1
,CHIEF COMPLAINT
The patient states:
“I’ve been having worsening pain in my lower abdomen for several days.”
HISTORY OF PRESENT ILLNESS (HPI)
The patient is a 48-year-old female who reports a four-day history of abdominal pain that has
progressively worsened. The pain initially began as generalized abdominal discomfort and later
localized to the right lower quadrant.
The pain is described as sharp and constant, rated 7 out of 10 in intensity. It is aggravated by
movement, coughing, and palpation, and minimally relieved by rest. The patient reports associated
nausea, anorexia, and subjective fever. She denies vomiting, diarrhea, melena, hematochezia, or
changes in bowel habits beyond mild constipation.
She denies urinary symptoms including dysuria, frequency, urgency, or hematuria. There is no vaginal
discharge, abnormal uterine bleeding, or pelvic pain distinct from the abdominal discomfort. The
patient denies recent trauma, dietary changes, travel, or exposure to sick contacts.
She has not experienced similar symptoms in the past and reports that the pain has steadily worsened
rather than fluctuated.
2
, PAST MEDICAL HISTORY
Hypertension, diagnosed 5 years ago
Hyperlipidemia
No history of gastrointestinal disease, inflammatory bowel disease, gallbladder disease, kidney disease,
or gynecologic disorders.
3
,CHIEF COMPLAINT
The patient states:
“I’ve been having worsening pain in my lower abdomen for several days.”
HISTORY OF PRESENT ILLNESS (HPI)
The patient is a 48-year-old female who reports a four-day history of abdominal pain that has
progressively worsened. The pain initially began as generalized abdominal discomfort and later
localized to the right lower quadrant.
The pain is described as sharp and constant, rated 7 out of 10 in intensity. It is aggravated by
movement, coughing, and palpation, and minimally relieved by rest. The patient reports associated
nausea, anorexia, and subjective fever. She denies vomiting, diarrhea, melena, hematochezia, or
changes in bowel habits beyond mild constipation.
She denies urinary symptoms including dysuria, frequency, urgency, or hematuria. There is no vaginal
discharge, abnormal uterine bleeding, or pelvic pain distinct from the abdominal discomfort. The
patient denies recent trauma, dietary changes, travel, or exposure to sick contacts.
She has not experienced similar symptoms in the past and reports that the pain has steadily worsened
rather than fluctuated.
2
, PAST MEDICAL HISTORY
Hypertension, diagnosed 5 years ago
Hyperlipidemia
No history of gastrointestinal disease, inflammatory bowel disease, gallbladder disease, kidney disease,
or gynecologic disorders.
3
