ALL SAINTS UNIVERSITY SCHOOL OF MEDICINE

COURSE: PATIENT-DOCTOR RELATIONSHIP

MEDICAL HISTORY REPORT FOR JESSICA ANDERSON

DATE: 24 OCTOBER 2023

PATIENT’S NAME: Jessica Anderson AGE: 21 ETHNICITY:
PATIENT’S NUMBER

CC: Abdominal pain

H.P.I
A 21-year-old female presents to the Emergency Department with a
complaint of abdominal pain. She reports that the pain started this
morning, which she described as strong, steady, and cramping in quality.
The pain is localized to the right lower abdomen and is worsening over
time. Jessica rates the pain intensity as 7/10. She denies any radiation of
the pain but complains that it is aggravated by movement and mentions
that it is not alleviated by any factor. She also experienced pain during
the ride to the hospital. There were no specific precipitating events
mentioned for the pain.
Regarding associated symptoms, Jessica mentions feeling slightly
feverish since this morning but she has not experienced any chills. She
also reports feeling nauseated and vomited once approximately 2 hours
ago, with vomitus consisting of sour, yellowish fluid with no blood in the
vomitus. However, Jessica experienced loose bowel movements this
morning with brown-coloured stools but no blood in the stool. She also
denies any urinary frequency or burning sensation.
Her, last menstrual period was five weeks ago, and she noted that today
was the first day of her menstrual period, describing the menstrual
spotting as brownish. She does not report any vaginal discharge. The
patient has no other complaints.