HISTORY AND PHYSICAL EXAMINATION
CHIEF COMPLAINT
Abdominal pain and vomiting.
PRESENT ILLNESS
This 10-year-old male has been complaining of a mild stomach pain off and on for 4 to 5 days. This pain initially began more in the epigastrium, according to his mother, but it was not unlike the “hunger pains” that he often complains of and did not interfere with his daily activities or with eating, playing, and going to school. Today, however, the pain has definitely become much worse and has shifted to the right lower quadrant and has been accompanied by vomiting. Patient has been vomiting everything he has been taking down all day long, including even sucking on ice chips. There has been no diarrhea, no upper respiratory symptoms, and no significant fever.
PAST HISTORY
Hospitalizations none. Surgery none. Serious medical illnesses reveal patient has had asthma, basically exercise-induced asthma, since age 2. For this he uses a Proventil inhaler p.r.n. and requires this perhaps once daily. Other current medications are none.
ALLERGIES
There are no known allergies to foods or medications. Patient may have allergies to pollens and dust.
FAMILY HISTORY
Mother and father are in excellent health as are the 2 older daughters (patient’s sisters). Maternal uncle and several other family members have had appendicitis. Paternal grandparents are diabetic, but neither the father nor his siblings have diabetes.
REVIEW OF SYSTEMS
Review of systems is unremarkable.
PHYSICAL EXAMINATION
GENERAL: Patient is an acutely ill-appearing 10-year-old boy who was lying on his back with his knees drawn up. He appears pale and ill.
VITAL SIGNS: Temperature is 99.6, pulse 90, respirations 20. Weight is 82 pounds.
HEENT: Head: Head is normocephalic. Eyes: Pupils equal, round, responding to light. Ears: Tympanic membranes are clear.
TEETH: Teeth are in good repair. Throat: Pharynx is clear.
NECK: Supple. No masses, no adenopathy.
LUNGS: Lungs are clear on auscultation.
HEART: Heart is normal size. Rate and rhythm are regular. No murmurs heard.
ABDOMEN: Abdomen is flat. The bowel sounds are hypoactive, in fact, virtually absent. There is right lower quadrant tenderness which is most acute over McBurney point. There is some rebound and some superficial tenderness to light palpation. I do not detect any referred tenderness.
GENITALIA: Normal male. No hernias.
RECTAL: Normal anus and rectum. There is no increase in abdominal pain with rectal examination.
EXTREMITIES: The extremities appear normal.
LABORATORY
CBC: Only partial results are available, but total white count is 17,500. On KUB x-ray there is a possibility of a fecalith seen.
IMPRESSION
Acute appendicitis.
FOOTNOTE
Line 12 (Page 1). Alternative: 4-5.
Lines 44 (Page 1)-17 (Page 2). Some subheadings were added.
Line 47 (Page 1). Temp was expanded to temperature.
Line 19 (Page 2). The heading Laboratory was added for clarity.
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