NR 509 Focused abd Exam
Chief complaint: patient complains of Ms. Park reports that she is
abdominal pain, diarrhea for one day “having pain in her belly.” She
with 3-4 episodes during that day experienced mild diarrhea three
followed by no bowel movement in five days ago and has not had a
a
days bowel movement since. She
vi
reports that she has been feeling
History of present illness: patient some abdominal discomfort for
d
states she started with abdominal pain close to a week, but the pain has
increased in the past 2-3 days.
e
that started 5 days ago. Patient
complaining of diffuse abdominal pain She now rates her pain at 6 out of
ar
the most painful area is the lower left 10, and describes it as dull and
crampy. She reports her pain level
sh
quadrant and lower right quadrant.
Patient states the pain is constant in at the onset at 3 out of 10. She is
nature. Patient states he pain is dull also experiencing bloating. She
as
and crampy. Patient states pain is did not feel her symptoms
currently 6 out of 10. Patient states warranted a trip to the clinic but
w
movement in eating exacerbates the her daughter insisted she come.
pain. Alleviating factors include rest. She describes her symptoms
Treatment includes rest and small sips primarily as generalized
m e
of warm water. discomfort in the abdomen, and
co rc
Current medications include accupril
states that her lower abdomen is
the location of the pain. She
o. ou
10 mg PO daily. denies nausea and vomiting,
blood or mucus in stool, rectal
er res
Allergies include latex which causes pain or bleeding, or recent fever.
pruritic skin rash. She denies vaginal bleeding or
discharge. Reports no history of
Past medical history includes: inflammatory bowel disease or
eH y
hypertension diagnosed at age 54 3 GERD. Denies family history of GI
rs ud
pregnancies surgical history includes disorders. Her appetite has
C-section at age 40 cholecystectomy decreased over the last few days
t
at age 42 reports hospitalizations for and she is taking small amounts
ss
hi
, the prior surgeries and after childbirth of water and fluids. Previously she
Patient is postmenopausal with last reports regular brown soft stools
menstrual period Occurring 20 years every day to every other day.
ago Social history patient is a retired
a
nurse. Patient Gardens takes walks
vi
attends exercise classes at the
community center which includes
d
water aerobics and also has recently
started working out with Pilates.
e
Patient states she does not drink often
ar
patient denies tobacco use. Patient
states she uses her seatbelt while in
sh
the car and has working smoke
detectors at home. Patient states her
as
diet consist of low-fat foods also
includes healthy proteins on holidays
w
she makes traditional Korean dishes
but usually eats very light. patient
states she tries to supplement fiber
m e
intake by eating at least one vegetable
co rc
a day. patient states she is currently
sexually active with a male partner.
o. ou
Family history includes mother
er res
deceased at age 88 history of
hypertension and Diabetes Type 2
father deceased at age 82 history of
hypertension hypercholesterolemia
eH y
Maternal grandparents family history
rs ud
of coronary artery disease and
Diabetes Type 2 paternal
t
grandparents family history of obesity
ss
hi
Chief complaint: patient complains of Ms. Park reports that she is
abdominal pain, diarrhea for one day “having pain in her belly.” She
with 3-4 episodes during that day experienced mild diarrhea three
followed by no bowel movement in five days ago and has not had a
a
days bowel movement since. She
vi
reports that she has been feeling
History of present illness: patient some abdominal discomfort for
d
states she started with abdominal pain close to a week, but the pain has
increased in the past 2-3 days.
e
that started 5 days ago. Patient
complaining of diffuse abdominal pain She now rates her pain at 6 out of
ar
the most painful area is the lower left 10, and describes it as dull and
crampy. She reports her pain level
sh
quadrant and lower right quadrant.
Patient states the pain is constant in at the onset at 3 out of 10. She is
nature. Patient states he pain is dull also experiencing bloating. She
as
and crampy. Patient states pain is did not feel her symptoms
currently 6 out of 10. Patient states warranted a trip to the clinic but
w
movement in eating exacerbates the her daughter insisted she come.
pain. Alleviating factors include rest. She describes her symptoms
Treatment includes rest and small sips primarily as generalized
m e
of warm water. discomfort in the abdomen, and
co rc
Current medications include accupril
states that her lower abdomen is
the location of the pain. She
o. ou
10 mg PO daily. denies nausea and vomiting,
blood or mucus in stool, rectal
er res
Allergies include latex which causes pain or bleeding, or recent fever.
pruritic skin rash. She denies vaginal bleeding or
discharge. Reports no history of
Past medical history includes: inflammatory bowel disease or
eH y
hypertension diagnosed at age 54 3 GERD. Denies family history of GI
rs ud
pregnancies surgical history includes disorders. Her appetite has
C-section at age 40 cholecystectomy decreased over the last few days
t
at age 42 reports hospitalizations for and she is taking small amounts
ss
hi
, the prior surgeries and after childbirth of water and fluids. Previously she
Patient is postmenopausal with last reports regular brown soft stools
menstrual period Occurring 20 years every day to every other day.
ago Social history patient is a retired
a
nurse. Patient Gardens takes walks
vi
attends exercise classes at the
community center which includes
d
water aerobics and also has recently
started working out with Pilates.
e
Patient states she does not drink often
ar
patient denies tobacco use. Patient
states she uses her seatbelt while in
sh
the car and has working smoke
detectors at home. Patient states her
as
diet consist of low-fat foods also
includes healthy proteins on holidays
w
she makes traditional Korean dishes
but usually eats very light. patient
states she tries to supplement fiber
m e
intake by eating at least one vegetable
co rc
a day. patient states she is currently
sexually active with a male partner.
o. ou
Family history includes mother
er res
deceased at age 88 history of
hypertension and Diabetes Type 2
father deceased at age 82 history of
hypertension hypercholesterolemia
eH y
Maternal grandparents family history
rs ud
of coronary artery disease and
Diabetes Type 2 paternal
t
grandparents family history of obesity
ss
hi
