Non-Specific Symptoms

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of ‍

Onset was ‍gradualsuddentraumatic, started ‍whileafter ‍

Location is ‍

Radiation ‍none to ‍

Rated at ‍012345678910 / 10 ‍

Described as ‍crampingburning

Pattern ‍constantintermittent

Episodes last for ‍ ‍, recur ‍ times per ‍

Worsening factors: ‍none ‍

Alleviating factors: ‍none, ‍effectiveineffective



Associated symptoms: *Try using right-click for negatives*

‍none





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍guarding, bowel sounds ‍normal, ‍, ‍CVA tenderness ‍

Skin: ‍rashlesions on ‍

Extremities: ‍warm, ‍dry, cap refill ‍< 3> 3 sec, pulses ‍intact, ‍edema ‍bilaterally, ‍





PLAN:

Investigations:

-

Treatments:

-

Further care:

- Follow-up in ‍ ‍daysweeksmonths

- Return if symptoms worsen or new symptoms develop