CHIEF COMPLAINT: Right rib pain.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male, otherwise healthy, who presents to the emergency department today complaining of rib pain, pain in his right rib cage, which has been present for approximately 3 days now. The patient reports that sometime around February or March, he was lifting a heavy object, and he did something to strain his chest wall on that side and has had pain intermittently since then. He denies any associated fevers or chills. He denies cough. He denies difficulty breathing or shortness of breath and reports that the pain gets worse whenever he attempts to move or twist using that side of his body. He has not taken anything to alleviate the pain and nothing in particular seems to make it better.
PAST MEDICAL HISTORY: Negative.
MEDICATIONS: None.
ALLERGIES: None.
SOCIAL HISTORY: The patient continues to smoke a half pack of cigarettes per day. He denies alcohol or drug use.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: Positive, as above. All other review of systems negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 114/72, pulse 84, respiratory rate 18, temperature 98.6, O2 sat 100% on room air.
GENERAL: The patient is alert and oriented, in no apparent distress. He is pleasant and conversive in full sentences.
HEENT: Pupils are equally round and briskly reactive to light. Extraocular muscles are intact. Oral mucous membranes are moist without lesions.
NECK: The patient has no noted JVD. No adenopathy is appreciated.
CHEST/LUNGS: The patient’s chest wall is nontender. There is no subcutaneous air. Breath sounds are equal bilaterally. There are no rhonchi, rales or wheezes appreciated to auscultation. There are no focal areas of consolidation.
HEART: The patient has a regular rate and rhythm. No murmurs, rubs or gallops are appreciated. Distal pulses are 2+. No carotid bruits appreciated.
ABDOMEN: The patient’s abdomen is completely soft, nontender, and nondistended. Bowel sounds are positive. No organomegaly is appreciated. No masses are appreciated. There are no peritoneal signs. There is no Murphy’s sign.
EXTREMITIES: The patient has no peripheral edema. There is no focal long bone tenderness or deformity.
SKIN: The patient’s skin is warm and dry, without rashes or lesions.
EMERGENCY DEPARTMENT COURSE: The patient was seen and evaluated.
IMPRESSION: Right chest wall pain.
MEDICAL DECISION MAKING: The patient presents with pain, which seems to be entirely related to his chest wall. His breath sounds are equal. He has got no constitutional symptoms, so we doubt anything like pneumonia or lymphoma as the etiology of this presentation.
PLAN:
1. The patient was given a prescription for ibuprofen, to be taken as needed for pain.
2. He is to return for worsening symptoms.
3. Follow up with his primary care physician.
DISPOSITION: Home.
