History 

Identifying Data: 

Full Name – SH

Sex – Female

Date of Birth – 1979

Date & Time – 3/18/21 

Location – Far Rockaway  

Race – AA

Source of Information – Self, Reliable 

Source of Referral – Self 

Chief Complaint: abdominal pain x 3 months

History of Present Illness: 

41 yo AA female with pmh of asthma, IDA, vitamin D deficiency, furuncle of back, asthma, HLD and obesity presents c/o abdominal pain x 3 months. Pt states since 01/2021 she has experienced intermittent, generalized abdominal pain. Pt states pain occurs in relapsing/remitting pattern. She can’t point to specific foods as a trigger or exacerbating/alleviating factors. Pt denies use of OTC agents for symptom relief. States this past week she experienced 2 bouts of 10/10 abdominal pain which influenced her to seek evaluation. Pt denies N/V/D, constipation, pregnancy (LMP 3/9/2021), acid reflux, pelvic abnormality, abnormal uterine bleeding or irregular menstrual cycle.

Past Medical History: 

Present Illnesses –

• Mild intermittent asthma
• Iron deficiency anemia
• Vitamin D deficiency
• Furuncle of back
• Hyperlipidemia
• Obesity, BMI (40.0-44.9), adult

Past illnesses, Childhood illnesses – N/A

Immunizations – up to date

Screenings –

• Pap smear 2020

Surgical history – N/A

Medications: 

• Ventolin HFA
• Ferrous sulfate
• Colace
• Doxycycline monohydrate
• Zofran
• Mupirocin calcium
• Ergocalciferol

Allergies:

NKDFSA

Family History: 

HTN runs in family

Social History: 

SH is a married female, lives with her husband.

Habits – Pt admits to occasional alcohol use, denies smoking or other illicit drug use.

Travel – none 

Diet – eats 1-2 meals a day of whatever she has time for, usually fast food. 

Exercise – rarely

Safety measures – admits to wearing a seat belt. 

Sleep – around 6 hours a night

Review of Systems 

General – Denies fever, chills, night sweats, fatigue, weakness, loss of appetite or recent weight gain or loss. 

Skin, Hair, Nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or change in hair distribution. 

Head – Denies headache, vertigo, head trauma, unconsciousness, coma or fracture.

Eyes – Denies contacts, glasses, visual disturbances, fatigue, lacrimation, photophobia or pruritus. Pt doesn’t know when her last eye exam was. 

Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids. 

Nose/Sinuses – Denies discharge, epistaxis or obstruction. 

Mouth and Throat – Denies bleeding gums, sore throat, sore tongue, mouth ulcers, voice 

changes, dentures. Pt’s last dental exam was 6 months ago. 

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion. 

Breast – Denies lumps, nipple discharge or pain. Pt has never had a mammogram. 

Pulmonary System – Denies dyspnea, SOB, cough, wheezing, hemoptysis, cyanosis, orthopnea or PND. 

Cardiovascular System – Denies chest pain, HTN, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur. 

Gastrointestinal System – Denies change in appetite, intolerance to foods, N/V, dysphagia, pyrosis, flatulence, eructation, + abdominal pain, diarrhea, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding, blood in stool, stool guaiac/colonoscopy/sigmoidoscopy or pain in flank.

Genitourinary – Denies urinary frequency, change in color of urine, incontinence, dysuria, nocturia, urgency, oliguria or polyuria.

Males – last prostate exam/PSA ___. Denies hesitancy, dribbling.

Sexual History – Denies sexual activity, impotence/anorgasmia, sexually transmitted infections or the use of contraception/protection. 

Menstrual and Obstetrical – Denies dysmenorrhea, menorrhagia, metrorrhagia, PMS, postcoital bleeding, vaginal discharge, dyspareunia or menopause. LMP: 3/9/21

Obstetrical History – GTPAL

Musculoskeletal System – Denies muscle/joint pain, deformity or swelling, redness or arthritis. 

Peripheral Vascular System – Denies intermittent claudication coldness or trophic changes, varicose veins, peripheral edema or color change. 

Hematologic System – Denies anemia, easy bruising or bleeding, lymph node enlargement or history of DVT/PE. 

Endocrine System – Denies polydipsia, polyphagia, polyuria heat or cold intolerance, goiter or hirsutism. 

Nervous System – Denies seizures, loss of consciousness, sensory disturbances (numbness, paresthesia, dysesthesias, hyperesthesia), ataxia, loss of strength, change in cognition/mental status/memory or weakness (asymmetric). 

Psychiatric – Denies depression/sadness (feelings of helplessness, feelings of hopelessness, lack of interest in usual activities, suicidal ideation), anxiety, obsessive/compulsive disorder, or ever seeing a mental health professional. 

Physical 

General: 

Noted good lighting and draping on patient. Average female, neatly groomed, good hygiene, looks her stated age. Patient is alert and oriented to person, place and time.

Vital Signs: 

BP: 140/90 

R: 16 breaths/min unlabored 

P: 86 beats/min, regular rhythm 

T: 97.8 degrees F (oral) 

O2 Sat: 98% Room Air

BMI: 41.02

Skin, Hair, Nails and Head:

Skin: Warm & moist, good turgor, smooth texture, non-icteric. No thickness, opacities noted. No lesions, masses, scars or tattoos noted. 

Hair: Average distribution and quantity. 

Nails: No clubbing, capillary refill <2 seconds throughout.

