Student name:

Alyssa Matulich Date: 3/12/19

UTC SON Health Clinic

Patient’s Name: B.C. Date of Birth: 1/12/98 Date of Office Visit: 2/18/19

Reason for Visit: birth control and right sided pain

HPI: Pt came in today for a 3 month follow up after starting birth control. Pt states she also has been experiencing pain on
her right side over the past six months that has progressively gotten worse and had a pretty bad "attack" one week ago.
Attack was after attending a party and drinking alcohol and eating junk food. Pt started taking Lo Loestrin OCP 3 months ago
after coming in and wanting a different method of birth control other than condoms which she was not using every time she
had sex. Pt is having her period every 28 days. LMP 3-5-19. Her period lasts for 5 days and has little bledding. Pt stated that
she does have mild cramping associated with her periods but it is relieved by taking Aleve. Denies any irregular bleeding or
spotting. Pt states that she has one current sexual partner who is a male. In the last six months she has had 2 sexaul
partners who are male and 3 sexual partners in the last year. Pt states that she has been been better about using condoms
but forgets sometimes. Denies history of STIs. Pt states she had complete Gardsil series while she was a teenager. Pt states
her right sided pain is located up near her ribs and radiates around toward her back. Pt denies fever, vomiting or diarrhea,
blood in urine or stool, change in weight. Pt states that when pain occurs it is extreme and comes with nausea. She is not
sure if the pain is associated with her menstrual cycle because she has only had it for three weeks. The pain waxes and
wanes and is dull and achy and can progress to being sharp. She is unsure if the pain has to do with the food she eats but
states it usuallt is worse after dinner which is her largest meal. She states that her diet is not that great and she does eat
foods high in fat. Both her mother and older sister have had their gallbladder removed. Denies personal history of ovarian
cysts and kidney stones. Denies any trauma to abdomen or back.

Past Medical History (illnesses, surgeries, hospitalizations, etc.): Pt has had her wisdom teeth removed two years ago. Up
to date on immunization per pt. States she has had Gardisil series as a teenager. .

Family History: Denies history of diabetes, CA, heart disease, migraines. Mother has HTN. Sister has hypothyroidism.

Social History: Pt lives with a roomate in an apartment not far from her college campus. Pt states she feels safe in her
home. Works as a nanny for 2 small children 3 days a week. She is majoring in child and family studies. Her family lives
about twenty minutes away from her and she is very active in her church .

Have you ever used tobacco? Yes Never smoked

Number of packs per day:     
Quit:     (year)
Number of years smoking:     
Do you plan to quit?
Yes No When?
How much alcohol do you drink? Yes None
How much? Less than 7 drinks per week
Have you ever used illicit drugs? Yes No
More information:      
Do you exercise? Yes No
How often? 1-3 times per week
What do you do? Walking
What does your diet consist of? 24 hour diet recall: Breakfast two eggo waffles with butter and
orange juice. Lunch peanut butter and jelly sandwich and smart

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 food popcorn. Dinner: Chik fil A spicy chicken sandwich and fries
with a diet coke.
Do you eat vegetables? Yes, a few times a week
Do you eat sweets? Yes, a few times a week
Do you drink water? Yes, everyday
Do you drink caffeine?
Yes No
Are you sexually active? Yes No In the past, but not currently
How many partners in the last 12 months? 3
How many lifetime partners? 5

Medications: Lo loestrin OCP Allergies & Reaction: NKA

REVIEW OF SYSTEMS
If positive, mark with an X and describe further. If all negative, select ‘denies all’. If not performed, leave blank.

Constitutional: Fever Chills Fatigue Weight gain Weight loss Diet changes Denies all Notes:      

Eyes: Itching Burning Vision changes Discharge Denies all Notes:      

ENT: Sore throat Hoarse Nosebleed Ear pain Drainage Congestion Dental problems Denies all
Notes:      

Respiratory: Shortness of breath Cough Sputum Wheezing Denies all Notes:      

Cardiovascular: Chest pain Palpitations Racing heart Edema Dyspnea on exertion Denies all Notes:      

GI: Abdominal pain Nausea Vomiting Heartburn Dysphagia Constipation Diarrhea Melena
Hematochezia Denies all Notes: SEE HPI

GU: Urinary frequency Burning Itching Vaginal Discharge Pain with sex Denies all Notes:

Female: Breast pain Breast lumps Breast discharge Heavy bleeding Painful periods Irregular periods
Denies all Notes:

MS: Pain Stiffness Swelling Joint pain Denies all Notes:      

Hematology / Lymph: Bleeding Bruising Enlarged lymph nodes Tender lymph nodes Denies all Notes:      

Endo: Excessive thirst Cold intolerance Heat intolerance Night sweats Hair loss Denies all Notes:      

Skin: Rash Lesion Ulcer Pigment changes Changing moles Nail problems Denies all Notes:      

Psych: Sadness Irritability Suicidal thoughts Anxiety Insomnia Sleep problems Denies all Notes:      

Neuro: Headache Numbness Tingling Burning Pain Dizziness Vertigo Denies all Notes:      

Immune: Environmental allergies Sneezing Rhinorrhea Denies all Notes:      

Additional ROS information:      

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 PHYSICAL EXAM
Height 5'5" Weight 220lbs BMI       BP 121/78 T 97.8 P 90 R 16 Pain 2/10 Reason for pain:right side pain

General: Caucasian female, sitting on edge of bed

Skin/Hair/Nails: Skin is warm, dry, smooth and clean throughout. Color is appropriate for race. Hair on scalp is
thick, black, shoulder length, and curly. Nails on hands are clean, well-groomed, firm and without deformities.

