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HPI:
Site (Location?) (Epigastric tenderness)
R (Radiation) No radiation
T (Time of the day that you feel it?) After eating, 2-3 hours after
S (severity) (7 at worst)
Allergies: NKA
Medications: Maalox
Drugs? NKD
Job? Stress? Works at a warehouse, and recently laid off looking for employment, this seems
to be adding to his stress
Sexual history?
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:
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