Patient ID: Miss. F
Date of Birth: 06/10/1993
Occupation: Works in a Factory in Yukon
Marital status : Divorced
Source: The patient gives her own history and appears to be a reliable source.
Chief Complaint: “I am having abdominal pain”
History of Present Illness
Miss F is 23 year old Hispanic female who presents today complaining of sharp, epigastric abdominal pain of 3-4 months duration. The pain has not changed or worsened acutely;. The pain is located in the epigastric region and left upper quadrant of the abdomen. It does not radiate. The pain is relatively constant throughout the day and night but does vary in severity. She rates the pain as 5/10 and remains the same. She …show more content…
Throat - No bleeding of gum. No throat pain .Dental visit up to date
Cardiovascular – denies chest pain; denies palpitations
Pulmonary – denies shortness of breath, denies cough
Gastrointestinal –complains of sharp, left lower abdominal pain; has diarrhea, denies nausea .no constipation.
Genitourinary – denies dysuria; denies increased frequency or urgency of urination
Neurologic – denies numbness and tingling; denies paresthesias
Musculoskeletal –No back pain; denies any muscle or joint pain
Endocrine – No thyroid trouble or No temperature intolerance or sweating. No history of gestational
Hematopoietic – denies easy bruising
Vital signs: Ht 5’3” Wt. 160lbs BMI: 28.3, HR 72 RR 16 BP 126/78 Temp : 97.8
General: Miss Fatima is a pleasant Hispanic 23 year old girl with no acute distress.
Skin; Skin is warm and no lesions. Palms are cold and moist. Nails are pink without clubbing or cyanosis.
Head: Hair black in color with good texture. Scalp with no lesions, Normocephalic/ Atraumatic
Eyes: Vision is 30/30 in each eye. extra ocular motions full, gross visual fields full to confrontation, conjunctiva pink and sclera white. Sclera non-icteric, Pupils 4 mm constricting to 2 mm , equal round and reactive to light and accommodation . No hemorrhages or exudates noted and disc margin