CASE 1-3A Initial Hospital Service

The patient in Cases 1-1 and 1-2 is again admitted, at a later time, to the hospital, this time for abdominal pain.

LOCATION: Inpatient, Hospital

PATIENT: Sally Jacobson

ATTENDING PHYSICIAN: Leslie Alanda, MD

CHIEF COMPLAINT: Abdominal pain for 48 hours.

HISTORY OF PRESENT ILLNESS: This is a 17-year-old female who presents with a 24- to 48-hour history of right lower-quadrant abdominal pain. The patient has a history of diabetes mellitus. The patient states that nothing has made it better and nothing has made the pain any more tolerable. She states that the pain is becoming gradually worse. She states she has taken Advil to no avail. The patient does have positive nausea with no vomiting. No diarrhea and no constipation. No dysuria. The patient states that she has eaten very little today because of the pain and is not hungry at this time.

PAST MEDICAL HISTORY:

1. Diabetes mellitus. 2. Sinusitis. 3. Asthma. MEDICATIONS:

1. Humalog 7 units in the morning, noon, and q.h.s. (each bedtime). 2. Ultralente 14 units q.a.m. (every morning) and 14 units q.p.m. (every afternoon or evening). 3. Elavil 100 mg (milligram) p.o. (by mouth) q.h.s. ALLERGIES: None.

SOCIAL HISTORY: The patient now states that she has drunk in the past. She does smoke three to five cigarettes daily. She is otherwise a normal, healthy senior high school student.

FAMILY HISTORY: Neither of her parents has diabetes mellitus; however, there is a history of diabetes in that her two brothers have it and that a cousin and uncle have it. There is also a history of CVAs (stroke/cardiovascular accident), myocardial infarctions, and cancer.

REVIEW OF SYSTEMS: General: The patient states she has been in good health other than the right abdominal pain.

HEENT (head, ears, eyes, nose, throat): The patient denies any headache, diplopia, blurred vision, eye pain, redness, cataracts, glaucoma, loss of vision, hearing loss, tinnitus, or epistaxis. Cardiovascular: The patient denies any chest pain, chest pressure, orthopnea, or PND (paroxysmal nocturnal dyspnea). Respiratory: The patient denies any coughing, wheezing, and hemoptysis. She does complain of the history of asthma as stated in the past medical history. She does not take medications for that. GI (gastrointestinal): The patient complains of right lower-quadrant pain and nausea but denies vomiting, constipation, or diarrhea. GU (genitourinary): The patient denies dysuria, hematuria, nocturia, or changes in frequency. Extremities: The patient has a good range of motion and states that she has no complications of gait. Neurologic: The patient denies any paresthesias or paralysis complications. Psychiatric: She denies any agitation, increased depression, or personality disorders.

PHYSICAL EXAMINATION: Vitals: Blood pressure 123/67, pulse 115, respirations 20, and temperature 35.0 C. HEENT: Head is normocephalic with no contusion or abrasions. Eyes: EOMS (extraocular movements) are intact. Ears: Tympanic membranes are visualized with no erythema. Nose: Nares are patent. Mucosa pink and moist. Throat: Mucosa pink and moist. Tongue and uvula midline. Cardiovascular: S1 (first heart sound) and S2 (second heart sound) with a regular rate and rhythm. No murmurs are audible. No bruits evident on examination. Respiratory: Lungs are clear to auscultation bilaterally. No wheezing or rhonchi. Abdomen: There are positive bowel sounds. There is right lower-quadrant pain, which she rates 8/10. There is also positive Rovsing's sign and negative rebound tenderness. There are no masses palpable on examination. Extremities: The patient has good range of motion and peripheral pulses are intact.

LABORATORY: White cell count of 5.46, with a hemoglobin of 14.0 and a hematocrit of 40.9.

ASSESSMENT:

1. Rule out appendicitis. 2. Diabetes mellitus, type 1. 3. Sinusitis, acute. 4. Asthma. PLAN: Admit the patient to the hospital. The patient will be n.p.o. (nothing by mouth). Will get her vitals q.4h. (every 4 hours). Will start IV (intravenous) fluids of D5 (dextrose 5% water) LR 125 cc (cubic centimeters) per hour. Will give Accu-Cheks q.i.d. (four times a day). Will get a CBC (complete blood count) and basic metabolic panel in the morning. We will continue the patient on her regular insulin regimen. We will also give her Demerol for pain, and we will re-evaluate in the morning. We will hold the Demerol at 4 AM so that our evaluation in the morning is adequate.

SERVICE CODE(S): ______________________________________

ICD-10-CM DX CODE(S): __________________________________