SUBJECTIVE
The patient returns today there was an ICS call on him last night, he still complains of the epigastric pains. He was seen yesterday at which time he stated that he had been having slowly increasing pain over the past five or six days prior. Denied any bloody stools or any black, tarry stools at that time. He is positive HIV he states a week ago. He was started on new medications. I do not really have the name of the medications at this time. I do have the consultant's note because of the handwriting unable to read it, nonetheless. Before the end of the discussion, he also told me that he was taking all three, naproxen, Motrin, and aspirin at the same time for different body aches that he was having. So at that time he also told me that yesterday he had some Mylanta and it helped relieve it somewhat, but this morning he states it is not helping. He was seen last night in ICS about 2:00 in the morning had emesis at that time. Denies any blood in the emesis. Denies any again black tarry stools. Last bowel movement, again was yesterday. Urinary problems none.
OBJECTIVE …show more content…
Holding his epigastric region at this time. His weight is 176 pounds. Blood pressure is 103/57, pulse 78, respirations right around 18, O2 sats 97%, temperature is 97 degrees. HEENT: All within normal limits. Pulmonary was clear. Cardiovascular: Regular rate and rhythm without murmur. Severe pain over the mid epigastric region on palpation. Abdomen itself positive bowel sounds, no rebound. I also failed to mention that two years ago patient told me that he went into the Fairmont Hospital and was told that he had a gallbladder that needed to come out, but doctor gave him antibiotics instead and it resolved so he never went back to the hospital, so I suspect he may have had some cholecystitis at that
The patient returns today there was an ICS call on him last night, he still complains of the epigastric pains. He was seen yesterday at which time he stated that he had been having slowly increasing pain over the past five or six days prior. Denied any bloody stools or any black, tarry stools at that time. He is positive HIV he states a week ago. He was started on new medications. I do not really have the name of the medications at this time. I do have the consultant's note because of the handwriting unable to read it, nonetheless. Before the end of the discussion, he also told me that he was taking all three, naproxen, Motrin, and aspirin at the same time for different body aches that he was having. So at that time he also told me that yesterday he had some Mylanta and it helped relieve it somewhat, but this morning he states it is not helping. He was seen last night in ICS about 2:00 in the morning had emesis at that time. Denies any blood in the emesis. Denies any again black tarry stools. Last bowel movement, again was yesterday. Urinary problems none.
OBJECTIVE …show more content…
Holding his epigastric region at this time. His weight is 176 pounds. Blood pressure is 103/57, pulse 78, respirations right around 18, O2 sats 97%, temperature is 97 degrees. HEENT: All within normal limits. Pulmonary was clear. Cardiovascular: Regular rate and rhythm without murmur. Severe pain over the mid epigastric region on palpation. Abdomen itself positive bowel sounds, no rebound. I also failed to mention that two years ago patient told me that he went into the Fairmont Hospital and was told that he had a gallbladder that needed to come out, but doctor gave him antibiotics instead and it resolved so he never went back to the hospital, so I suspect he may have had some cholecystitis at that