Guadalupe Romero 

Guadalupe Romero
U9DT1
COLLAPSE
Patient: 70-year-old white female.
History and physical

Chief complaint: abdominal pain in the LRQ

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HPI: the pain as sharp and experiences N & V with pain. She is unrelieved with her PRN medications. She reports the pain is worse after meals.

Past medical history:long history of HTN, DMII, Obesity, and arthritis of the knee

Surgeries: unknown

Medications: unknown

Allergies: NKDA
Review of systems:

HEENT: denies any head trauma,denies any vision problems, denies any denies rhinorrhea, denies epistaxis, denies sore throat, denies any hearing issues

Respiratory: denies any cough, sputum production, SOB, wheezing

Cardiovascular: Denies any chest pain, palpitations, or edema in extremities

GI: N & V with right lower quadrant pain

GU: Denies Pain with urination,denies discharge, denies hematuria, sexually active

Musculoskeletal: arthritis of the knee

Skin: denies any rashes, wounds, sores,

Assessment:

Vital signs:
B/P 150/88, P: 84, R: 23, T: 102, Weight: 186 Height: 5’5”
HEENT head normocephalic, no abnormalities to scalp
Eyes: PERRLA, EOMI CN-intact
Ears: Right normal canals tympanic membrane clear, Left normal canal tympanic membrane clear
Nose: no deviations noted or evidence of epixatis
Throat: tongue midline, normal pharynx, normal voice,
Neck: no thyroid enlargement, no carotid bruits

Chest: normal breath rate, lungs clear in all lobes

Heart:heart rhythm regular, normal heart sounds S1and S2, no murmurs or extra sounds heard no chest rub, capillary refill less than 3 seconds, no edema present
Abdomen:tenderness in right lower quadrant, rebound tenderness

Genitalia/rectum:deferred

Musculoskeletal: intact reflex in all extremities,

Skin:warm, dry, no open ares, rashes,

Diagnosis: Appendicitis

Differential Diagnosis: Peritonitis

Plan: CBC with differential, CT scan, Antibiotic, laparoscopy appendectomy

The patient has the presenting symptoms that would suggest Appendicitis. Appendicitis is the inflammation of the appendix, which can cause the patient to had abdominal pain with the most disteing paing being in the right lower quadrant (Appendicitis – Symptoms and causes, 2018). The patient can present with nausea, vomiting and fever. The diagnostic test that would help diagnose would be CBC with differential, and CT scan to see if appendix is inflamed. The treatment can be antibiotics and appendectomy, to prevent the rupture of the appendix and cause the sepsis. The differential diagnosis can be peritonitis which happens in elderly the perforation of the GI tract (Dains, Baumann, & Scheibel, 2012)

References:
Appendicitis – Symptoms and causes. (2018). Retrieved from https://www.mayoclinic.org/diseases-conditions/appendicitis/symptoms-causes/syc-20369543
Dains, J.E.; Baumann, L. C.; & Scheibel, P. (2012). Advanced health assessment and clinical diagnosis in primary care, 4th ed. St. Louis: Elsevier Mosby.

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