Student name: Ashley Rhoby
ABDOMINAL ASSESSMENT
Pt. Initials: MR
Gender: Male
Age: 28
S:
CC: “I have a stomach ache”
HPI: Patient presents to the office c/o a stomach ache that has been
going on for about one day. Patient states the symptoms started
shortly after lunch yesterday when he “ate at a shady Mexican
restaurant.” Patient states his lunch yesterday consisted of a bean and
chicken burrito with sides of rice and refried beans. Patient states his
stomach began “hurting and feeling crampy” within an hour of leaving
the restaurant. He denies nausea and vomiting but states he did have
one episode of diarrhea this morning upon waking up. Patient states he
was unable to eat dinner last night or breakfast today due to his
stomach ache. Patient denies difficulty swallowing, lifestyle changes,
stressors, or blood in stool. Patient denies any sick contacts, denies
travel out of the country, or contact with any other food substance that
was out of his normal diet. Patient denies taking any prescription
medications, vitamins, supplements, herbals, or over the counter
medications at this time.
PMH: Patient has a past medical history of chicken pox, and tonsillitis
and underwent a tonsillectomy in 2015.
FH: Patient’s father has a history of heart disease, high blood pressure,
and high cholesterol. Patient’s mother has a history of hypothyroidism
and gestational diabetes. Patient denies any family history of
abdominal issues, abdominal cancers, appendicitis or cholecystitis.
SH: Patient is a nonsmoker, nondrug user, and consumes 1-2 beers per
week. Patient participates in a regular exercise regimen 3-4 days per
week. Patient is married and is sexually active.
ROS: Patient denies any skin, nail, or hair changes. Patient denies
changes with vision or hearing at this time. Patient denies any throat or
mouth changes, neck changes, or sinus changes. Patient denies any
respiratory or cardiovascular changes. Patient denies any
gastrointestinal changes besides his “stomach ache.” Denies urinary
changes. Patient denies any musculoskeletal or neurological changes.
O:
General appearance: General appearance: 28-year-old white male,
appropriately dressed, BMI 22.5, VSS, cooperative and pleasant. Good
historian. Patient lying supine on exam table. Demeanor is calm.
ABDOMINAL ASSESSMENT
Pt. Initials: MR
Gender: Male
Age: 28
S:
CC: “I have a stomach ache”
HPI: Patient presents to the office c/o a stomach ache that has been
going on for about one day. Patient states the symptoms started
shortly after lunch yesterday when he “ate at a shady Mexican
restaurant.” Patient states his lunch yesterday consisted of a bean and
chicken burrito with sides of rice and refried beans. Patient states his
stomach began “hurting and feeling crampy” within an hour of leaving
the restaurant. He denies nausea and vomiting but states he did have
one episode of diarrhea this morning upon waking up. Patient states he
was unable to eat dinner last night or breakfast today due to his
stomach ache. Patient denies difficulty swallowing, lifestyle changes,
stressors, or blood in stool. Patient denies any sick contacts, denies
travel out of the country, or contact with any other food substance that
was out of his normal diet. Patient denies taking any prescription
medications, vitamins, supplements, herbals, or over the counter
medications at this time.
PMH: Patient has a past medical history of chicken pox, and tonsillitis
and underwent a tonsillectomy in 2015.
FH: Patient’s father has a history of heart disease, high blood pressure,
and high cholesterol. Patient’s mother has a history of hypothyroidism
and gestational diabetes. Patient denies any family history of
abdominal issues, abdominal cancers, appendicitis or cholecystitis.
SH: Patient is a nonsmoker, nondrug user, and consumes 1-2 beers per
week. Patient participates in a regular exercise regimen 3-4 days per
week. Patient is married and is sexually active.
ROS: Patient denies any skin, nail, or hair changes. Patient denies
changes with vision or hearing at this time. Patient denies any throat or
mouth changes, neck changes, or sinus changes. Patient denies any
respiratory or cardiovascular changes. Patient denies any
gastrointestinal changes besides his “stomach ache.” Denies urinary
changes. Patient denies any musculoskeletal or neurological changes.
O:
General appearance: General appearance: 28-year-old white male,
appropriately dressed, BMI 22.5, VSS, cooperative and pleasant. Good
historian. Patient lying supine on exam table. Demeanor is calm.
