HPI:

Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.

Mr. Rodriguez is a 39-year-old male that recently immigrated to the United States from Dominican Republic. He complains of epigastric pain that began approximately one year ago. He describes the pain as “burning” and occurring daily. He states that the pain sometimes worsens with eating and sometimes it improves. He states that spicy foods make the pain worsen. He admits to weekly NSAID usage and drinking 3-4 alcoholic beverages a week. He quit smoking 6 months ago. He drinks an herbal tea but does not experience any relief or change in the symptoms. He denies any fever, chills, nausea, hematemesis, hematochezia, or melena.

Medications: (list with reason for med )

PMH

Allergies: No known drug allergies

Medication Intolerances: Takes ibuprofen “almost daily” for aches and pains associated with working. Drinks herbal tea meant to improve GI symptoms.

Chronic Illnesses/Major traumas: Not indicated

Hospitalizations/Surgeries: No history of surgery.

Family History Does your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with:

lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.

Patient states family history of heart disease. Father had hypertension and his mother had diabetes.

Social History

ETOH, tobacco, marijuana. Safety status

Patient denies smoking. Patient states that he quit smoking 6 months ago. Patient states that he drinks 3-4 beers weekly. No illicit drugs.