2-8 PATIENT NOTES STOMACH ACHE HISTORY: Describe the history you just obtained from this patient.

. Include only information (pertinent positives and negatives) relevant to this patients problem(s). HPI: 32 YO F C/O RLQ PAIN, STARTED THIS MORNING, 6/10 INTENSITY, CRAMPING, CONSTANT AND GETTING WORSE. PATIENT REPORTS CHILLS VOMITED ONE TIME YELLOW FLUID, DIARRHEA FOR ONE DAY OF BROWN LOOSE STOOLS. NO BLADDER CHANGES. OBGYN: G1, MENARCHE 13 YO, LMP 2 WEEKS AGO, EVERY 30 DAYS LAST 5 DAYS 4 PADS A DAY. PAP SMEAR 1 YEAR AGO NORMAL. CLEAR VAGINAL DISCHARGE, BROWN SPOTTING BETWEEN MENSES. STD 6 MONTHS AGO, DOES NOT KNOW NAME RELIEVE WITH MEDICATIONS PARTNER WAS NOT TREATED. SEXUALLY ACTIVE WITH 3 PARTNERS IN THE LAST YEAR. ROS: NEGATIVE EXCEPT AS NOTED ABOVE ALLERGIES: NONE MEDICATIONS: NONE PMH: STD 6 MONTHS AGO TREATED WITH MEDICATION AND RESOLVED PSH: NONE FH: PARENTS ALIVE AND WELL SH: SMOKES 1 PPD FOR 10 YEARS, DRINKS BEER ON WEEKENDS, WORKS INA RESTAURANT. PHYSICAL EXAM: Describe any positive and negative findings relevant to this patients problem(s). Be careful to include only those parts of examination you performed in this encounter. SHE IS IN ACUTE PAIN AND HER VITALS ARE WITHIN NORMAL LIMITS. HER BREATH SOUNDS ARE CLEAR BILATERALLY. HER HEART SOUNDS ARE NORMAL WITHOUT RUBS, GALLOPS OR MURMURS. HER ABDOMEN IS SOFT AND BOWEL SOUNDS ARE PRESENT. SHE HAS TENDERNESS IN HER RLQ ON PALPATION. SHE HAS A POSITIVE PSOAS, OBTURATOR AND ROVSINGS SIGN. SHE HAS NO CVA TENDERNESS. DATA INTERPRETATION: Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patients complaint(s). List your diagnoses from most to least likely. For some cases. Fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from the history and physical examination (if present) that support each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis (e.g. restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc. Diagnosis #1: PID HISTORY FINDING(S) PHYSICAL EXAM FINDING(S) -C/o cramping RLQ pain with 6/10 intensity - Patient is in acute pain -Associated with chills and vomiting - Abdomen: tenderness present -H/o STD 6 months ago in the RLQ

Diagnosis #2: APPENDICITIS HISTORY FINDING(S) PHYSICAL EXAM FINDING(S) -C/o cramping RLQ pain with 6/10 intensity - Patient is in acute pain -Associated with chills, vomiting, diarrhea - Abdomen: Tender abdomen -Pain is constant and getting worse + psoas, +obturator, +rovsings Diagnosis #3: RUPTURED OVARIAN CYST HISTORY FINDING(S) PHYSICAL EXAM FINDING(S) -C/o cramping RLQ pain - Patient is in acute pain -Pain is constant and getting worse - Abdomen: Tenderness present -Associated with chills and vomiting in the RLQ Diagnostic Studies: - RECTAL EXAM - PELVIC EXAM - URINE HCG - UA - CERVICAL CULTURES