H&P
History
Identifying Data:
Full Name: MY
Address: N/A
Date of Birth: N/A
Date & Time: 05/31/23, 11:00 am
Location: CUC
Religion: N/A
Source of Information: Mother & Self
Reliability: Reliable
Source of Referral: Self
Mode of Transport: N/A
Chief Complaint: “My son has been vomiting and with diarrhea” x 1 day.
8 y/o with no PMH, up to date on immunizations, accompanied by mother, presenting for cough, abdominal pain, and vomiting x 1 day. Pt reports sharp, constant pain that started last night in the epigastric region which then radiated to the suprapubic region. Pain is exacerbated by bowel movements, walking, laying down, getting up from supine position. Rates pain 7/10. Last took Motrin at 7am without any relief. Has also has 3 episodes of non-bilious, non-bloody vomiting and loss of appetite. Last meal was at 7pm last night and has not been able to keep solids or liquids down. Last bowel movement was last night. Denies fever, chills, diarrhea, SOB, chest pain, bloody stools, or recent sick contacts.
Initial DDx:
Appendicitis
Small Bowel Obstruction
Gastroenteritis
Testicular Torsion
Nephrolithiasis
Past Medical History:
Childhood Illnesses- N/A
Immunizations – Up to date; flu vaccine yearly
Screening test and results – N/A
Past Surgical History:
No past surgical history.
Denies any blood transfusions.
Medications:
Not on any medications at this time.
Allergies:
NKDA
Family History:
Mother – 35 y/o, alive and well
Dad – 34 y/o, alive and well
Maternal grandparents – alive and well
Paternal grandparents – alive and well
Denies family h/o cancer, asthma, kidney disease, diabetes.
Social History:
Patient lives with mother and father.
Habits –No history of smoking, alcohol abuse, or history of illicit substances. Denies drinking coffee.
Travel – No recent travel.
Diet – Has a well-balanced diet.
Exercise – Mom states he is pretty active.
Safety measures – Admits to wearing a seatbelt.
Sexual Hx – N/A
Review of Systems:
General – Admits to loss of appetite. Denies recent weight loss or gain, fever or chills, night sweats, 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 or head trauma.
Eyes – Denies discharge. lacrimation, pruritus, visual disturbances. Does not wear glasses.
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.
Pulmonary system –Denies dyspnea on exertion. Denies 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 – Admits to nausea, vomiting, diarrhea, and abdominal pain. Usually has regular bowel movements daily. Denies diarrhea. Denies 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 – N/A
Musculoskeletal system – Denies muscle/joint pain from arthritis. Denies deformity or swelling, or redness.
Nervous – Denies loss of strength or weakness. Denies seizures, headache, ataxia, change in cognition.
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: Male appears clean, casually-groomed, well-developed, well-nourished, and has good posture. Alert. Also appears uncomfortable holding belly due to pain. Able to speak clearly and in full sentences.
Vital Signs: BP: (R) 117/69 (sitting) P: 108 beats/min, regular
(L) 120/65 (sitting)
R: 22 breaths/min, unlabored
O2 Sat: 98 % on room air
T: 36.33 degrees C (oral)
Weight: 74 lbs
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 –No erythema or discharge noted. No induration or pain with EOM. Not warm to touch. No strabismus, exophthalmos, or ptosis. Sclera white, cornea clear, conjunctiva pink. Visual acuity uncorrected – 20/0 OS, 20/20 OD, 20/20 OU. Visual fields full OU. PERRLA, EOMs intact with no nystagmus.
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 and no use of accessory muscles noted. Non-tender to palpation throughout.
Lungs – No wheezing, rales, stridor, or rhonchi. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout.
Cardiac Exam
Heart: PMI in 5th ICS in midclavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular 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, and no scars, striae, or pulsations noted. Pt is tender to palpation RLQ and LLQ, mildly distended, (+) Rovsing, (+) rebound tenderness, (-) guarding. (-) obturators sign, (-) psoas signs, (-) Murphy’s sign. Bowel sounds normoactive in all four quadrants with no aortic/iliac or femoral bruits. No hepatosplenomegaly to palpation, no CVA tenderness appreciated.
Neurologic:
Mental status: Patient is alert. 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: Extremities are normal in color and temperature, no edema. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing or cyanosis. 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.
Assessment:
8 y/o M with no PMH presenting with vomiting and abdominal pain for 1 day. Exam notable for RLQ and LLQ tenderness to palpation, (+) Rovsing, (+) rebound tenderness, and mild distension most consistent with appendicitis.
Differential Diagnosis After:
Appendicitis
ADD MORE DIFFERENTIALS
Plan:
Discussed concern for possible appendicitis. Mother and patient advised to go to the ER emergently for further imaging, testing, and care to rule out possible appendicitis. Transport by ambulance offered but refused by mother as she was going to have her husband drive them to the nearest ER. Emphasized importance of seeking medical attention as the risk of appendiceal rupture is increased after the 1st 24 hrs of symptoms. Mother expressed understanding. Recommend following up with PCP within the next week.
