NURS550 Focused Note Esther Park Nursing assignment

Ammara Chaudhry NURS 550 Focused Note Subjective: Date of encounter: April 25, 2019 Patient Name or initials: Esther Park Informant: 78-year-old woman who is a reliable historian. Chief Complaint (CC): Abdominal pain. History of present illness (HPI): Ms. Park reports that she is having abdominal pain for almost a week now, beginning 5 days ago. She notes the pain is generalized across her entire abdomen, however, hurts more along the left lower quadrant. The pain is increasingly getting worst in the past 2-3 days. She rates her pain a 6 out of 10 and describes it as dull and cramping. She has not tried any medications for pain relief. Ms. Park denies any recent travel. 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. 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 left abdomen is the location of the pain. She denies any radiating 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 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. Her pain is aggravated when she moves around and is active. Staying still at rest lessens the pain but does not eliminate it completely. Ms. Park denies taking