Source And Reliability : Patient Alert And Oriented At Time Place And Person, Reliable Historian

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II. SOURCE AND RELIABILITY: Patient alert and oriented to time place and person, reliable historian.
III. REASON FOR SEEKING CARE (CC): 38 y/o female c/o abdominal pain throughout the entire abdominal cavity, states she has always had abdominal discomfort, but the past 3 days’ pain has become unbearable. Describes pain as a burning churning through out 8/10. Pain intermittent c/o of sour stomach after meals accompanied by nausea, denies vomiting, diarrhea or anorexia, last bowel movement 4 days ago. States she moves bowels 2-3 times a week. She states this happened about 2 years she went to emergency room, CT was done, no blockage, she was sent home without meds, CT contrast helped her move bowels at the time, symptoms eventually resolved on their own. Pt c/o of waking up feeling unrested, had trouble falling asleep ever since she could remember, wakes up frequently with difficulty getting back to sleep. She reports sleep disorder sometimes coincide with inability to get comfortable due to shoulder and neck pain especially in the winter months. Pt states the head and shoulder pain are the result of a MVI in 1995 where she had spinal nerve damage and bulging disc.
IV. PRESENT HEALTH OF HISTORY OF PRESENT ILLNESS:
Abdominal pain 8/10
O. Started 3 days ago after eating large meal.
P. Pain is intermittent, worst when laying down on back or sitting down, relief felt when laying on stomach.
Q. Pain is severe, churning and feeling or sour stomach after eating.
R. Pain is felt in the RLQ, but the sour feeling throughout the entire abdominal cavity, denies radiating.
S. Pain 8/10, Milk of Magnesia taken without relief, pain the same for the past 24 hours.
T. Pain and discomfort intermittent, last 2 hours with about half hour relief,...

... middle of paper ...

...ks, but eats at home with her 2 children and significant other. Patient states she buys cooked cultural food from local Haitian restaurant to last a couple of days, she reheats and eat, but at work she orders from local restaurants. Patient admits eating out daily is costly but, she cannot cook and does not have the time or energy to cook.
Interpersonal Relationships/Resources: Patient is head of household and her parents live close by. She has friends from work and school, but does not interact daily with friends outside of work, patient states most close friends live out of state. Her sister also lives out of states. Patient has good relationship with family, but does not interact with them.
Patient states family and boyfriend are very supportive and also declares that she does not get to spend enough time alone, she is only alone on her drive to and from school.

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