Medical History: Steve Smith

Chief Complaint: Belly Pain

HPI:
Site (Location?) (Epigastric tenderness)

Onset (when?) (few weeks ago)

C (Describe the pain?) (Burns after food)

R (Radiation) No radiation

A (What other symptoms are you presenting with?) No associated symptoms

T (Time of the day that you feel it?) After eating, 2-3 hours after

E (makes it better/worse) 2% milk makes it better, fattier foods make it worse

S (severity) (7 at worst)

Past Medical History (PMH): Knees have arthritis

Past Surgical History (PSH): Tonsillectomy

Allergies: NKA

Medications: Maalox

Family History: Dad has pancreatic cancer, mom is OK

Social History (Including Sexual History):

Drink? 1-2 beers every other day in 1 week

Drugs? NKD

Smoke? Claimed to never have smoked

Job? Stress? Works at a warehouse, and recently laid off looking for employment, this seems
to be adding to his stress

Diet/Exercise/Habit (use discretion) generally healthy, doesn’t exercise as much as he wants

to

Sexual history?

Do you have a partner? Has a wife

Are you sexually active? Yes

Are you monogamous? Yes

 Do you use protection? Didn’t ask

Have you ever had an STD? No

ROS:
General: Unremarkable
Eyes: No changes in vision
HEENT: No headache
Cardiovascular: No reported heart changes
Respiratory: No known respiratory changes
Gastrointestinal: Epigastric tenderness
Genitourinary: Normal urination
Lymphatics: Did not ask
Neurological: Normal neuro,
Musculoskeletal: Did not ask
Dermatological: No new lesions
Psychiatric: Did not ask
Other:
Physical Exam (Please Document the Skills Tested as well in the Exam):
Vitals: Age 48, Temp 37.9 C, Pulse 89, BP: 132/78, RR: 18, O2: 98%

General:

HEENT: Did not perform

Cardiovascular: Did not perform

Respiratory: Did not perform

Breast: Did not perform

Gastrointestinal: Inspection was normal and showed a few moles on abdomen, auscultation showed
normal bowel noises in all 9 quadrants, Percussion of liver showed normal liver and spleen margins,
Liver was barely palpable on exhalation, palpation elicited epigastric tenderness on pushing, no
rebound tenderness

Genitourinary: Not performed

Neurological: Not performed

Extremities: Not performed

Musculoskeletal: Not performed

Dermatological: Not performed

Psychiatric: Not performed

Hypotheses: Cholecystitis, cholelithiasis, pancreatic stone blockage

Student Signature _ Vish Bysani____________________ Date:___11/28/17_______________