Retype the following data into correct H&P form. The
patient is J. J. “Kip” Siegler. The physician is Felix Rios, MD.
Use today's date and the format of your choice. Please indicate
which format you have selected for your assignment by writing the
name of the format on the top of your page.
The chief complaint is right-sided, abdominal pain, eight
hours duration. The present illness is as follows: this is the
first Brookside Hospital admission for this twenty-four year old
unemployed carpenter who was in his usual state of excellent health
until approximately eight hours prior to admission when he
developed some high, transverse midepigastric abdominal pain
following completion of a Chinese meal. The pain became
progressively more intense and gradually, over the following four
hours, localized in the right lower quadrant. One hour prior to
admission, while preparing to come to the hospital, the patient had
one episode of emesis. The patient denies any subsequent nausea and
diarrhea but has been “constipated” for the past two days. The past
medical history: Serious injuries: None. Surgery: None. Illnesses:
None. Allergies: Assorted pollens, undetermined. Medications: None.
Smoke: None. Alcohol: Very infrequently. Immunizations: None in the
past four years. The father is deceased, age twenty-one, apparent
suicide. The mother is living and well, age forty-one. One sister,
age twenty-two, living and well. The patient is married and has one
child and has been unemployed for the past six months. He spends
most of his time refurbishing an old sailboat. Systemic review is
unremarkable. On physical examination there is an alert, oriented
Caucasian male in very mild abdominal distress, lying supine with
his right hip flexed. His temperature is one hundred one point two
degrees, pulse is eighty eight, respirations twenty, blood pressure
is one hundred thirty over seventy eight. The skin is warm and
moist without pallor, icterus, or cyanosis. There are no acute
lesions or petechiae. Tympanic membranes are clear. Pupils are
equal and reactive to light. Conjunctivae are mildly injected.
Nares, likewise mildly injected. Pharynx and mouth, likewise, very
minimally injected, without evidence of purulent debris. The neck
is supple, without cervical adenopathy. The lungs are clear to
auscultation and percussion. The heart rhythm is regular without
murmurs or enlargement. The abdomen is somewhat protuberant with
absent bowel sounds, with moderate tenderness and guarding in the
right lower quadrant without rebound. There is also very mild
tenderness in the right “See vee a” area. There are no apparent
herniae determined in the supine position. Rectal: Prostate is
normal. There is moderate to exquisite tenderness in the right
quadrant. Stool is brown, and HemeSelect is negative. Genitalia:
Patient is circumcised. Testicles are bilaterally descended, appear
normal in size and shape. Extremities: No deformities or edema.
Neurologic: Deep tendon reflexes are two plus bilaterally.
Diagnosis: Acute appendicitis.