3-5 PATIENT NOTE: ABDOMINAL PAIN N&V HISTORY: Describe the history you just obtained from this

patient. Include only information (pertinent positives and negatives) relevant to this patients problem(s). 32 YO C/O ABDOMINAL PAIN AND NAUSEA AND VOMITING, STARTED YESTERDAY. ABDOMINAL PAIN 9/10 INTENSITY, EPIGASTRIC THROBBING AND CONSTANT SINCE LAST NIGHT. PRIOR EVENTS HE WENT OUT FOR PIZZA AND BEER. VOMITING YELLOE FLUIDS WITH FOOD APPROXIMATELY TWO CUPS FULL SINCE EVERY HOUR. PATIENT REPORTS DIARRHEA 4 BOWEL MOVEMENT IN LESS THAN 24 HOURS, WARM FEELING, CHILLS AND NIGHT SWEATS. DENIES DIZZINESS, CHEST PAIN OR PREVIOUS EPISODES. NO AGGRAVATING OR ALLEVIATING FACTORS, NO BLADDER CHANGES. ALLERGIES: NONE MEDICATIONS: MAALOX PMH: NONE PSH: FRACTURE FINGER 2 YEARS AGO SH: DENIES TOBACCO, ETOH OR DRUG USE, WORKS AS A STOCK BROKER, SINGLE, LIVES WITH ROOMATES, SEXUALLY ACTIVE WITH 1 GIRLFRIEND FOR A YEAR PHYSICAL EXAM: Describe any positive and negative findings relevant to this patients problem(s). Be careful to include only those parts of examination you performed in this encounter. THE PATIENT IS IN ACUTE DISTRESS AND THE VITALS ARE WITHIN NORMAL LIMITS. THE BREATH SOUNDS ARE CLEAR TO AUSCULTATION BILATERALLY. HIS HEART SOUNDS ARE NORMAL WITH S1/S2. HIS ABDOMEN IS SOFT WITH BOWEL SOUNDS HEARD. THERE WAS NO TENDERNESS OR DISTENTION OF THE ABDOMEN. THE MURPHYS SIGN IS NEGATIVE. DATA INTERPRETATION: Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patients complaint(s). List your diagnoses from most to least likely. For some cases. Fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from the history and physical examination (if present) that support each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis (e.g. restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc.

Diagnosis #1: Gastroenteritis HISTORY FINDING(S) PHYSICAL EXAM FINDING(S) - ABDOMINAL PAIN AND NAUSEA - IN ACUTE DISTRESS SINCE YESTERDAY -ABDOMEN NONTENDER - ABDOMEN PAIN 9/10 IN -MURPHYS SIGN NEGATIVE INTENSITY -VOMITINGS & DIARRHEA Diagnosis #2: Duodenal ulcer HISTORY FINDING(S) -ABDOMEN PAIN AND NAUSEA SINCE YESTERDAY -VOMITINGS & DIARRHEA -H/O FOOD INTAKE PRECIPITATED SYMPTOMS Diagnosis #3: PUD HISTORY FINDING(S) -ABDOMEN PAIN AND NAUSEA SINCE YESTERDAY -VOMITINGS AND DIARRHEA -H/O FOOD INTAKE PRECIPITATED SYMPTOMS Diagnostic Studies: -RECTAL EXAM -STOOL FOR BLOOD -U/S ABDOMEN -CBC -H.PYLORI ANTOBODY TESTING

PHYSICAL EXAM FINDING(S) -IN ACUTE DISTRESS - ABDOMEN NONTENDER - MURPHYS SIGN NEGATIVE

PHYSICAL EXAM FINDING(S) - IN ACUTE DISTRESS -ABDOMEN NONTENDER -MURPHYS SIGN NEGATIVE