Identifying Data: 

Full Name: XX

Address: XX

Date of Birth: XX

Date & Time: 01/04/2024 3PM

Location: Nao Medical Hicksville, NY

Religion: Catholic

Source of Information: Self 

Reliability: Reliable 

Source of Referral: Self 

Mode of Transportation: Self 

 

Chief Complaint: “Pain on my back right side” x 2 days 

History of Present Illness: 

A 35 year old male with no known PMHx presents to the clinic complaining of constant right upper quadrant pain accompanied with nausea that began 2 days ago. He explains that the pain came on suddenly and rates it a 6/10, radiating to the right scapula and flank. He reports a subjective fever and chills. He states that the pain feels worse after eating large meals. He denies experiencing this in the past. The patient reports that he took OTC Tylenol with mild relief, bringing the pain down to a 4/10. He denies jaundice, vomiting, changes in bowel movements, history of gallstones, urinary frequency or urgency. 

Past Medical History: 

Present Illnesses – no known illnesses

Immunizations: Fully up to date

Screening tests & results: None

Childhood illnesses: None 

 

Past Hospitalizations: 

Surgical repair of left ankle in 2010 

 

Past Surgical History:  

Left ankle repair 2010 

 

Medications: 

None

 

Allergies: 

No known food allergies

No known drug allergies

 

Family History: 

Mother – alive with HTN

Father – alive with DM2 

Maternal Grandmother – deceased

Maternal Grandfather – deceased

Paternal Grandmother –  deceased 

Paternal Grandfather –  deceased

 

Social History: 

Mr. JP is a male living in a house with his girlfriend. Mr. JP regularly attends work as a plumber.

Habits: Denies smoking. Denies smoking marijuana recreationally. Endorses mild alcohol consumption, occasionally and socially. Denies illicit drug use. Denies consumption of coffee.

Travel: Denies recent travel  

Diet: Denies a well balanced diet, mainly consisting of fast food. 

Exercise: Denies regular exercise or 60 minutes of physical activity daily.

Safety measures: Admits to using seatbelt in moving vehicles. 

Sexual history: Admits to being sexually active with one female partner. Denies history of STIs.

 

Review of Systems:

General – Endorses subjective fever. Denies weight loss, malaise, weight change, or night sweats.

Skin, hair, nails – Denies discoloration, pruritus, excessive sweating, skin changes, and hair changes.

Head – Denies headache, dizziness, trauma, fainting, and Hx of vertigo.

Eyes – Denies discharge, diplopia, eye pain, visual changes, and photophobia. Last eye exam: unknown.

Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids. 

Nose/Sinuses – Denies sinus pressure, epistaxis, nasal congestion, discharge, swelling.  

Mouth/Throat – Denies dysphagia, sore throat, hoarseness, cough. Last dental exam: 5 months ago.

Neck – Denies pain with movement, stiffness, swollen glands and trouble swallowing.  

Breasts – Denies skin changes, lumps, nipple discharge. 

Pulmonary System – Denies cough, SOB, DOE, wheezing, hemoptysis or cyanosis. 

Cardiovascular System – Denies chest pain, palpitations, edema. Last EKG: never.

Gastrointestinal System – Endorses abdominal pain. Denies loss of appetite, changes in stool, hemorrhoids, constipation, rectal bleeding or diarrhea. 

Genitourinary System – Endorses flank pain. Denies frequency, oliguria, urgency, nocturia, incontinence.

Sexual History – Admits to being currently sexually active. Denies history of STIs. 

Nervous – Denies dizziness, sensory disturbances, paresthesia, or changes in cognition/mental status. 

Musculoskeletal system – Denies swelling/stiffness, joint pain, muscle soreness, reduced mobility. Denies tenderness to palpation and erythema. 

Peripheral vascular system – Denies pins and needles, edema, calf pain, varicosities, cyanosis. 

Hematological System – Denies Hx of DVT/PE, lymph node enlargement, blood transfusions, anemia, clotting.

Endocrine system – Denies diabetes, heat or cold intolerance, excessive hunger/thirst.

Psychiatric – Denies changes in mood, suicidal ideations, irritability, and changes in eating habits.

 

Physical 

General: Well groomed male, with proper posture, appearing as his stated age of 35 years, with large build. He appears awake, alert, oriented to person, place, time and situation. He is cooperative and appears to be a reliable source of information. He is in no acute distress.

Vital Signs: 

BP: Seated – (R) 149/91

R: 18 breaths/min, unlabored 

P: 74 beats/min, regular rate and rhythm 

T: 98.7 (Tympanic)

O2 Sat: 96%, room air 

Height: 5’9 inches     Weight: 330 lbs      BMI:  48.73

 

Skin, Hair, Nails, Head:

Skin: Warm and moist. No discoloration. Good turgor. No tattoos, no masses, no bruises, no ulcerations. No visible scarring.

Hair: Regular quantity, even distribution. Color is dark brown, and the texture is normal. No visible dandruff or lice.

Nails: No clubbing, pitting, signs of infection. Presence of lunula on all nails. Capillary refill < 2 seconds in upper extremities.

Head: Normocephalic, atraumatic, non-tender to palpation. 

 

Eyes:

Eyes appear symmetrical. Eye lashes are well distributed. No strabismus, lid lag, or ptosis noted. Sclera white with no jaundice, cornea clear with no signs of abrasion or nodules. Conjunctiva is clear with no foreign bodies. 

 

Thorax/Lungs

Clear to auscultation. Chest was symmetrical with no signs of deformities or trauma. Respirations were unlabored and no accessory muscle use was noted. Tenderness noted upon palpation of the right costal margin.

 

Heart

Regular rate & rhythm. Distinct S1/S2 with no murmurs, splitting, friction rubs, or S3/S4 appreciated. Carotid pulses are 2+ bilaterally, no bruits present. 

 

Abdomen

Normoactive bowel sounds in all four quadrants with no bruits or pulsations appreciated. Abdomen is symmetrical and distended. Striae present. No ecchymosis. Positive Murphy’s sign. Pain refers to the right scapula with palpation under the right costal margin. Mild guarding, negative McBurney’s point tenderness. 

Neuro Exam 

Mental Status: A&O x3, cooperative, thoughts & speech coherent.

 

Differential Diagnosis

• Acute Cholecystitis  

• Choledocholithiasis

• Pancreatitis

• Peptic Ulcer Disease

 

Assessment

An 35 year old male with large body habitus presents to the clinic with RUQ pain radiating to the back and flank, accompanied with nausea and subjective fever. Patient is currently afebrile and non-toxic appearing. Physical exam demonstrates mild guarding, normoactive bowel sounds, positive Murphy’s sign, and radiating pain to the scapula upon palpation under the right costal margin. No rebound or guarding. Patient declined pain medication and was advised to go to the ER for further medical evaluation. 

Problem List

• RUQ pain radiating to the flank and scapula – possible acute cholecystitis  
• Obesity
• Elevated blood pressure without diagnosis of hypertension

Plan 

• ER visit recommended to get a RUQ ultrasound and to treat cholecystitis or rule out other gastrointestinal pathology. Patient declined pain medication and blood work and will proceed to the ER right away.   
• Limit salt intake and avoid fatty foods. 
• Follow up with a primary care provider to address elevated blood pressure and BMI. 
• Seek nutritional counseling if having trouble establishing a well-balanced diet.