OSCE abdominal pain Unit 5 lab.docx - DEMOGRAPHICS Patient...

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DEMOGRAPHICS Patient Initials: C. Age: 64 Sex: Male Race/Ethnicity: Caucasian SUBJECTIVE CHIEF COMPLAINT (CC): Abdominal Pain HISTORY OF PRESENT ILLNESS (HPI): A 64-year-old male who recently separated from his wife. He presents with an increase in epigastric pain over the past two days and excess drinking. The patient states that his pain is an 8 out of 10. He states that the pain never really goes away. He has had stomach pains in the past. PAST HISTORY PMH: Unspecified stomach pains in the past PSH: Denies any past surgical history PSYCHIATRIC HISTORY: Denies any history of psychiatric issues FAMILY HISTORY / SOCIAL HISTORY FAMILY HISTORY (FH): No significant family history SOCIAL HISTORY: Drinks and smokes MEDICATION RECONCILIATION / REVIEW MEDICATIONS & INDICATIONS: (Prescribed & OTC) Motrin, Advil, and Tums ALLERGIES / IMMUNIZATIONS ALLERGIES: None IMMUNIZATIONS: Up to date HEALTH PROMOTION / HEALTH MAINTENANCE NUTRITION / DIET: Tries to eat as healthy as he can
EXERCISE REGIMEN: denies TOBACCO/ALCOHOL: Smokes a pack and a half a day. Drinks 4 to 6 beers a day. ILLICIT DRUG USE: denies SAFETY MEASURES: hand hygiene SCREENINGS / EXAMS: Denies any past screenings or exams other than yearly physicals REVIEW OF SYSTEMS CONSTITUTIONAL / GENERAL: No weight gain or losses; no weaknesses, fatigue Positive fever EYES: No vision changes, eye pain, redness or swelling, excessive tearing, double vision, blurred vision, or scotoma EARS/NOSE/MOUTH/THROAT: No hearing changes, tinnitus, earaches, infections, discharge, hearing loss, or hearing aids used No colds, congestion, nasal obstructions, discharge, itching, hay fever or allergies, nosebleeds, change in sense of smell, or sinus pain CARDIOVASCULAR: Denies any chest pain or discomfort, palpitations, dyspnea, orthopnea, edema, cyanosis, nocturia Denies hx of murmurs, HTN, anemia, or CAD RESPIRATORY: Denies hx of lung disease, or exposure to toxins and/or pollution GASTROINTESTINAL/ABDOMEN:

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