5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health
Focused Exam: Abdominal Pain Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-April-2018
Return to Assignment
Your Results Lab Pass
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Document: Vitals Document: Provider Notes
Objective Data Collection
Education & Empathy Document: Provider Notes
Documentation
Student Documentation Model Documentation
Self-Reflection
Subjective
Ms. Park reports that she is “having pain in her
Miss Park is a 78 year old female of Korean to send belly.” She experienced mild diarrhea three days
date of birth Jan 17. ago and has not had a bowel movement since. She
CC Miss Park States" I have some pain in my belly reports that she has been feeling some abdominal
and I am having difficulty going to the bathroom my discomfort for close to a week, but the pain has
daughter was worried about me." increased in the past 2-3 days. She now rates her
C: pain in belly with difficulties going to the pain at 6 out of 10, and describes it as dull and
bathroom, dull crampy feeling. 6/10 on pain sacele crampy. She reports her pain level at the onset at 3
O: 5 days ago, gradual, constant and bloating out of 10. She is also experiencing bloating. She did
L: lower belly, entire bellly not feel her symptoms warranted a trip to the clinic
D: constant pain but her daughter insisted she come. She describes
E: moivng and eating , has missed both of her her symptoms primarily as generalized discomfort in
exercise classes and states " never misses her the abdomen, and states that her lower abdomen is
exercise classes." the location of the pain. She denies nausea and
R: resting helps a little but no real relief, sips of vomiting, blood or mucus in stool, rectal pain or
warm water a friend suggested not helping bleeding, or recent fever. She denies vaginal
R: patient has not tried any medication, aggravated bleeding or discharge. Reports no history of
with eating and physical activity also reports low inflammatory bowel disease or GERD. Denies family
energy level, a dull crampy feeling a 6 out of 10 on history of GI disorders. Her appetite has decreased
the Pain Scale. over the last few days and she is taking small
A: Bowel movement noted a few days ago was amounts of water and fluids. Previously she reports
diarrhea, denies any history of constipation. Reports regular brown soft stools every day to every other
having diarrhea about 2 to 3 days ago sudden onset day.
lasting one day, record very loose and watery:
normal normal bowel movements description of
brown formed and soft are usually every day until 5
days ago. Reports recent slight decrease in
frequency of urination do to decrease water intake.
Urine darker than usual. Denies blood in urine.
Denies any GI history disorders. Denies history of
1/5
, 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health
GERD heartburn or ulcers. No history of
appendicitis, stomach cancer, or history of liver
disease. Report C-section at age 40 in
cholecystectomy at age 42 no post-op
complications noted. Last pap smear noted about
10 years ago
Current medications: Accupril 10 po QD( last dose
at (0800 this morning), denies any OTC medications
Allergies: Latex : contact dermatitis
PMHx:
1. Hypertension diagnosed at age 54
2.3 Pregnancies
4. Surgical history C-section at age of 40;
cholecystectomy at age 42
Reports hospitalizations for past surgeries as noted
above and after childbirth denies any other
hospitalizations. Last pap smear and colonoscopy
10 years ago.
SocHx:
Last meal with toast for breakfast not eating well.
Usually appetite is three meals a day does not eat
snacks. Typical meal for breakfast is usually
somesort of fruit usually a banana. Typical lunch is
usuallysoup reports sometimes skipping lunch
period and typical dinner is chicken or fish with
some sort of rice or vegetable. No fiber supplements
reported.
Patient reports believes gets enough fiber supports
eating a vegetable or fruit each day. Reports
decrease in thirst especially over the last few days
typically patient drinks 6 typically patient drink 6
denies caffeinated drinks such as coffee or soda on
occasion drinks chamomile tea. Deny sexual activity
reports no STI testing. Report moderate activity
attend Fitness classes and reports gardening as a
hobby. Lives with her daughter named Jennifer and
has a strong support system with her daughter and
gentleman friend Max denies any recent travel.
Report sexually active no vaginal intercourse
reported does report oral sex.
1. No past or present tobacco use
2. Reports drinking one alcoholic (wine)beverage
per week, 4 per month only on Sunday's white wine
3. Denies using marijuana, cocaine, heroin or illicit
drugs
FAM Hx:
1. Mother- deceased at age 88 history of
hypertension and Diabetes Type 2
2. Father: deceased at 82 history of hypertension
and hypercholesterolemia
3. Maternal grandparents: family history of coronary
artery disease and Diabetes Type 2
4. Paternal grandparents: history of obesity, CVA,
hypertension
5. Siblings: brother had history of hypertension,
hypercholesterolemia, prostate cancer
6. Son: healthy age 48
7. Daughter: healthy age 46
ROS:
General: denies any recent fever chills or night
sweats although patient does report short-term
feeling of tiredness I need to rest more often.
