Physical Exam Jot down

 Physical Test Write Up Article

HISTORY

PP: 39 yo female-Allergies: none. Medications: Occasional Ibuprofen 400mg, 1 year

CC: " Lower belly pain after the marathon”.

HPI: This Pt's first episode -- Pt reported with decrease abdominal soreness 2 times after managing a marathon. The girl developed belly pain the night after the competition. The discomfort was identified as sharp and initially centered on the epigastrium. She had a loose stool early on the morning before presentation. The discomfort intensified the whole day, and her appetite decreased as the girl felt nauseated. Pt refused vomiting. The lady had no prior abs surgeries. The person rated her pain since 9/10. The lady continued to feel nauseated and to have got pain irrespective of pain medications (Ibuprofen 400 mg). Pt reports frequent menstrual cycle and pain free. Currently Pt is in mid-cycle. Rehabilitation denied virtually any gastrointestinal concerns in the past. PHx: Medical – non-e. Medical – non-e. G0 P0 A0

FHx: Mo: 70 yo A& W

Fa: 70 por mi parte A& Watts

No bros

MGM: ↓93 yo CHF

MGF: ↓76 yo CHF

PGM: ↓86 yo CHF

PGF: ↓74 yo MI

SHx: The Pt holds a PhD in Physical Chemistry and it is a successful scientist in the Polymer bonded industry. She is happily married to a patent Attorney. They do not include children. Pt likes to make and travelling.

Smokes: Õ

Medicines: Õ

EtOH: Õ

L of S: Skin: Õ

Head:

Eye: myopia since 21 years old; wears eyeglasses, has spare pair.

Ear canal: Õ

Nasal area: Õ

Throat: Õ

Lung area: Õ

Cardiovascular: Õ

GI: Õ

Belly: see HPI

GU: Õ

Neuro-pysch: Õ

Ortho: Õ

Endocrine: Õ

Heme: Õ

Extremities: Õ

PHYSICAL EXAM

General: WD, WN 23yo girl in NAD

Vital Indicators: BP: 120/80 RR: 12 P: 68 T: 99. 6 F

Skin: Simply no rash, freckles, petechiae.

Brain: Normocephalic, shaped, no signs of trauma. Gleaming and curly black locks.

Eyes: Students equal, rounded, reactive to light and accommodation. No erythema or perhaps discharge. Extra Ocular Muscles intact. Eyebrows – typical size and shape. Not any edema in orbital area. Eye lids usual, close completely.

The ears: External hearing...

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