Health Assessment

System Being Assessed: Abdomen/GI

Chief Complaint: consistent sharp and aching lower abdomen pain
History of Present Illness: Pt complains of an extreme pain at the bottom of stomach. Started
about last week and worsening over time. Pt states it is a sharp pain and is a 7 out of 10
contently, Worsening when he eats to a 10 out of 10. Pt also reports nausea, and bloating. Has
tried taking Tylenol at home with no relief. Pt denies any fever, chills or vomiting.
General Survey: This is a pleasant 28 year old male admitted through the ER. Appears stated age,
well-groomed with appropriate clothing for the weather. Sitting upright in chair, appears relaxed.
Alert and oriented to person, place and time. Able to respond appropriately to questions. In no
apparent distress.
Medications: Lisinopril 10mg PO QD, Pt state I have not taken it in about a week
Allergies: NKDA
Past Medical History:
Diverticulitis
Cellulitis of scrotum
Hepatomegaly
Fatty liver

Sleep apnea
HTN
Morbid obesity

Past Surgical History:

Tonsillectomy & adenoidectomy
Drainage of scrotal abscess
Family History: Father deceased with heart attack at age 54 with history of HTN. Mother
alive and well at age 58.
Social History: Denies any smoking history. Occasional ETOH use, drinks once a
month. Caffeine use state I drink about 3 sodas a day.
Review of systems: Temp 97.1F. Pulse 97 and regular, Blood pressure 134/74, respirations
20 easy and unlabored. Oxygen saturation 96% on room air. Weight 352 lbs, height 510.
Pupils 4mm PERRL. Conjunctivae pink. Skin is pink, warm and dry. Lips pink, mucous
membranes moist. No ecchymosis or skin lesions noted. Cap. Refill less than 3 seconds.
Hand grips equally strong. Denies dizziness, headaches and SOB. LS clear bilaterally. BS +
x4. Complains of tenderness in LLQ upon palpation. States pain is 5 out of 10 at present
time. Denies any bloating at present time. Abdomen is soft, round and obese. States last BM
was yesterday morning, small, brown, soft with no blood noted. Denies any recent N/V.
voiding clear yellow urine, no odor. No bladder distension noted. No edema in lower
extremities. Active ROM and 2+ reflexes noted. Gait is steady.