S.
CC: “I have a fever and have been vomiting for the past two days after eating shellfish from a
new restaurant.”
HPI: Patient is a 20- year – old Caucasian female who presents to the clinic with a 2-day old
comp
...
S.
CC: “I have a fever and have been vomiting for the past two days after eating shellfish from a
new restaurant.”
HPI: Patient is a 20- year – old Caucasian female who presents to the clinic with a 2-day old
complaint of nausea, vomiting, and fever. Her symptoms are associated with consuming shellfish
two days ago at a new restaurant. Patient denies any diarrhea. Patient has not taken any
medications. Symptoms have not worsened over the duration of illness. Verbalizes no appetite
since symptoms started. Denies headache, visual disturbances, diaphoresis or dizziness.
Location: abdominal region
Onset: 2 days ago
Character: facial pressure around cheek bones and eyes
Associated signs and symptoms: abdominal pain, decreased appetite, nausea, fever
Timing: varies throughout the day and night
Exacerbating/ relieving factors: symptoms worsen when attempt to drink or eat / nothing
seems to relieve symptoms
Severity: 5/10 pain scale
Current Medications: Zyrtec 10 mg daily; Tylenol prn for headaches/fever.
Allergies: Codeine
PMHx: Patient reports history of Bronchitis and seasonal allergies. Denies gall bladder or liver
disease, denies Hx of GERD, Pancreatitis, Kidney stones, Urinary tract infections, Diverticulitis,
Inflammatory Bowel Disease, or Pelvic Infection
Childhood Illness: Scarlett Fever
Past Surgical History (PSH): None.
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