Identification
Full Name : G. G.
Address: Unknown
Date & Time: 3/15 – 8:17AM
Location: NYPQH
Religion: Unknown
Source of Information: Self (using a Translator – pt is Spanish speaking)
Reliability: Reliable
Mode of Transport: Ambulance
CC. “Stomach pain” x 1 day
History of Present Illness:
23 y/o Female with PMH of Ulcerative Colitis Presents with abdominal pain and vomiting that started 1 day ago. Pt notes the abdominal pain is diffuse and does not localize to one area. Pt also notes vomiting 3 times in the past day. Pt also vomited in the ED bed while giving illness history. Pt notes she vomited while trying to take aspirin for a headache. Pt did not swallow the aspirin. The abdominal pain has been constant since yesterday but worsened today. Pt describes the abdominal pain as a “cramping pain”. Pt notes pain is 10/10. Pt denies aggravating or relieving factors. Pt has not been taking her prescribed Ulcerative Colitis medication for 6 months. Pt notes her menstrual cycle was irregular last month with menses on the 7th and the 28th of February. Pt denies diarrhea, constipation, chest pain, SOB, fever, dizziness, dysphagia,
Past Medical History
Ulcerative Colitis x 1 year
Immunizations – Pt is unsure if she is up to date
Pt has never had a colonoscopy
Past Surgical History
Pt denies any past surgeries
Medications
Pt does not remember the name of the medication she was prescribed for Ulcerative Colitis
Allergies
Pt denies drug, environmental, animal, and food allergies.
Family History
Pt notes both of her parents are deceased
Pt denies siblings
Social history
Pt has 1 or 2 alcoholic drinks once a week
Pt denies recent travel
Pt is single
Pt is currently unemployed
Pt notes she often eats fast food.
Pt has normal sleep patterns
Pt is not physically active
Pt wears a seatbelt
Review of Systems
General: Denies recent weight loss or gain, loss of appetite, generalized weakness/fatigue, fever, chills, or night sweats
Skin, Hair, nails: Pt denies change in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution
Head: Headache – 1 day ago. headache on right side of head. lasted 2 hours. Pt describes it as Dull-pain. Denies alleviating or aggravating factors. Pt denies any pattern in pain. Pt notes the headache was 5/10
Eyes: denies visual disturbance, blurring, diplopia, fatigue with use of eyes, scotoma, halos, lacrimation, photophobia, priuitis, does not remember last eye exam, pt does not wear glasses.
Ears – denies Deafness, pain, discharge, tinnitus, hearing airs
Nose/Sinuses: pt denies Discharge, epistaxis, obstruction
Mouth and throat: denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, dentures. Pt notes good dental hygiene
Neck: denies localized swelling/lumps, stiffness/decreased range of motion
Breasts: denies lumps, nipple discharge, pain. Pt has never had a mammogram
Pulmonary system: denies Dyspnea or dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, paroxysmal nocturnal dyspnea
Cardiovascular System: Pt denies chest pain, HTN, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur
Gastrointestinal system: See HPI
Genitourinary System: pt denies frequency, nocturia, urgency, oliguria, polyuria, dysuria, color of urine : yellow, Denies incontinence, awakening at night to urinate or flank pain
- Pt is sexually active with males
- Pt has 1 partner
- Pt denies impotence/anorgasmia
- Pt denies any past or present STI’s
- Pt denies use of contraception
Menstrual and Obstetrical: Date of last normal period – 5/1. Menarche: 12 y/o. Pt not currently menstruating. Pt denies postcoital bleeding, denies change in vaginal discharge, dyspareunia. Pt denies menopause. Pt denies past pregnancy.
Nervous: pt denies seizures, headache, LOC, sensory disturbances, ataxia, loss of strength, change in cognition/ mental status/memory, weakness.
Musculoskeletal system: denies muscle/joint pain, deformity or swelling, redness.
Peripheral Vascular System: Intermittent claudication, coldness or tropic changes, varicose veins, peripheral edema, color change.
Hematologic system: denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, hx of DVT/pe
Endocrine System: denies polyuria, heat or cold intolerance, goiter, excessive sweating, hirtruism
Psychiatric – pt denies depression/sadness, anxiety, obsessive/compulsive disorder. Pt has never seen a mental health professional and is not taking psychiatric medications.
Physical
General: slightly underweight, neatly groomed, does not appear in distress
Hair: The head is normocephalic and atraumatic without tenderness, visible or palpable masses, depressions, or scarring. Hair is of normal texture and evenly distributed.
Skin: Skin is warm, dry, and intact without rashes or lesions. Appropriate color for ethnicity.
Nail: Nailbeds pink with no cyanosis or clubbing.
Eyes: Orbits, eyelids, conjunctivae and sclera are normal. Pupils are equal, round, reactive to light with extraocular movements intact. Vision is grossly intact, and funduscopic examination is unremarkable
Vitals Signs
Blood Pressure
Right arm- Seated: 119/76. Supine: 121/76
Left arm – Seated: 120/80. Supine: 124/72
Height: 63 inches
Weight: 110
BMI:27
