1. 31104944-Version:2
</PRIMARY CARE PROVIDER/>
George Glass, MD.
</CHIEF COMPLAINT/>
Abdominal pain.
</HISTORY OF PRESENT ILLNESS/>
The patient is a 13-year-old female who presents to the Emergency Department complaining of
abdominal pain. Apparently, she was pushed over and landed on a rock when a friend sat on her. The
patient is complaining of right-sided rib pain. There has been no nausea or no vomiting. No epistaxis, no
hemoptysis. There has been no dysuria. There has been no blood in her stool. The patient is
complaining of pain underneath her left rib cage on the anterior side. She is having no difficulty breathing.
She does not know the size of the rock. She states her friend weighed approximately 213 pounds and
was on her for over a minute.
</PAST MEDICAL HISTORY/>
None.
</CURRENT MEDICATIONS/>
None.
</SOCIAL HISTORY/>
Patient is in the 8th grade. She is present with her family.
</REVIEW OF SYSTEMS/>
A full review of systems is negative, otherwise noted above.
</PHYSICAL EXAMINATION/>
VITAL SIGNS: Show temperature of 37.3, pulse of 93, respiratory rate is 15, blood pressure is 110/69,
and O2 sat is 99% on room air.
GENERAL: The patient is a 13-year-old female who appears older than her stated age.
SKIN: Warm and dry. There is no evidence of any ecchymosis on her right rib cage and right abdomen.
HEENT: Head is atraumatic and normocephalic. Eyes; pupils are equal, round, and reactive to light.
NECK: Supple. No nuchal rigidity.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm. No murmur, rub, or gallop. The patient does have chest wall
tenderness under her right rib cage. There is no sternal tenderness. The pain does not radiate around to
her back.
ABDOMEN: Soft, nontender, and nondistended. Normoactive bowel sounds. There is no guarding or
rebound tenderness. There is no CVA tenderness. There is no periumbilical tenderness.
EXTREMITIES: The patient has flexion and extension of her upper and lower extremities and her back.
</EMERGENCY DEPARTMENT COURSE/>
The patient is a 13-year-old female who presents to the Emergency Department after stuffing some form
of trauma after being pressed upon a rock. I do think she has a chest wall contusion. I do not think she
has any organ damage. There is no evidence of any pathologic abdomen. There is no significant
reproducible pain other than palpation under her left rib cage. I believe she has a chest wall contusion.
Her lungs are clear. There is no disfigurement of her spine or her rib cage. There is no sternal
tenderness. I did state to mom that I think that this is a contusion based on my exam and imaging is not
needed at this time; however, if the patient develops any hemoptysis, bleeding in her urine or blood in her
stools, uncontrollable nausea or vomiting, or uncontrollable back pain, to return to the Emergency
Department for further evaluation.