HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He
has not taken any medications because he did not know what to take. He states the pain is a 5/10
today but has been as much
...
HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He
has not taken any medications because he did not know what to take. He states the pain is a 5/10
today but has been as much as 9/10 when it first started. He has been able to eat, with some
nausea afterwards.
Current Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units
qhs
Allergies: NKDA
PMHx: HTN, Diabetes, hx of GI bleed 4 years ago
Soc Hx:. Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
Fam Hx: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia,
GERD
O.
VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs
Heart: RRR, no murmurs
Lungs: CTA, chest wall symmetrical
Skin: Intact without lesions, no urticaria
Abd: soft, hyperactive bowel sounds, positive pain in the LLQ on palpation
Diagnostics: None
A .
Differential Diagnoses: Left lower quadrant pain, Gastroenteritis
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