Brenda James gastrointestinal issues 1. What bring you in today? 2. Where is abdominal pain? 3. How severe is the pain on your stomach? 4. How long have you had the pain? 5. When did the pain start? Does the pain radiate someplace else? 6. Is the pain constant or intermittent? 7. Any recent hospitalization or surgeries? 8. Have you ever had abdominal surgery? 9. Have you ever had this pain before? 10. Anything makes the pain better or worse? 11. Do you have nausea or vomiting? 12. Do you have black or bloody stool? 13. Do you have diarrhea or change in bowel habits? 14. Do you have Any allergy? 15. Anything food trigger pain? 16. Do you have a history of diverticulitis, pancreatitis, kidney failure, gallstones inflammatory bowel disease? 17. Are you taking antibiotics or steroids? 18. How is your appetite? Any wight gain or lost? 19. Do you use any antiacids medication? 20. How is your diet? 21. Any fever? 22. Do you drink any alcohol or smoke? 23. Do you have a history of vascular or heart disease, hypertension, or atrial fibrillation? 24. How is your parents’ health? 25. Have you had any more stress in your life lately? 26. When is last period? 27. Do you have your immunization up to date? 28. Do you have any other symptoms or concerns we should discuss? CC: “Stomach hurting last two days, haven’t able to go to work.” HPI: Lt Col Brenda James is a 48-year-old female presenting with a chief complaint of crampy, gnawing, achiness for two days. She started her pain and discomfort localized at her right upper anterior abdomen under her lower ribs. The pain exacerbated when she take deep breathing. She states that she has had a similar pain start a few months ago that discomfort has come and gone. However, her abdomen pain has been constant for the last two days. She reports that the pain radiates to her right shoulder but did not recall any inciting event when this pain began, but the pain of the event worsened after she ate, especially eating fast food. She reports she tried taking antacids over-the-counter medication, but it does not alleviate that issue. She currently rates her pain 3 to 4 out of 10, but she has experienced the pain as bad as a 6 to 7. She also stated that last two days, she feels feverish, although she has not taken her temperature. Furthermore, she reports 15 lbs. weight loss compared with four months ago Dr. visit. She stated she has no appetite, three episodes of emesis over the past two days, and bowel movements since to a lighter color recently. She reports a history of heartburn and describes her current discomfort as feeling noticeably different from her previous heartburn episodes. The patient also has had arthritis, and she is taking 400 mg of Ibuprofen three times a day as needed for knee pain. ROS: Constitutional: Brenda James, a 48-year-old female, tall is 5’ 6’, weight 170lb, mild obesity, present with right upper abdomen pain, has nausea, vomiting, weight loss, pale stools, pain with deep breathing, and felt feverish. Denies constipation, hematemesis, yellowing of the skin, abdominal trauma, breast tenderness, chest pain, swelling difficulty or swallowing, denied night sweats, changes or pain with urination, any change in the amount of physical activity, any change in frequency of bowel movement. • HENT: Negative • Eyes: Negative • Respiratory: Negative • Cardiovascular: Negative for chest pain • Gastrointestinal: Positive for abdominal pain, Positive for nausea and vomiting • Genitourinary: negative • Musculoskeletal: Positive for arthralgias and myalgia, arthritis knee pain in lower back pain from past injury, denied other joint pain, joints swelling, muscle cramps, muscle weakness, stiffness. • Skin: Skin intact • Neurologic: denies transient paralysis, paresthesia, seizures, syncope, tremors, vertigo. • Psychiatric/Behavioral: Negative • Endocrine: denies cold intolerance, heat intolerance, polydipsia, polyphagia, polyuria History: Heart burn, arthritis Family History: Dad heart disease Mom breast cancer and has cholecystectomy