Abdominal Pain Physical Assessment Assignment _ Documentation.pdf - Abdominal Pain Physical Assessment Assignment Results | Turned In Advanced Health

Abdominal Pain Physical Assessment Assignment _ Documentation.pdf

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Abdominal Pain Physical Assessment Assignment Results | Turned In Advanced Health Assessment - Chamberlain, NR509-October-2018 Return to Assignment Your Results Lab Pass Lab Pass Document: Vitals Document: Provider Notes Document: Provider Notes Student Documentation Model Documentation Subjective CC: abdominal pain and constipation Onset: started 5 days ago Location: constant, lower abdomen Duration: worse over past few days Characteristics: straining to have BM for several days then finally a few days ago had a BM but was diarrhea, then pain got worse. Denies pain during BM. Pain was 1 or 2 out of 10 at onset on pain. Curently states pain is dull and cramping, currently 6/10. Pain has interfered with daily activities such as exercising and cleaning. Aggravating Factors: moving and eating, pt states she cannot eat more than a few bites. Eating also causes bloating. Relieving Factors: resting Treatment: None Allergies: Latex- contact dermatitis Denies environmental or food allergies Medications: Accupril 10mg po daily for blood pressure, last taken at 8am PMHx: All immunizations current No influenza vaccine this year Hypertension- age 54 C-section- age 40 Cholecystectomy- age 42 Hospitalizations for above surgeries and childbirth, Ms. Park reports that she is “having pain in her belly.” She experienced mild diarrhea three days ago and has not had a bowel movement since. She reports that she has been feeling some abdominal discomfort for close to a week, but the pain has increased in the past 2-3 days. She now rates her pain at 6 out of 10, and describes it as dull and crampy. She reports her pain level at the onset at 3 out of 10. She is also experiencing bloating. She did not feel her symptoms warranted a trip to the clinic but her daughter insisted she come. She describes her symptoms primarily as generalized discomfort in the abdomen, and states that her lower abdomen is the location of the pain. She denies nausea and vomiting, blood or mucus in stool, rectal pain or bleeding, or recent fever. She denies vaginal bleeding or discharge. Reports no history of inflammatory bowel disease or GERD. Denies family history of GI disorders. Her appetite has decreased over the last few days and she is taking small amounts of water and fluids. Previously she reports regular brown soft stools every day to every other day. Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Self-Reflection Documentation / Electronic Health Record
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Student Documentation Student Documentation Model Documentation Model Documentation denies other hospitalizations Dr. Keller-PCP No recent eye exam Last PAP smear 10 years ago Last pelvic exam 3 years ago
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