HPI:
This is a 20-year-old female with past medical history of cholelithiasis and was diagnosed back in November 2021 who presents emergency department complaining of epigastric pain that radiates to mid upper back pain the past 2 days. Patient states that it occurred yesterday while she was at work eating yogurt. Patient also reports nausea vomiting. Patient was informed by LAC USC when she was diagnosed with gallstones that her symptoms returns to check for possible cholecystitis patient denies any fever, chills, shortness of breath. Said ibuprofen insert mg noon with relief.
Onset: Acute
Timing: 2 days
Character: Burning sensation
Location: Epigastric region
Duration: Gradual
Radiation: To mid upper back
Intensity: Moderate
Modifying factors: Better with medications.
Associated signs and symptoms:
No fever, no chills.
Past Medical History: Cholecystitis.
Past Surgical History: patient states no hx of any surgery
Family History: Not pertinent to this visit.
Allergies: no food allergies, the drug allergy is state in nursing document
PSHx: Lives here in town, denies drug use.
Patient received 2 doses of COVID vaccine. Denies any recent travels.
ROS:
All pertinent positives and negatives are stated in HPI, all other systems reviewed and are negative.
HEENT: no headache, no blurry vision
CVS: no syncope, no SOB
GI: + abdominal pain, + nausea, + vomiting
GU: no painful urination
Ortho: no bone pain, no muscle pain
Skin: no rash or skin lesions
Neuro: no seizure, no stiffness, no weakness
Endo: no polyuria or polydipsia
HEMA: no anemia
Allergy/imm: No urticarial, no season allergy.
General: no weakness, no fever, no chills
Resp: no SOB, no distress
PHYSICAL EXAM
GENERAL APPEARANCE: Patient is alert, awake, resting, talking in complete sentences with no acute distress.
HEENT: No facial trauma or abnormalities. No tonsillar hypertrophy, no uvula deviation. No tongue swelling.
NECK: Supple, no lymphadenopathy.
LUNGS: Clear to auscultation bilaterally. Normal breath sound. No Wheezing.
HEART: Auscultation: RRR. Normal heart sound. No Gallop. No Murmur.
Palpation: Normal cap refill. Normal skin turgor. No JVD. No Pedal edema
ABDOMEN: Normal bowel sounds. Patient has positive Murphy sign.
EXTREMITIES: Patient ambulatory. Good muscle tone.
NEUROLOGIC: GCS 15. Patient is ambulatory with no gait abnormalities.
VASCULAR: Bilateral radial pulses, strong, equal.
SKIN: Pink, warm, dry. No pathological skin rash.
PSYCH: normal mentation, awake, alert, not suicidal, not homicidal.