History template
[Basic info] 30 yo female c/o [CC] pain in abdomen x 2 days.
[ODP and CC description] Pain is in the lower half of her abdomen, colicky, 7/10 without any radiation. Pain started at rest and gradually worsened to present state. Has taken 2 tabs of Tums today morning with partial relief. There is no specific aggrevating factor.
[Associated symptoms from the affected system] She has associated Nausea and Vomiting. She vomited 2 times today morning. Non bilious/non bloody. No diarrhea.
[Review of other systems] No cough. No pain elsewhere in the body, No trauma, No urinary complaints.
[ODP and CC description] Pain is in the lower half of her abdomen, colicky, 7/10 without any radiation. Pain started at rest and gradually worsened to present state. Has taken 2 tabs of Tums today morning with partial relief. There is no specific aggrevating factor.
[Associated symptoms from the affected system] She has associated Nausea and Vomiting. She vomited 2 times today morning. Non bilious/non bloody. No diarrhea.
[Review of other systems] No cough. No pain elsewhere in the body, No trauma, No urinary complaints.
[P]Past medical history is significant for asthma for which she takes [M] budesonide and albuterol. No previous surgeries. [A]Allergic to penicillin and sea food. [S]Is sexually active with her husband and uses condom for contraception. [O] Has one living child that was born vaginally at term 3 years ago. No pregnancy or delivery related complications. [H] That was her only hospitalization. [U] No urinary complaints. [G] LMP was 4 weeks back. Is normally regular every month and lasts 2-3 days. [S] Does not smoke or drink alcohol. Works as a teacher in primary school. [F]Family history significant for grandmother with ovarian cancer. No DM or HTN in family.
Physical exam template
[General] Appears to be in pain but in no acute distress.
[Vitals] Vitals HR: 80/min, RR 20/min, BP 120/80mmHg, Temp 37 C
[GPE] No pallor or icterus. Neck supple. HEENT normal with moist mucous membranes.
[Sytemic Exam]Abdomen: Non distended, Normal bowel sounds in all 4 quadrants. Tenderness on palpation of thr right illiac fossa. No rebound tenderness. No masses or organomegaly.
Chest: Symmetric movements, Normal vesicular breath sounds bilaterally.
Heart: S1S2 normal. No murmur.
Differential diagnosis
1) Acute appendicitis
2) Ectopic pregnancy
3) Ovarian torsion
4) Pelvic inflamatory disease
5)
[Remember to write the Differential in order or possibility]
Diagnostic Work Up
1) Pelvic exam
2) US abdomen and pelvis
3) CBC
4) Urine pregnancy test
5)
[Remember to write Pelvic and other such exams in your Diagnostic Work Up. Examples of commonly forgotten things include
Pelvic exam
Digital rectal exam
Orthostatic vitals
Minimental state exam
Pure tone audiometry]