GI: reports bloating, slight increase in flatus, recent
loss of appetite. No reports of nausea vomiting or
2/5
Focused Exam: Abdominal Pain Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-April-2018
Return to Assignment
Your Results Lab Pass
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Document: Vitals Document: Provider Notes
Objective Data Collection
Education & Empathy Document: Provider Notes
Documentation
Student Documentation Model Documentation
Self-Reflection
Subjective
Ms. Park reports that she is “having pain in her
Miss Park is a 78 year old female of Korean to send belly.” She experienced mild diarrhea three days
date of birth Jan 17. ago and has not had a bowel movement since. She
CC Miss Park States" I have some pain in my belly reports that she has been feeling some abdominal
and I am having difficulty going to the bathroom my discomfort for close to a week, but the pain has
daughter was worried about me." increased in the past 2-3 days. She now rates her
C: pain in belly with difficulties going to the pain at 6 out of 10, and describes it as dull and
bathroom, dull crampy feeling. 6/10 on pain sacele crampy. She reports her pain level at the onset at 3
O: 5 days ago, gradual, constant and bloating out of 10. She is also experiencing bloating. She did
L: lower belly, entire bellly not feel her symptoms warranted a trip to the clinic
D: constant pain but her daughter insisted she come. She describes
E: moivng and eating , has missed both of her her symptoms primarily as generalized discomfort in
exercise classes and states " never misses her the abdomen, and states that her lower abdomen is
exercise classes." the location of the pain. She denies nausea and
R: resting helps a little but no real relief, sips of vomiting, blood or mucus in stool, rectal pain or
warm water a friend suggested not helping bleeding, or recent fever. She denies vaginal
R: patient has not tried any medication, aggravated bleeding or discharge. Reports no history of
with eating and physical activity also reports low inflammatory bowel disease or GERD. Denies family
energy level, a dull crampy feeling a 6 out of 10 on history of GI disorders. Her appetite has decreased
the Pain Scale. over the last few days and she is taking small
A: Bowel movement noted a few days ago was amounts of water and fluids. Previously she reports
diarrhea, denies any history of constipation. Reports regular brown soft stools every day to every other
having diarrhea about 2 to 3 days ago sudden onset day.
lasting one day, record very loose and watery:
normal normal bowel movements description of
brown formed and soft are usually every day until 5
days ago. Reports recent slight decrease in
frequency of urination do to decrease water intake.
Urine darker than usual. Denies blood in urine.
Denies any GI history disorders. Denies history of
1/5
, 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health
GERD heartburn or ulcers. No history of
appendicitis, stomach cancer, or history of liver
disease. Report C-section at age 40 in
cholecystectomy at age 42 no post-op
complications noted. Last pap smear noted about
10 years ago
Current medications: Accupril 10 po QD( last dose
at (0800 this morning), denies any OTC medications
Allergies: Latex : contact dermatitis
PMHx:
1. Hypertension diagnosed at age 54
2.3 Pregnancies
4. Surgical history C-section at age of 40;
cholecystectomy at age 42
Reports hospitalizations for past surgeries as noted
above and after childbirth denies any other
hospitalizations. Last pap smear and colonoscopy
10 years ago.
SocHx:
Last meal with toast for breakfast not eating well.
Usually appetite is three meals a day does not eat
snacks. Typical meal for breakfast is usually
somesort of fruit usually a banana. Typical lunch is
usuallysoup reports sometimes skipping lunch
period and typical dinner is chicken or fish with
some sort of rice or vegetable. No fiber supplements
reported.
Patient reports believes gets enough fiber supports
eating a vegetable or fruit each day. Reports
decrease in thirst especially over the last few days
typically patient drinks 6 typically patient drink 6
denies caffeinated drinks such as coffee or soda on
occasion drinks chamomile tea. Deny sexual activity
reports no STI testing. Report moderate activity
attend Fitness classes and reports gardening as a
hobby. Lives with her daughter named Jennifer and
has a strong support system with her daughter and
gentleman friend Max denies any recent travel.
Report sexually active no vaginal intercourse
reported does report oral sex.
1. No past or present tobacco use
2. Reports drinking one alcoholic (wine)beverage
per week, 4 per month only on Sunday's white wine
3. Denies using marijuana, cocaine, heroin or illicit
drugs
FAM Hx:
1. Mother- deceased at age 88 history of
hypertension and Diabetes Type 2
2. Father: deceased at 82 history of hypertension
and hypercholesterolemia
3. Maternal grandparents: family history of coronary
artery disease and Diabetes Type 2
4. Paternal grandparents: history of obesity, CVA,
hypertension
5. Siblings: brother had history of hypertension,
hypercholesterolemia, prostate cancer
6. Son: healthy age 48
7. Daughter: healthy age 46
ROS:
General: denies any recent fever chills or night
sweats although patient does report short-term
feeling of tiredness I need to rest more often.
GI: reports bloating, slight increase in flatus, recent
loss of appetite. No reports of nausea vomiting or
2/5
