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5/28/2018Focused Exam: Abdominal Pain | Completed | Shadow Health1/5Focused Exam: Abdominal Pain Results | Turned InAdvanced Health Assessment - Chamberlain, NR509-April-2018Return to AssignmentYour ResultsLab PassDocument: VitalsDocument: Provider NotesDocument: Provider NotesStudent DocumentationModel DocumentationSubjectiveMiss Park is a 78 year old female of Korean to senddate of birth Jan 17. CC Miss Park States" I have some pain in my bellyand I am having diﬃculty going to the bathroom mydaughter was worried about me." C: pain in belly with diﬃculties going to thebathroom, dull crampy feeling. 6/10 on pain sacele O: 5 days ago, gradual, constant and bloating L: lower belly, entire bellly D: constant pain E: moivng and eating , has missed both of herexercise classes and states " never misses herexercise classes." R: resting helps a little but no real relief, sips ofwarm water a friend suggested not helping R: patient has not tried any medication, aggravatedwith eating and physical activity also reports lowenergy level, a dull crampy feeling a 6 out of 10 onthe Pain Scale. A: Bowel movement noted a few days ago wasdiarrhea, denies any history of constipation. Reportshaving diarrhea about 2 to 3 days ago sudden onsetlasting one day, record very loose and watery:normal normal bowel movements description ofbrown formed and soft are usually every day until 5days ago. Reports recent slight decrease infrequency of urination do to decrease water intake.Urine darker than usual. Denies blood in urine.Denies any GI history disorders. Denies history ofMs. Park reports that she is “having pain in herbelly.” She experienced mild diarrhea three daysago and has not had a bowel movement since. Shereports that she has been feeling some abdominaldiscomfort for close to a week, but the pain hasincreased in the past 2-3 days. She now rates herpain at 6 out of 10, and describes it as dull andcrampy. She reports her pain level at the onset at 3out of 10. She is also experiencing bloating. She didnot feel her symptoms warranted a trip to the clinicbut her daughter insisted she come. She describesher symptoms primarily as generalized discomfort inthe abdomen, and states that her lower abdomen isthe location of the pain. She denies nausea andvomiting, blood or mucus in stool, rectal pain orbleeding, or recent fever. She denies vaginalbleeding or discharge. Reports no history ofinﬂammatory bowel disease or GERD. Denies familyhistory of GI disorders. Her appetite has decreasedover the last few days and she is taking smallamounts of water and ﬂuids. Previously she reportsregular brown soft stools every day to every otherday.OverviewTranscriptSubjective Data CollectionObjective Data CollectionEducation & EmpathyDocumentationSelf-ReﬂectionDocumentation / Electronic Health Record