History of Present Illness
Review of Systems
Past Medical History
Physical Examination
Essential Differential Diagnosis
Relevant Next Steps
Test Result 1
Test Result 2
Diagnosis
Treatment Orders
Question 1
Question 2
Question 3
Question 4
About the Case
Left-sided Abdominal Pain in a 45-yr-old Man
Physical Examination
General appearance
: Appears nontoxic but seems uncomfortable on the exam bed.
Vital signs
:
Temperature: 37° C
Pulse: 99 beats/min
BP: 150/90 mm Hg
Respirations: 16/min
Height: 6 ft (1.83 m)
Weight: 300 lb (136 kg)
BMI: 40.7
Skin
: Warm and dry to the touch. No rash or lesions.
HEENT
: Unremarkable
Pulmonary
: Breath sounds present and equal bilaterally. No stridor, rales, or wheezing.
Cardiovascular
: Regular rate and rhythm; no murmurs or rubs. Radial and pedal pulses present and equal bilaterally. No pedal edema.
Gastrointestinal
: No ecchymoses. Bowel sounds normal in all quadrants. Abdomen nondistended, soft, and nontender to light and deep palpation; no guarding, rigidity, rebound, or masses. Negative Murphy sign. Rectal exam is heme-negative.
Genitourinary
: Circumcised penis, bilateral descended testes. Testes and epididymal bodies nontender to palpation. No costovertebral angle tenderness.
Musculoskeletal
: Muscle strength is intact in all four limbs without any tenderness to palpation or movement.
Neurologic
: Unremarkable
Mental status
: Alert and oriented to person, place, time, and event.
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