Sp Template.docx

  • Uploaded by: Teehee Jones
  • 0
  • 0
  • October 2019
  • PDF

This document was uploaded by user and they confirmed that they have the permission to share it. If you are author or own the copyright of this book, please report to us by using this DMCA report form. Report DMCA


Overview

Download & View Sp Template.docx as PDF for free.

More details

  • Words: 350
  • Pages: 3
Medical History: Steve Smith Chief Complaint: Belly Pain HPI: Site (Location?) (Epigastric tenderness) Onset (when?) (few weeks ago) C (Describe the pain?) (Burns after food) R (Radiation) No radiation A (What other symptoms are you presenting with?) No associated symptoms T (Time of the day that you feel it?) After eating, 2-3 hours after E (makes it better/worse) 2% milk makes it better, fattier foods make it worse S (severity) (7 at worst) Past Medical History (PMH): Knees have arthritis Past Surgical History (PSH): Tonsillectomy Allergies: NKA Medications: Maalox Family History: Dad has pancreatic cancer, mom is OK Social History (Including Sexual History): Drink? 1-2 beers every other day in 1 week Drugs? NKD Smoke? Claimed to never have smoked Job? Stress? Works at a warehouse, and recently laid off looking for employment, this seems to be adding to his stress Diet/Exercise/Habit (use discretion) generally healthy, doesn’t exercise as much as he wants to Sexual history? Do you have a partner? Has a wife Are you sexually active? Yes Are you monogamous? Yes

Do you use protection? Didn’t ask Have you ever had an STD? No ROS: General: Unremarkable Eyes: No changes in vision HEENT: No headache Cardiovascular: No reported heart changes Respiratory: No known respiratory changes Gastrointestinal: Epigastric tenderness Genitourinary: Normal urination Lymphatics: Did not ask Neurological: Normal neuro, Musculoskeletal: Did not ask Dermatological: No new lesions Psychiatric: Did not ask Other:

Physical Exam (Please Document the Skills Tested as well in the Exam): Vitals: Age 48, Temp 37.9 C, Pulse 89, BP: 132/78, RR: 18, O2: 98% General: HEENT: Did not perform Cardiovascular: Did not perform Respiratory: Did not perform Breast: Did not perform Gastrointestinal: Inspection was normal and showed a few moles on abdomen, auscultation showed normal bowel noises in all 9 quadrants, Percussion of liver showed normal liver and spleen margins, Liver was barely palpable on exhalation, palpation elicited epigastric tenderness on pushing, no rebound tenderness Genitourinary: Not performed Neurological: Not performed Extremities: Not performed Musculoskeletal: Not performed Dermatological: Not performed Psychiatric: Not performed

Hypotheses: Cholecystitis, cholelithiasis, pancreatic stone blockage

Student Signature _ Vish Bysani____________________

Date:___11/28/17_______________

Related Documents

Sp
November 2019 73
Sp
June 2020 48
Sp
June 2020 44
Sp
October 2019 66
Sp
November 2019 79
Sp
August 2019 73

More Documents from "peggy sun"