HPI Templates

Biliary Colic

Pain described as sharp and episodic. Pain is often postprandial with an association with fatty foods.
Denies exertional component. No recent binge drinking episodes. No history of alcohol abuse or smoking. Denies any recent abdominal trauma.
Patient denies SOB and cough.
Patient denies personal history of cardiac disease and family history of cardiac disease under the age of 50yo.
Patient denies dysuria and gross hematuria.
Patient denies any unilateral abdominal rash.

Related: Gallbladder Problems MDM

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GERD

Endorses epigastric pain.
Pain described as burning, gradual, and episodic.
Patient is not diaphoretic during pain. No radiation to arm. Denies exertional component.
Pt denies personal history of cardiac disease and family history of cardiac disease under the age of 50yo.
Reports no specific relationship with fatty meals. No recent binge drinking episodes. No history of alcohol abuse or smoking.
Patient denies SOB or productive cough.
Pt without dysuria or changes to urinary/bowel habits. Denies history of abdominal surgery.
Denies F/N/V.

Pt has never trial’ed antacid therapy or conservative GERD measures such as timing eating before lying flat or avoiding trigger foods.

Related: GERD MDM

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GI Bleed

Endorses moderate GI bleeding characterized as hematemesis that began today.

There is associated abdominal pain.
The patient endorses feeling weak or lightheaded.
There is a history of similar bleeding.
Positive for melena.
The patient endorses a history of alcohol abuse and liver disease.

Associated symptoms include:
No recent illness or fever
+ nausea and vomiting

Related: GI Bleed MDM

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Nausea Vomiting Diarrhea

Endorses watery, brown, diarrhea, occurring less than 10 times per day.
There is no blood in the stool.
No recent camping, travel, or antibiotic use.
There are occasional mild abdominal cramps, but generally no pain.
Symptoms are not worsened or improved by anything.
Denies fever. No known sick contacts. Denies LOC.

Related: Nausea/Vomiting/Diarrhea MDM