Name: Kiana Alexa Brigondo
Section Code: RLE 112
History of Present Illness
A 45-yr-old man comes to the emergency department because of a 6-h history of acute-onset
left-sided lower abdominal pain. He describes the pain as starting over his left flank and radiating down
toward his groin. The pain comes and goes but is intense when present. He has had some mild nausea
without vomiting. The pain does not change with eating. The pain is less when he walks around than
when he sits or lies down flat. He has not had any bloody stools, black stools, or change in bowel
habits. He denies having diarrhea and constipation. He has noticed his urine looks "dark" but denies
pain during urination and urinary frequency. He says that he swims several times a week for exercise,
and this pain started immediately after swimming. He also notes that several days ago, his son ran into
his left side while playing football. He took some acetaminophen, which minimally relieved his
discomfort. He now presents for evaluation at the emergency department because the pain has not
subsided. He says he has never experienced pain like this.
Review of Systems
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General: Has otherwise felt well before onset of his current symptoms. Denies fevers, chills,
weight loss, and fatigue.
Skin: Denies rashes, itching, and any lesions.
HEENT: Noncontributory
Pulmonary: Noncontributory
Cardiovascular: Denies palpitations and chest pain. No lower-extremity edema.
Gastrointestinal: Reports nausea when pain is at its most intense but no vomiting. No
constipation or diarrhea. Last bowel movement yesterday; no hematochezia or melena. No
appetite; he has not eaten since the pain began.
Genitourinary: No dysuria, hematuria, urinary frequency or urgency, or increased volume of
urine. States urine appears "dark."
Musculoskeletal: Occasional low back pain with strenuous activity
Neurologic: Noncontributory
Psychiatric: Noncontributory
Past Medical History
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Medical history: Diabetes mellitus since his 20s that is well-controlled with oral drugs, diet,
and exercise. Hypertension and hyperlipidemia both well-controlled on drugs. Obstructive sleep
apnea for which he uses a CPAP machine. Recent deep venous thrombosis that developed after
a long international flight and that is currently being treated with an oral anticoagulant. Denies
history of UTIs, difficulty with urination, COPD, renal stones, and immunosuppressive disorders.
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Surgical history: Wisdom tooth extraction as a teenager; no abdominal surgical procedures.
Medications: Lisinopril 10 mg daily, aspirin 81 mg daily, rosuvastatin 10 mg daily, rivaroxaban
20 mg daily, metformin 850 mg daily, and niacin 1 g daily.
Allergies: No known drug allergies.
Family history: Mother and father have hypertension; sibling has history of kidney stones.
Social history: He denies current and previous tobacco use. He works at a desk job and swims
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laps at his local pool several times a week. All immunizations are up-to-date. He denies exposure
to any sick contacts. For the past 15 yr, he has had unprotected sex only with his wife.
Physical Examination
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General appearance: Appears nontoxic but seems uncomfortable on the exam bed.
Vital signs:
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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.
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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.