Head: Normocephalic, atraumatic, no deformities and specific faces noted, non-tender to palpation throughout.

Eyes:

Symmetrical OU. Eyebrows and eyelashes even distribution, eyelids have no discharge or swelling, lacrimal glands have no excessive tearing, dryness, enlargement or erythema, lacrimal sac not inflamed or swollen. No strabismus, exophthalmos or ptosis. Sclera white, conjunctiva clear. 

No other eye examinations done as per the patient’s request (legally blind). 

Visual acuity uncorrected – 20/20 OS, 20/20 OD, 20/20 OU

Visual fields full OU. PERRLA, EOMs intact with no nystagmus. 

Fundoscopy – Red reflex intact OU. Cup to disk ratio <0.5 OU. No AV nicking, hemorrhages, exudates or neovascularization OU. 

Ears:

Symmetrical and normal size. No lesions, masses or trauma on external ears. No discharge/foreign bodies in external auditory canals AU. Tympanic membrane pearly white/intact with cone of light in normal position AU. Auditory acuity intact to whispered voice AU. Weber midline/Rinne reveals AC>BC AU.

Nose: 

Symmetrical, no masses lesions or deformities, trauma or discharge. Nares patent bilaterally, nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions, deformities, injection or perforation. No foreign bodies. 

Sinuses:

Non-tender to palpation and percussion over bilateral frontal and maxillary sinuses. 

Mouth:

Lips – Pink, moist; no cyanosis or lesions. Non-tender to palpation.

Mucosa – Pink ; well hydrated. No masses; lesions noted. Non-tender to palpation. No leukoplakia.

Palate – Pink; well hydrated. Palate intact with no lesions; masses; scars. Non-tender to palpation; continuity intact. 

Teeth – Good dentition / no obvious dental caries noted.

Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge. Non-tender to palpation.

Tongue – Pink; well papillated; no masses, lesions or deviation noted. Non-tender to palpation.

Oropharynx – Well hydrated; no injection; exudate; masses; lesions; foreign bodies. Tonsils present with no injection or exudate. Uvula pink, no edema, lesions. 

Neck – Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to palpation.   FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no palpable adenopathy noted.

Thyroid: 

Non-tender; no palpable masses; no thyromegaly; no bruits noted.

Thorax & Lungs: 

Chest – symmetrical, no deformities, no evidence of trauma. Respirations unlabored, no paradoxical respirations or use of accessory muscles notes. Lat to AP diameter 2:1. Non-tender to palpation. 

Lungs – clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus throughout. No adventitious sounds. 

Abdomen: 

Abdomen flat and symmetric with no scars, striae or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Non-tender to palpation and tympanic throughout, no guarding or rebound noted. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness appreciated. 

Heart:

JVP is 25cm above sternal angle with the head of the bed at 30 degrees. PMI in 5th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Normal rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. 

Genitalia: 

External genitalia without erythema or lesions. Vaginal mucosa pink without inflammation, erythema or discharge. Cervix nulliparous, pink, and without lesions or discharge. No cervical motion tenderness. Uterus anterior, midline, smooth, non-tender and not enlarged. No adnexal tenderness or masses noted. Pap smear obtained. No inguinal adenopathy. 

Rectal: 

Rectovaginal wall intact. No external hemorrhoids, skin tags, ulcers, sinus tracts, anal fissures, inflammation or excoriations. Good anal sphincter tone. No masses or tenderness. Trace brown stool present in vault. FOB negative.  

Neuro:

Alert and oriented x3. CN’s II-XII grossly intact, DTR’s 2+ bilaterally and symmetric. PSYCH appropriate mood and affect.

Mental Status = A/O to person place and time. Memory and attention intact. Receptive and expressive abilities intact; thought coherent. No dysarthria, dysphonia or aphasia noted.

Cranial Nerves:

II, III, IV, VI –> see physical exam 

V–> Normal sensation. Masseter muscles and temporalis muscles intact 

VII–> Able to wrinkle forehead, smile, and close eyes normally 

VIII –> Hearing loss intact and equal bilaterally 

IX and X –> Palate rises equally and uvula is midline 

XI –> Normal shoulder shrug and SCM muscle 

XII –> Tongue is midline and normal movements

Peripheral Vascular Exam:

The extremities are normal in color, size and temperature. Peripheral pulses are 2+ bilaterally.

MSK:

No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM (Full Range of Motion) of all upper and lower extremities bilaterally.  No evidence of spinal deformities.  

Assessment & Treatment/Plan:

1. Unspecified abdominal pain
   1. Abdominal pain of unclear etiology, pt with positive family h/o uterine fibroids (sister)
   1. f/u labs to r/o organic causes, pt given referral for abdominal
   1. RTC in 1 week to f/u results
2. Mild intermittent asthma
   1. Continue Ventolin HFA Aerosol solution, 2 puffs prn q6 hours
3. Iron deficiency anemia
   1. Continue Ferrous Sulfate Tablet, continue Colace capsule
   1. Continue medical management
4. Vitamin D deficiency
   1. Pt counseled on use of OTC vitamin D
5. Furuncle of back
   1. Stable
6. Hyperlipidemia
   1. Low cholesterol diet and exercise
7. Other obesity due to excess calories
   1. Benefits of weight loss through proper diet and exercise
8. BMI 42.00
   1. Benefits of weight loss through proper diet and exercise