Diagnostic Testing, Cardiovascular Problems, Abdominal
Problems, Renal Problems - Discussion Part Two 2022
Demographicdata:PatrickSmith,Caucasianmale,age42
S:Subjective:
CC:Abdominalpain
HPI: Wokeupat5a.m.startedoutaspainononesideofhisback.Hethoughthepulledamuscle. Now
pain is spreading to his stomach and is getting worse. The pain sometimesshoots down into
his groin. He feels nauseous. He seems to be going to the bathroom moreoften.
Hethinkshemighthave afever becausehe has beensweating.
O: Thismorning
L:Startedinback,spreadto abdomenandgroin
D:Painhasgottenprogressivelyworsesince onset
C:Describesbackandstomachpainasthrobbing.Thepainseemscomeinwavesandattimeshootsdow
n into his groin.
A: No information
givenR: No information
givenT:Noinformationgi
ven
S:Reportscurrentpain as8/10
PMH: Describes health as good. Has hay fever and psoriasis, medication which was given
atlast visit worked, not using at this time. No previous back injuries. No daily medications.
Noherbal medication use.Appendectomy at age 10. Previous hospitalization for broken
legrequiringtractionatage8.Smokescigarettes,apackaday.NoETOHorillicitdruguse.
Sleeps 5-6hoursanight.NKDA.ImmunizationsUTD.
Family History: Parents are deceased. Mother died at age 51 from a brain tumor and
fatherdied age53 leukemia. Has onebrotherin good health.
Social History: Married, has four children. Lives with his immediate family and in-
laws.Works full time as a plumber. Work has been so busy no time lately for regular
exercise.ROS:
General/Constitutional: He thinks he might have a fever because he has been
sweating.Eyes: Deniers visualchanges
Ears,Nose,Mouth,Throat:Deniesearpain,difficultyhearingorringingintheears.Denieschanges in
smell or increased nasal drainage.Denies dry mouth, sores, or lesions on
themucosalmembrane.Denies sorethroat.
Cardiovascular: Denies chest pain, palpitations, and
dizziness.Respiratory: Deniescough, shortnessof breath.
Musculoskeletal:Deniesjointpainorstiffness.Hematologic/Lymphatic:De
niesswellingortendernessoflymphnodes.Allergies/Immunologic:NKDA.
ImmunizationsUTD
O:Objective:
T-98.9,P100,R 22,BP160/96,SpO2: 98% Ht:5’9”Wt: 195 lbs, BMI:28.8.
General:Alert,orientedand cooperative.
Head:Headnormocephalic.Hairthickanddistributionthroughoutscalp.
Eyes:Scleraclear,conjunctivawhite.
Ears:Tympanicmembranesgrayandintactwithlightreflexnoted.Pinnaandtragusnontender.
