Week 5 predictor ass
Dr Martin and Class,
Chief Complaint – upper abdominal pain and feeling sick
Demographics - 40 yo Caucasian female
PMHx – Hypothyroidism, seasonal allergies (worse in fall)
PSHx – appendicitis as a teen, C-section x 2,
Home Meds
Levothyroxine 100mcg PO daily -
compliant Loratadine 10 mg PO prn
Tylenol 1000mg PO prn (taking BID x 7 days)
Allergies - PCN (unknown reaction, as a child), bees, strawberries
Immunizations – received all childhood vaccines, receives annual
influenza vaccine, tdap 2018 after laceration repair, did not receive
vaccines prior to South America trip, unsure of hepatitis B vaccine
status
Lifestyle
• employed in sales with daily local travel, eats at restaurants
with clients several times/week
• traveled to South America for 2 weeks about a month ago
• recently divorced, 1 new sex partners, sexual interest men
• former smoker – 4 years in early 20’s ½ PPD
• ETOH 2 glasses wine/night, 2 time/week out with friends and
drinks 5+ drinks
• denies any illicit drug use
• Usually participates in exercise classes 3/wk but has not gone in
2 weeks b/c pain is worse with jumping and quick movements.
HPI – 10 days ago URQ abdominal pain with fatigue, decreased
appetite, body aches and nausea. Noticed very dark urine and slightly
yellow eyes 2 days ago. Pain is constant and not related to food intake.
Has been taking Tylenol 1000mg BID for 5 days, to help with body
aches, it has not improved. Pain is a deep dull ache, 6/10 that is worse
with any jarring movements.
, Associated risk factors/demographics that contribute to the
chief complaint and differential diagnoses
Female
gender Age –
40
BMI -overweight
Unknown hepatitis B vaccine status
Recent travel out of country without travel
vaccines Frequent restaurant meals
Tylenol
use
Alcohol
use
New sexual partner
ROS
Constitutional: + body aches, + decreased appetite
- chills, - fever
Skin: - itching, - color changes, - rash, -
bruising HEENT: +sclera slightly yellow
Respiratory: -SOB, -cough
Cardiovascular: -CP, -edema
Neurological: -dizziness, -HA, -
syncope Musculoskeletal:
+myalgia
-swelling
GI/GU: +URQ abd pain, +nausea, + heartburn, +dark colored urine
- diarrhea, -constipation, - stool changes, -vomiting, - bloody stool, -
dysuria, - urinary frequency
Psychiatric: - anxiety, - depression, - increased stress
Dr Martin and Class,
Chief Complaint – upper abdominal pain and feeling sick
Demographics - 40 yo Caucasian female
PMHx – Hypothyroidism, seasonal allergies (worse in fall)
PSHx – appendicitis as a teen, C-section x 2,
Home Meds
Levothyroxine 100mcg PO daily -
compliant Loratadine 10 mg PO prn
Tylenol 1000mg PO prn (taking BID x 7 days)
Allergies - PCN (unknown reaction, as a child), bees, strawberries
Immunizations – received all childhood vaccines, receives annual
influenza vaccine, tdap 2018 after laceration repair, did not receive
vaccines prior to South America trip, unsure of hepatitis B vaccine
status
Lifestyle
• employed in sales with daily local travel, eats at restaurants
with clients several times/week
• traveled to South America for 2 weeks about a month ago
• recently divorced, 1 new sex partners, sexual interest men
• former smoker – 4 years in early 20’s ½ PPD
• ETOH 2 glasses wine/night, 2 time/week out with friends and
drinks 5+ drinks
• denies any illicit drug use
• Usually participates in exercise classes 3/wk but has not gone in
2 weeks b/c pain is worse with jumping and quick movements.
HPI – 10 days ago URQ abdominal pain with fatigue, decreased
appetite, body aches and nausea. Noticed very dark urine and slightly
yellow eyes 2 days ago. Pain is constant and not related to food intake.
Has been taking Tylenol 1000mg BID for 5 days, to help with body
aches, it has not improved. Pain is a deep dull ache, 6/10 that is worse
with any jarring movements.
, Associated risk factors/demographics that contribute to the
chief complaint and differential diagnoses
Female
gender Age –
40
BMI -overweight
Unknown hepatitis B vaccine status
Recent travel out of country without travel
vaccines Frequent restaurant meals
Tylenol
use
Alcohol
use
New sexual partner
ROS
Constitutional: + body aches, + decreased appetite
- chills, - fever
Skin: - itching, - color changes, - rash, -
bruising HEENT: +sclera slightly yellow
Respiratory: -SOB, -cough
Cardiovascular: -CP, -edema
Neurological: -dizziness, -HA, -
syncope Musculoskeletal:
+myalgia
-swelling
GI/GU: +URQ abd pain, +nausea, + heartburn, +dark colored urine
- diarrhea, -constipation, - stool changes, -vomiting, - bloody stool, -
dysuria, - urinary frequency
Psychiatric: - anxiety, - depression, - increased stress
