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DEMOGRAPHICSPatient Initials:C.Age:64Sex:MaleRace/Ethnicity:CaucasianSUBJECTIVECHIEF COMPLAINT (CC):Abdominal PainHISTORY 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 hashad stomach pains in the past.PAST HISTORYPMH:Unspecified stomach pains in the pastPSH:Denies any past surgical historyPSYCHIATRIC HISTORY:Denies any history of psychiatric issuesFAMILY HISTORY / SOCIAL HISTORYFAMILY HISTORY (FH):No significant family history SOCIAL HISTORY:Drinks and smokesMEDICATION RECONCILIATION / REVIEWMEDICATIONS & INDICATIONS:(Prescribed & OTC)Motrin, Advil, and TumsALLERGIES / IMMUNIZATIONSALLERGIES:NoneIMMUNIZATIONS:Up to dateHEALTH PROMOTION / HEALTH MAINTENANCENUTRITION / DIET: Tries to eat as healthy as he can
EXERCISE REGIMEN: deniesTOBACCO/ALCOHOL: Smokes a pack anda half a day. Drinks 4 to 6 beers a day.ILLICIT DRUG USE: deniesSAFETY MEASURES: hand hygieneSCREENINGS / EXAMS:Denies any past screenings or exams other than yearly physicalsREVIEW OF SYSTEMSCONSTITUTIONAL / GENERAL:No weight gain or losses; no weaknesses, fatiguePositive feverEYES:No vision changes, eye pain, redness or swelling, excessive tearing, double vision, blurred vision, or scotomaEARS/NOSE/MOUTH/THROAT:No hearing changes, tinnitus, earaches, infections, discharge, hearing loss, or hearing aids usedNo colds, congestion, nasal obstructions, discharge, itching, hay fever or allergies, nosebleeds, change in sense of smell, or sinus painCARDIOVASCULAR:Denies any chest pain or discomfort, palpitations, dyspnea,orthopnea, edema, cyanosis, nocturiaDenies hx of murmurs, HTN, anemia, or CADRESPIRATORY:Denies hx of lung disease, or exposure to toxins and/or pollutionGASTROINTESTINAL/ABDOMEN: