelling / erythema /

ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM of all upper and lower extremities bilaterally.  No evidence of spinal deformities.

DDx after H&P:

• Small Bowel obstruction
• Appendicitis

Labs:

• BMP – unremarkable
• CBC – unremarkable
• UA – (+) ketones
• Lactate – unremarkable
• CRP – unremarkable
• Hepatic Panel – unremarkable
• Lipase & Amylase – unremarkable
• Type & Screen
• Coags
• RPR – unremarkable

Imaging:

• US (abdominal & pelvic ) – unremarkable
• CT – small bowel obstruction in lower abdomen within the midline. Findings were suspicious for closed loop and small amount of abdominal and pelvic ascites.

Assessment: 11 y/o female w/ PMH exploratory laparotomy for Meckel’s diverticulum and volvulus with small bowel resection in Sept 2022 presenting today for abdominal pain and vomiting since 3am most likely due to appendicitis or small bowel obstruction given prior surgical history. Unlikely to be ovarian pathology. Will order CBC, BMP, UA, lactate, CRP, hepatical panel, lipase and amylase, Type and screen, Coags and a viral panel. Will place IV and begin fluids and mediation for pain. Will obtain US, but will likely require a CT with IV contrast.

Plan: Based on patient’s persistent pain, surgical history, and CT imaging results, will consult surgery for further evaluation. Will start pt on famotidine 20mg IV, Ketorolac 15mg IV, Ondansetron 4mg IV, NaCl 20 mL/kg IV, and Lactated Ringers 20 mL/kg IV. Discussed findings, diagnosis and treatment plan with patient and patient’s mother. Pt and mother understand and agree to move forward with plan. Will re-evaluate patient’s disposition based on surgical consult, but will most likely need to be transferred as there is no pediatric surgical service at this facility.