N380

GI/GU History and Exam

IDENTIFYING INFORMATION
Patient H. E. Age 36 Gender male
SUBJECTIVE
Chief Complaint (CC): Why is patient here today?

History of Present Illness (HPI):

Three days ago, the patient started describing the discomfort in their lower abdomen as
cramps. The lower abdomen is the exact location of the discomfort, which is described as being
quite severe—an 8 out of 10 grades for severity. It's interesting to note that there are no
obvious causes of the discomfort. Furthermore, the patient has not mentioned feeling
discomfort in any other bodily area. They've tried taking Tylenol to ease the pain, but nothing
seems to be working to better their situation. This patient's presentation of severe, ongoing
lower abdomen discomfort that is not alleviated by over-the-counter painkillers calls for
further testing and assessment by a medical specialist in order to identify the underlying cause
and the best course of action.

Past Medical History Yes No None Comments the patient hasn’t given it
PMH: Normal
No
HTN Normal
No
DM Normal
No
Heart disease Normal
No
Kidney stones Normal
No
UTI Normal
No
Gall stones Normal
No
Ulcers Normal
No
Anorexia Normal
No
Appendicitis Normal
No
Diverticulitis Normal
No
Irritable bowel syndrome Normal
No
Colon cancer Normal
No
Blood transfusions Normal
No
Hepatitis Normal
No
Abdominal surgery Normal
No
Normal
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GI/GU History and Exam
FH: No Normal
Crohn’s disease No Normal
Colitis No Normal
Kidney disease No Normal
DM No Normal
HTN No Normal
Heart disease No Normal
Colon or stomach cancer No Normal

Social History: yes He is single and has no marital responsibilities. He

Diet (24 hour recall) enjoys drinking wine, dipping tobacco, and smoking.
He makes bad nutritional choices, often indulging in
fast food in between preparing his own meals. All
things considered, his personal habits and way of
living point toward a lack of emphasis on social
relationships and health.
Smoking yes He smokes tobacco
Alcohol yes Drinks wine
Recreational drug use no Not stated
Exercise No Not stated
Work environment no Not provided
Living arrangement yes Not social. He is still single and does not know
anything about history. Among his vices include
drinking, dipping tobacco, and smoking. Although
he cooks for himself, he usually orders takeout.
Recent travel No Not provided
Allergies: seasonal, no None
environmental, food and
medications

Medications No none

Immunizations yes As child and Covid 19

Last Examination No He states none

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GI/GU History and Exam
Last colonoscopy No
REVIEW OF SYSTEMS Yes No Comments (OLDCARTS)
Pain yes A year's worth of lower abdomen ache that has
become worse during the last three days
Nausea/Vomiting no He states that he is not experiencing this
Diarrhea No He states that he is not experiencing this
Constipation No He states that he is not experiencing this
Weight loss No He states that he is not experiencing this
Weight gain No He states that he is not experiencing this
Goal weight No He states that he is not experiencing this
Change in appetite, taste, No He states that he is not experiencing this
smell
Food sensitivities No He states that he is not experiencing this
Heartburn no He states that he is not experiencing this
Gas/Bloating no He states that he is not experiencing this
Difficulty swallowing No He states that he is not experiencing this

Changes in urine color No He states that he is not experiencing this

Urinary frequency or no He states that he is not experiencing this
urgency
Dysuria No He states that he is not experiencing this
Nocturia No He states that he is not experiencing this
Hematuria No He states that he is not experiencing this
Jaundice No He states that he is not experiencing this
Rectal bleeding No He states that he is not experiencing this
Black stools No He states that he is not experiencing this
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GI/GU History and Exam

OBJECTIVE: PHYSICAL EXAM

Vital signs
BP 140/90 Pulse 96 RR 18 Temp 36.9 C
Height 5’8” Weight 150lbs BMI 22.8

Physical Exam Normal Comments

Y N
Physical Exam Normal Y N Comments
INSPECTION
Skin: color, scars, rashes or Skin is pink, appropriate for ethnicity and
lesions y clean.
Contour: shape y Abdomen is flat, symmetric
Symmetry y Abdomen is flat, symmetric
Umbilicus y Abdomen is flat, symmetric
Visible pulsations y No pulsations noted
Hernia y No apparent hernias
AUSCULTATION
Bowel sounds n None
Bruit y No bruits
PERCUSSION
4 quadrants, note tones n Tympany predominated in all 4 quadrants
Increased size of liver/spleen n No enlargement noted
CVA tenderness y Negative CVA tenderness
PALPATION
Abdomen is soft to palpation with no
Light palpation n masses or tenderness
Abdomen is soft to palpation with no
Deep palpation n masses or tenderness

Normal Exam Findings

Abdomen is flat, symmetric with no apparent masses, lesions, or

scars. No pulsations noted on inspection. Skin is appropriate for
ethnicity. Hair distribution is WDL.

Bowel sounds present with no bruits. Tympany predominated in all

4 quadrants. Negative CVA tenderness. Abdomen is soft to
 N380
GI/GU History and Exam
palpation with no masses or tenderness.

Diagnosis

Differential Diagnoses

 Urinary Tract Infection (N39.0): Characterized by infections in any part of the urinary
tract, often caused by various organisms. Symptoms vary but may include fever,
vomiting, nausea, lower abdominal pain, painful urination, and blood in urine. The
patient presents with lower abdominal pain but is negative for other urinary symptoms,
making urinary tract infection less likely.
 Irritable Bowel Syndrome (K58): A gastrointestinal disorder with irregular bowel habits
and abdominal discomfort. No specific causative organisms are identified. Symptoms
include irregular bowel habits, abdominal pain, distention, diarrhea, and constipation.
The patient presents with abdominal pain but lacks other typical symptoms, making
irritable bowel syndrome less likely.

 Diverticulitis (K57.92): Characterized by outpocketings in the inner layer of the colon,

leading to symptoms such as abdominal pain, vomiting, nausea, fever, and bloating. The
patient presents with abdominal pain but lacks other typical symptoms.
Diagnosis
 Appendicitis (K35.8): Inflammation of the internal lining of the appendix. Clinical
presentation includes abdominal pain, nausea, vomiting, anorexia, and diarrhea. The
patient presents with abdominal pain and nausea, suggesting a possible diagnosis of
appendicitis.
Plan/Therapeutics
Diagnostics:
 Abdominal ultrasound for lower abdominal pain x3 days
 Pharmacotherapeutics: Ampicillin 1.5g IV/IM every 6 hours; cefepime 2g IV every 12
hours for 7 days; Gentamicin 3.5mg/kg in a day IV/IM every 8 hours (Craig, 2022).
 Education: Advise patient to rest and stay hydrated.
 Non-medication treatments: rest and hydration.
 Referrals: none
 Followup in 7 days (Craig, 2022).
Remarks
Assessment of patient contact
was able to accurately measure and check the abdomen during the patient
encounter. I was able to provide specific indications to rule out any potential
differences. If I encounter a patient similar to this one in the future, I will
make an effort to rule out all potential causes of the symptoms before
making therapy suggestions.
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GI/GU History and Exam
References

Craig, S. (2022). Appendicitis Medication: Penicillins, Cephalosporins,

Aminoglycosides, Carbapenems, Fluoroquinolones, Anti-infective Agents, Analgesics.

Medscape. https://emedicine.medscape.com/article/773895- medication#1

Ghoulam M. (2019). Diverticulitis: Practice Essentials, Background,

Pathophysiology. https://emedicine.medscape.com/article/173388-overview#a1