TIna GI model note.docx - Chief complaint abdominal pain History of present illness Onset was 1 month ago has progressively become worse Patient

TIna GI model note.docx - Chief complaint abdominal pain...

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Chief complaint abdominal pain History of present illness Onset was 1 month ago has progressively become worse. Patient describes the location as epigastric. Patient states the pain is intermittent and usually happens around feedings. Patient states currently the pain is a 1 out of 10 but after eating can become a 5 out of 10. Patient describes the pain as a burning and sharp pain. Aggravating factors include eating. Relieving factors include antacids, fasting, and sitting upright. Treatments include using antacids over-the-counter when pain gets bad. Current medications Flovent 2 puffs daily Albuterol 2 puffs as needed for shortness of breath ibuprofen 600mg as needed for menstrual cramps Tylenol as needed for headaches Chewable Tums 4 tabslets as needed for heartburn Allergies Patch cause runny nose, itching, and sneezing. Dust causes runny nose, sneezing, and breathing problems. penicillin: causes rash and hives Past medical history: Diabetes diagnosed at age 24. Asthma diagnosed at 2.5 years old patient denies surgical history Patient states your last menstrual period was 1 month ago Last tetanus booster was one year ago Social HIstory: Patient is a single African American female who is a supervisor at Mid American ship. She is pursuing her bachelor's degree in accounting. Spends free time reading, attending free talks at church, and watching television. Denies tobacco use. Patient states she drink up to for drinks and social encounters but usually does not drink during the week. Patient states she uses her seatbelt whenever in the car. Patient states for the past 24 hours at breakfast she had a bowl of cereal for lunch she had a piece of pizza for dinner she had baked potatoes and broccoli with cheese soup this morning she had toast with butter and honey and orange juice. Patient denies any recent dietary changes. Family history: mother is currently alive and suffers from HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of upper stomach pain after eating. She noticed the pain about a month ago. She states that she experiences pain daily, but notes it to be worse 3-4 times per week. Pain is a 5/10 and is located in her upper stomach. She describes it “kind of like heartburn” but states that it can be sharper.
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