Patient :Hello, I happen to be a scribe, so for simplicity I'll just create my own HPI and ROS because I am in moderate to severe discomfort as present.
I am a 23 y/o female with a hx of hyperprolactinoma. I began having mild mid-low back aching and tightness since roughly 1100 today that exacerbates with movement, standing, ambulating, or sitting, and decreases/ almost resolves while lying flat in supine position. Throughout the day my pain has progressed is now also in my chest and abdomen. I would rate the pain a "8/10" considering it's debilitating and can only write this to you as I'm lying flat. On exertion (when my pain is worst) I have difficultly obtaining a deep breath secondary to the extreme tightness, and can both feel and see a pulsating rhythm in my abdomen just below epigastric region and right above umbilicus. I have no n/v/d, fever, dysuria, hematuria, radiating pain, dizziness, HA, numbness, diaphoresis, rash, cough, melena, swelling, or any other exacerbated/associated Sx.
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