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The history was taken by me and Dr. Elias and Dr. loay from the patient himself with good reliability.
History of present illness: The above mentioned patient, a known case of HTN and DM for 1 year,
presented to the emergency department complaing of epigastric pain since last saturday, it was sudden
in onset, with progressive course, the pain reached its peak within few minutes. The pain is associated
with anorexia, nausea, feverish sensation (not documented), chills, constipation, and vomiting one time
of gastric contents that did not relieve the pain.
The patient was treated conservatively with IV fluids and analgesics in the hospital, and then he was
discharged. But in the afternoon the patient returned with a more severe epigastric pain.
Systemic review:
SKIN no Rash/Pruritus/Acne
Past surgical history: no history of trauma or falling down, no history of surgical procedures.
Drug history: the patient does not take any regular medications.
Social history:
WORk ?????????
heavy smoker: 40 pack year.
living with his family, has 7 sons and 8 daughters.
has governmental insurance.
has no pets in his house.
no history of travel to foreign countries, blood transfusion, or tattoos.
Not alcoholic.
Physical Examination:
Vital Signs:
BP: 145/73.
Tempreture: 37.3.
Respiratory rate: normal.
Heart rate: 87.
General examination: the patient was sitting comfortably on the edge of the bed , not in pain or a
respiratory distress. He is not jaundiced, cyanosed, or pale. He has 2 drains in his abdomen (Rt and Lt
lumbar regions) closed system, drain by gravity, serrousangiosus (???? ml ??????????) He has a canula in
his left hand with nothing running in. he is not connected to a cardiac monitor or a nasal canula.
Hand: Warm. Not Sweaty. No leukonichia, kylonichia, clubbing, nicotine statining, splinter hemorrhage,
osler nodes, janway lesions, muscle wasting, rheumatic deformity, dupuytren's contracture, palmar
erythema.
Abdiminal Examination:
Inspection: the abdomen was completely covered with dressings. So we couldn’t examine it.
Cardiovascular Examination:
Inspection: moves symmetrically with breathing, no masses, dilated veins, visible pulsation, scars. The
nipples are symmetrical but inverted.
Palpation: apex beat is present in the fifth intercostals space, medial the midclavicular line. No thrills or
heaves.
Auscultation: normal S1, Normal S2, no added sounds, no murmurs.
Respiratory Examination:
Inspection: no deformities, moves symmetrically with breathing, no masses, dilated veins, visible
pulsation, scars. The nipples are symmetrical but inverted.
Palpation: apex beat is present in the fifth intercostals space, medial the midclavicular line. Trachea is
centrally located. Normal symmetrical chest expansion, normal vocal fremitus.
Percussion: normal resonant.
Auscultation: normal vesicular breathing, with diffuse wheezes on the right side.