Sp Template.docx

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_______________