NR 509 Abdominal Pain Documentation Shadow.pdf - Abdominal Pain Physical Assessment Assignment | Completed | Shadow Health Abdominal Pain Physical

NR 509 Abdominal Pain Documentation Shadow.pdf - Abdominal...

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12/10/2018Abdominal Pain Physical Assessment Assignment | Completed | Shadow Health1/5Abdominal Pain Physical Assessment Assignment Results | CompletedAdvanced Health Assessment - Chamberlain, NR509-October-2018Return to AssignmentYour ResultsTurn InTurn InLab PassLab PassDocument: VitalsDocument: Provider NotesDocument: Provider NotesStudent DocumentationStudent DocumentationModel DocumentationModel DocumentationSubjectivePatient Info: Esther Park, 78 years, Asian female CC: Patient states that they are "having pain in herbelly" and that she is having trouble "going to thebathroom." HPI: The patient, Ms. Park, came into the officecomplaing of abdominal pain and not being able tohave a bowel movement. She states that this painstarted 5 days ago and has gotten worse over thepast 2 to 3 days. The pain is in the lower abdomenand does not radiate. She does not have painanywhere else. She states that her currentabdominal pain could be rated a 6 out of 10. Shedescribes the pain as "dull and crampy." She statesthat it does get worse sometimes, especially afterphysical activity or eating. She states that restingdoes help, but the only treatment she has pursued is"taking small sips of warm water," a method herfriend infromed her of. This has not been an effectivetreatment. She states that she is not being able to goabout her normal daily activities due to the pain. Shealso reports a low energy level. She is currentlyconstipated, and issue that she has no history of.She has been constipated for about 5 days, but hasnot pursued any treatment. She had a bout ofdiarrhea about 3 days ago that she described as"loose and watery." It lasted for one day. Before theonset of the abdominal pain 5 days ago, the patientstates that they had normal bowel habits, but has nothad a movement in 3 days. No mucus or blood instool. Patient states that the frequency of herMs. Park reports that she is “having pain in herbelly.” She experienced mild diarrhea three days agoand 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.
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