focused abd exam.docx - Chief complaint patient complains of abdominal pain diarrhea for one day with 3-4 episodes during that day followed by no bowel

focused abd exam.docx - Chief complaint patient complains...

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Chief complaint: patient complains of abdominal pain, diarrhea for one day with 3-4 episodes during that day followed by no bowel movement in fivedays History of present illness: patient states she started with abdominal painthat started 5 days ago. Patient complaining of diffuse abdominal pain the most painful area is the lower left quadrant and lower right quadrant. Patient states the pain is constant in nature. Patient states he pain is dull and crampy. Patient states pain is currently 6 out of 10. Patient states movement in eating exacerbates the pain. Alleviating factors include rest. Treatment includes rest and small sipsof warm water. Current medications include accupril 10 mg PO daily. Allergies include latex which causes pruritic skin rash. Past medical history includes: hypertension diagnosed at age 54 3 pregnancies surgical history includes C-section at age 40 cholecystectomy at age 42 reports hospitalizations for 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 of10, and describes it as dull and crampy. She reports her pain levelat 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 GIdisorders. Her appetite has decreased over the last few days and she is taking small amounts
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the prior surgeries and after childbirth Patient is postmenopausal with last menstrual period Occurring 20 years ago Social history patient is a retired nurse. Patient Gardens takes walks attends exercise classes at the community center which includes water aerobics and also has recently started working out with Pilates. Patient states she does not drink oftenpatient denies tobacco use. Patient states she uses her seatbelt while in the car and has working smoke detectors at home. Patient states her diet consist of low-fat foods also includes healthy proteins on holidays
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  • Fall '15
  • Crohn's disease, Bowel obstruction

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