Eyes: Sclera white bilaterally.

ENT/Mouth: Buccal mucousa intact throughout.

Neck/Thyroid: Neck is symmetrical without deformities. Thyroid midline, symmetrical, without enlargement or
tenderness.

Lungs: CTA throughout bilaterally. Symmetrical chest expansion.

CV: Heart RRR. S1 and S2 equal. No splitting, gallops, rubs, murmurs, or snaps.

Breasts:      

Abdomen: Flat, soft, and symmetrical. Tenderness on palpation in upper outer right quadrant. Positive
Murphy's sign. Negative McBurney's point Bowel sounds active in all four quadrants.

Female Genitalia:

Vagina: .

Cervix:      

Uterus:      

Adnexa:      

Rectum:      

MS: Upper and lower extremities with full ROM and strength 5/5. Denies CVA tenderness

Neuro: A&Ox3.PERRLA. Speech clear and organized.

Lymph: No pre/postauricular, ant/posterior cervical chain, occipital, submandibular, submental,

supraclavicular,

infraclavicular, axillary, inguinal node lymphadenopathy

Psych: Pt cooperative and pleasant during interview.

Additional PE information:      

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In-Office Diagnostics and Results:

UPT- negative
UA- WNL

Differential Diagnoses (provide rationales and references):

1. Cholelithiasis- Typically, gallstones are asymptomatic but can progress to symptomatic disease. The
most common symptom seen in patients with gallstones is biliary colic which is pain located in the
upper right quadrant of the abdomen . The pain is typically steady, moderate to severe, lasts one to five
hours and then subsides. Biliary colic is due to the intermittent blocking of the biliary duct by a
gallstone . Nausea and vomiting may accompany the biliary colic but there will not be a change in
bowel patterns. Fatty foods can trigger biliary colic and should be avoided by the patient (Abraham et
al., 2014).
2. Appendicitis- abdominal pain is the most common symptom along with anorexia, right lower quadrant
pain, and nausea and vomiting. Patients may also have indigestion, flatulence, bowel irregularity,
diarrhea, and general malaise. This diagnosis is not likely. (Martin, 2018)
3. Kidney stones- pain is the most common symptom and varies from mild and barely noticeable ache to
intense discomfort. The pain typically waxes and wanes in severity. The site of the stone or obstruction
determines the location of the pain. (Churan, 2018)
4.      
5.      
6.      
Additional information:      

Assessment (ICD 10 codes, visit level codes, CPT codes):

K80.81- cholelithiasis
Z30.41- encounter for surveillance of OCP
99214- visit code
UA- 8100
UPT- 81025

Plan (evidence-based diagnostics, treatments, patient education, health promotion, health maintenance,
referrals, and follow-up for each assessment diagnosis):

Cholelithiasis
- Preformed UA to rule out UTI and to asses for blood in urine (kidney stone). UPT to rule out eptopic
pregnancy.
-Referred for US of gallbladder to be done 3/14/19 and results faxed to office. Will call pts with results and
refer to GI if necessary.
- Educated pt about diet low in fat and high in fiber to aid in emptying gallbladder and avoiding alcohol which
can cause symptoms. Also disscussed causes of gallstones and losing weight slowly.
- Discussed using tylenol and NSIADS for pain relief.

Birth Control:
- Discussed using condom for STI protection

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- Re-enforced education about proper way to take OCP what to do if a pill is missed.
- Discussed possible side effects and monitoring blood pressure and preforming SBE.
- Refilled prescription for Lo Loestrin.

Health Promotion and Prevention

- Yearly gynecological exam and pap starting at 21 or three years after first sexual encounter.
- Discussed slef breast exams

Additional Information:

Provider signature: Alyssa Matulich Date: 3/20/19

References:

Abraham, S., Rivero, H. G., Erlikh, I. V., Griffith, L. F., & Kondanudi, V. K. (2014, May 15). Surgical and Nonsurgical
Management of Gallstones. American Family Physician, 10, 795-802.

Churan, G. (2018, September 21). Diagnosis and acute management of suspected nephrolithiasis in adults.

Hawkins, J. W., Roberto-Nichols, D. M., & Stanley-Haney, J. L. (2016). Guidelines for nurse practitioners in gynecologic
settings (11th ed.). New York, NY: Springer Publishing Company, LLC.

Martin, R. (2018, April 27). Acute appendicitis in adults: Clinical manifestations and differential diagnosis.

Siddiqui, A. A. (2016). Cholelithiasis. Mereck Manual.