DATE OF SERVICE: MM/DD/YYYY
CHIEF COMPLAINT: Abdominal discomfort.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old woman with multiple medical problems, including hypertension, high cholesterol, gastroesophageal reflux disease, incontinence, allergies, back pain, morbid obesity, and recent evaluation of the eyes who comes in for evaluation of abdominal discomfort.
The patient states that the symptoms started in the fall. The reason why she is here is because they seem more frequent and persistent. She states that she would have these sporadic episodes of diffuse abdominal discomfort, which would last anywhere from one to two hours associated with nausea. She had vomiting with it as well and then it would just go away. She might not have it for days or weeks and then it would just come back out of nowhere.
She had an episode today and then she had it three days ago. She feels it is just getting worse, and she is getting concerned. She does not have diarrhea, but she did have episodes of vomiting. It is not severe, but she definitely has the discomfort. Nothing makes it better. Nothing makes it worse. She does not feel that it is associated with food. It will just come, stay with her for a few hours, make her sick, and then it would go away.
PAST MEDICAL HISTORY: Hypertension, high cholesterol, gastroesophageal reflux disease, incontinence, allergies, back pain, and obesity.
MEDICATIONS: Atenolol 100 mg daily, doxazosin 4 mg daily, Dyazide 25 mg, omeprazole 20 mg, Lipitor 20 mg, Flonase, doxycycline 100 mg daily since late summer, multivitamin, iron, Probiotica, and Lasix.
PHYSICAL EXAMINATION: Blood pressure 140/82, heart rate 78. In general, she is not in acute distress, but she is a little fatigued appearing. Heart: S1, S2. Lungs are clear. Abdomen: Obese. She has bowel sounds. She did have some diffuse tenderness to palpation in her lower abdomen.
ASSESSMENT AND PLAN: The patient is a (XX)-year-old woman who comes in for evaluation of abdominal discomfort. The abdominal discomfort has been present for months, getting more frequent, associated with some nausea and vomiting. No diarrhea. Not related to food. The patient already had a cholecystectomy.
Differential diagnosis would include gastritis, side effects of the doxycycline, possibly colitis. For now, we will take a CT of the abdomen and pelvis. We will change her Prilosec to Nexium.
The patient is also going to discuss it with her doctor to try to substitute the doxycycline with a different antibiotic or possibly put it on hold. If it turns out that the patient feels better off the antibiotic, that would be reassuring to know the etiology of her symptoms. The patient states that unless it gets worse, she is willing to stay on the antibiotic and just bear with the symptoms.
