H&P #1

Identifying data:

  • Date & Time: 1/12/23 5:30 pm
  • Full name: Ms. T. I.
  • Address: Queens, NY
  • Date of birth: June 26, 1981
  • Location: Centers Urgent Care, Middle Village
  • Religion: Christian
  • Marital status: Single
  • Source of information: Self
  • Reliability: Reliable
  • Source of referral: Self
  • Mode of transport: Self via car

 

Chief Complaint: “Abdominal pain on my lower right side” x 7 days

History of Present Illness:

41 y/o F with no significant past medical history c/o RLQ abdominal pain x 7 days. States pain began as sharp but over last 3 days has become a moderate intermittent colicky pain. Reports that pain does not radiate anywhere. States pain has been improving over past 3 days. Patient states she typically drinks plenty of water but recently has not been drinking as much. Reports that pain worsens at night. Admits to slight pressure with urination. States she has not noticed blood in urine. Denies trauma, history of kidney stones, history of ovarian cysts, history of STDs. Denies fever, chills, nausea, vomiting, diarrhea, flank pain, vaginal discharge, dysuria, urinary frequency, urinary urgency.

Last menstrual period (LMP): 12/26/22 – 12/30/22; states she is not currently on period. Patient is currently sexually active, admits to condom use.

Last bowel movement: yesterday; normal.

No OTC pain medication use.

 

Past Medical History:

  • No past medical history

Past Surgical History:

  • No past surgical history

Medications:

  • No medications
  • No herbal supplement use

Allergies:

  • No known drug allergies
  • No known food or environmental allergies

Family History:

  • Mother: alive and well, PMH HTN
  • Father: alive and well, no significant PMHx
  • Maternal grandparents: unknown
  • Paternal grandparents: unknown

Social History:

  • Smoking: non-smoker
  • Substance use: denies alcohol or drug use
  • Caffeine: 1 cup per day
  • Occupational history: sales associate
  • Home situation: lives at home with boyfriend
  • Exercise: attends weekly yoga classes

 

Review of Systems:

  • General: denies generalized weakness/fatigue, fever, chills, night sweats, weight loss or gain, changes in appetite.
  • Skin, hair, nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution.
  • Head: Denies head trauma, vertigo.
  • Ears: Denies deafness, ear pain, discharge, tinnitus, hearing aid use.
  • Nose: Denies discharge, obstruction, epistaxis.
  • Mouth/throat: Denies voice changes, bleeding gums, sore tongue, sore throat, mouth ulcers, dentures use.
  • Neck: Denies localized swelling/lumps, stiffness/decreased ROM
  • Breast: Denies lumps, nipple discharge, pain.
  • Pulmonary: Denies dyspnea, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, cough, wheezing, cyanosis, hemoptysis.
  • Cardiovascular: Denies to edema/swelling of ankles or feet, hx of HTN, chest pain, palpitations, irregular heartbeat, syncope, known heart murmur.
  • Gastrointestinal: Admits to abdominal pain. Has regular bowel movements daily. Denies change in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructations, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.
  • Genitourinary: Denies urinary frequency, urinary urgency, nocturia, oliguria, polyuria, dysuria, incontinence, flank pain, hematuria, history of hernias.
  • Menstrual/Obstetrical: G0, P(T0 P0 A0 L0), menarche age 15, LMP 12/26/22, regular menstrual cycles every 28-30 days. Denies hot flashes, vaginal discharge.
  • Sexual History: Admits to being sexually active with males. Contraceptive use with condoms. Denies history of STIs.
  • Musculoskeletal: Denies arthritis, muscle pain, deformity or swelling, redness.
  • Nervous system: Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory.
  • Peripheral vascular: Denies intermittent claudication, varicose veins, coldness or trophic changes, color changes, peripheral edema.
  • Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, history of DVT/PE.
  • Endocrine: Denies polydipsia, polyphagia, heat or cold intolerance, excessive sweating, goiter, hirsutism.
  • Psychiatric: Denies depression/sadness, anxiety, OCD, or ever seeing a mental health professional.

 

Physical Exam:

Vitals:

  • BP: 124/83 (seated, left arm)
  • HR: 77 BPM (regular)
  • RR: 18/min (unlabored)
  • T: 97.8 F (oral)
  • O2: 98% (room air)
  • Height: 64in
  • Weight: 120 lbs
  • BMI: 20.6

General: AAO x 3, appears in no acute distress, well groomed, appears stated age

Skin: Warm & moist; good turgor; non-icteric; no rashes or lesions noted

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

Eyes: PERRLA. Visual fields full OU. EOM intact, no nystagmus. Sclera white, cornea clear, conjunctiva pink.

Ears: Symmetrical and appropriate in size. TM pearly grey and intact with light reflect in good position AU. No tenderness, discharge or foreign bodies.

Nose: Symmetrical. Nares patent bilaterally, nasal mucosa pink and well hydrated.

Sinus: Non-tender to palpation.

Mouth/Pharynx: Mucosa pink and well hydrated. Pharynx non-erythematous. No exudates or lesions visualized. Uvula midline.

Neck: Trachea midline. Supple and non-tender to palpation. No cervical adenopathy noted.

Cardiac: Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmur.

Chest: Symmetrical, no deformities. Respirations unlabored, no accessory muscle use.

Lungs: Clear to auscultation bilaterally.

Abdomen: RLQ tenderness to palpation. Abdomen flat and symmetric, no scars, striae or pulsations noted. Bowel sounds normoactive in all four quadrants. Tympanic throughout, no guarding or rebound noted. Negative CVA tenderness. Negative McBurney, Rovsing, Obturator, Psoas signs.

Nervous system: Cranial nerves I-XII intact.

Peripheral vascular: Pulses 2+ bilaterally in upper and lower extremities. No clubbing, cyanosis or edema noted.

Musculoskeletal: FROM (full range of motion) of all upper and lower extremities bilaterally. Non tender to palpation.

 

Initial Differential Diagnosis Based of Chief Complaint:

  1. Appendicitis
  2. Ectopic Pregnancy
  3. UTI
  4. Gastroenteritis
  5. Ovarian Cyst
  6. PID or TOA
  7. Nephrolithiasis
  8. Pyelonephritis

 

Workup:

  • Urinalysis
    • Leukocyte esterase (-)
    • Nitrites (-)
    • Urobilinogen (-)
    • Protein (-)
    • pH (6.0)
    • Blood (2+)
    • Specific gravity (1.010)
    • Ketones (-)
    • Bilirubin (-)
    • Glucose (-)
  • Urine HCG pregnancy: negative

 

Adjusted Differential:

  1. Nephrolithiasis
  2. PID or TOA
  3. Ovarian cyst

 

Diagnosis: Nephrolithiasis

 

Assessment: 41 y/o F with no significant PMHx presents with RLQ pain x 7 days. Pain is intermittent and colicky. Patient has not been consuming adequate amounts of water recently. Patient is afebrile and non-toxic appearing. On physical exam, she has normal bowel sounds, RLQ tenderness present, no guarding, no rebound, negative McBurney, Rovsing, Psoas and Obturator. Urine HCG is negative. Urinalysis reveals 2+ blood; patient not currently on menstrual cycle.

 

Plan:

  • Hydration: Patient advised to drink plenty of fluids at home
  • Pain: Ibuprofen 600 mg q6h PRN
  • Patient education: Patient informed that most stones pass on their own with adequate hydration.
  • ER precautions: Patient should go to ER if develops fever, chills, vomiting, worsening or intolerable abdominal pain, foul smelling urine, inability to urinate for 8+ hours, dizziness. Patient expressed understanding.
  • Follow up: with PCP for preventative measures