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PEN Note Exemplar 2021

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“My stomach hurts and it hasn’t gone away” HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts (Subjective) Mr. Fitzwalter is a 22 year old male who presented to the clinic ... today with complaints of persistent abdominal pain to the lower right abdomen. He seems moderately distressed and has difficulty getting on exam table. Onset:8 hours ago Location: right lower quadrant abdomen Duration: approx.. 8 hours. Character: He reports 6/10 severity, non-radiating, achy pain and pressure that is progressively worsening with time Aggravating/alleviating factors: Worse with any movement of any kind, Tender to touch, unable to get relief with position change Related symptoms: anorexia with onset of symptoms 8 hours ago; Unable to have BM today. Denies any prior similar episodes, recent known illnesses or exposure to other ill contacts. His last meal consisted of a protein shake, fruit and granola. States he regularly drinks water. Has not eaten in the past 10 years and has not ingested any raw or uncooked food that he is aware of in the past 24 hours. Treatments: Has tried OTC pepto bismol twice without relief Significance: Pain on scale 1-10, rated at “6-7”. Otherwise he reports he is in good health and has never had any s/s like this before. [Show More]

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