documentationofhistoryandphysicalexam.docVIP

DOCUMENTATION OF HISTORY AND PHYSICAL EXAM Patient Name (Initials only) : Date examined: 3/12/09 Preceptor Name: Dr. G CHIEF COMPLAINT Swelling in abdomen and scrotum HISTORY OF PRESENT ILLNESS (chronology and progression, pertinent positives and negatives) Patient is a 59 year old Caucasian male who was in his usual state of health until Thursday, 3/5/09, when he noticed diffuse swelling throughout his abdomen and lower extremities. Swelling increased throughout Thursday and Friday. Patient reports that over the weekend the condition caused marked discomfort, pain and tenderness. Over the weekend, the patient attempted to reduce the swelling by applying ice to affected regions. On Monday, 3/9/09, the patient came to the Veteran’s Administration Hospital (VAH) for a scheduled appointment to monitor his hepatitis C. He presented with ascites, diffuse edema in the lower extremities, and a grossly swollen and chafed scrotum. At that time, his doctor admitted him. Since admission, he has been treated with paracentesis and diuretics, which has reduced the swelling in his abdomen and scrotum. Patient reports greatly reduced discomfort, some residual tenderness, and denies any pain. Patient had a history of hepatitis C which was adequately controlled until November of 2008. At that time, he reports that he was admitted to the hospital with ascites and was told his kidneys were failing. His abdomen was drained and diuretics were prescribed for him. Fluid was drained biweekly until February of 2009, when he was admitted with ascites to the VAH one week post-drainage. He was discharged after 5 days, and fluid has been drained weekly since then. Today the patient’s abdomen shows frank ascites, and diffuse pitting edema is evident in his lower extremities. His conjunctiva are pale bilaterally. Patient attributes his condition to fluid collecting as a result of liver dysfunction. PAST MEDICAL HISTORY Childhood Adult Illness (hypertension, tubercul