Patient Information:
NY 41yo Caucasian male
S.
CC: left sided flank pain.
HPI: NY is a 41 year-old Caucasian male who had a sudden onset of left sided flank pain that
started suddenly this morning and has progressiv
...
Patient Information:
NY 41yo Caucasian male
S.
CC: left sided flank pain.
HPI: NY is a 41 year-old Caucasian male who had a sudden onset of left sided flank pain that
started suddenly this morning and has progressively gotten worse, patient states that the pain
comes and goes and is sharp when the pain is present, patient states that the pain does not radiate
Pt has not tried anything to relieve the pain, patient states pain is 2/10, but states the pain was
10/10 when it started.
Current Medications: no current medications
Allergies: Sulfa, patient gets a rash. Denies any environmental allergies
PMHx: Immunizations up to date, last Td June 2010, No past surgeries, no past medical history
Soc Hx: patient is married with no children, denies any tobacco use, denies any recreational drug
use, occasional alcohol use. Patient is an electrician for Alliant Energy
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason
for death of any deceased first degree relatives should be included. Include parents, grandparents,
siblings, and children. Include grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule out a differential diagnosis You
should list each system as follows: General: Head: EENT: etc. You should list these in bullet
format and document the systems in order from head to toe.
GENERAL: No fever, chills, weakness or fatigue.
RESPIRATORY: No shortness of breath or cough
GASTROINTESTINAL: No nausea, vomiting or diarrhea. No abdominal pain.
GENITOURINARY: No difficult urinating, no frequency, no urgency, no burning, no blood in
the urine
MUSCULOSKELETAL: left lower to mid back pain
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