Name: Sophia Gabbiadini DOB: November 20th, 1992 Age: 23 Occupation: Student/ grocery clerk
Chief complain: Abdominal Pain, Muscle weakness, Dizziness
History of present illness: This is a 23year-old Asian female previously healthy who went out for a party two nights ago. Sophia has been complaining of stomach pain snice after. Most people in the party apparently had problems afterwards with regard to their abdomen. She awoke up this morning with the pain worsen in her abdomen. Her pain continued on the right lower abdomen and apparently now has move to the whole stomach. She states she is in significant pain. She had some nausea and one incident of vomiting earlier this morning. She states it was dark/brownish in color and mostly watery. …show more content…
She is attending college; she is seeking a degree in communication and English. She works mostly on weekends as a cashier at her local gas station. She is trying a new diet which is high in protein, such as vegetables, corn, and beans. Patient has not been consuming enough fluids. She tries to sleep about 6 to 7 hours per night, but sometimes it’s difficult because of school work overload. Patient doesn`t abuse alcohol, but drinks socially, no use of tobacco or smokes or use of illegal drugs.
Review of systems
• Vital signs:
RR = 20
BP = 138/74
P = 88
% sat = 98% (RA)
T = 99.2 (oral)
• HEENT: patient hair is normal, pupils are equal, and do respond to light, tympanic membranes are normal pharynx is
Chief complain: Abdominal Pain, Muscle weakness, Dizziness
History of present illness: This is a 23year-old Asian female previously healthy who went out for a party two nights ago. Sophia has been complaining of stomach pain snice after. Most people in the party apparently had problems afterwards with regard to their abdomen. She awoke up this morning with the pain worsen in her abdomen. Her pain continued on the right lower abdomen and apparently now has move to the whole stomach. She states she is in significant pain. She had some nausea and one incident of vomiting earlier this morning. She states it was dark/brownish in color and mostly watery. …show more content…
She is attending college; she is seeking a degree in communication and English. She works mostly on weekends as a cashier at her local gas station. She is trying a new diet which is high in protein, such as vegetables, corn, and beans. Patient has not been consuming enough fluids. She tries to sleep about 6 to 7 hours per night, but sometimes it’s difficult because of school work overload. Patient doesn`t abuse alcohol, but drinks socially, no use of tobacco or smokes or use of illegal drugs.
Review of systems
• Vital signs:
RR = 20
BP = 138/74
P = 88
% sat = 98% (RA)
T = 99.2 (oral)
• HEENT: patient hair is normal, pupils are equal, and do respond to light, tympanic membranes are normal pharynx is