12/10/201
8
Abdominal Pain Physical Assessment Assignment Results |
Completed
Advanced Health Assessment - Chamberlain, NR509-October-2018
Return to Assignment
Your
Turn In Lab Pass
Results
Overvie
w
shared
This study via
resource
Documentation / Electronic Health Record
CourseHero.com
was
Transcri Document: Vitals Document: Provider Notes
pt
Subjective Data Document: Provider Notes
Collection Objective
Student Documentation Model Documentation
Data Collection
Subjective She has been
Education & Empathy constipated for
Patient Info: Esther Park, 78 years, Asian about 5 days, but
female has not pursued any
treatment. She had
CC: Patient states that they are "having pain a bout of diarrhea
in her belly" and that she is having trouble about 3 days ago
"going to the bathroom." that she described
as "loose and
HPI: The patient, Ms. Park, came into the office watery." It lasted for
complaing of abdominal pain and not being one day. Before the
able to have a bowel movement. She states onset of the
that this pain started 5 days ago and has abdominal pain 5
gotten worse over the past 2 to 3 days. The days ago, the
pain is in the lower abdomen and does not patient states that
radiate. She does not have pain anywhere they had normal
else. She states that her current abdominal bowel habits, but
pain could be rated a 6 out of 10. She has not had a
describes the pain as "dull and crampy." She movement in 3
states that it does get worse sometimes, days. No mucus or
especially after physical activity or eating. She blood in
states that resting does help, but the only
treatment she has pursued is "taking small
sips of warm water," a method her friend
infromed her of. This has not been an
effective treatment. She states that she is not
being able to go about her normal daily
activities due to the pain. She also reports a
low energy level. She is currently constipated,
and issue that she has no history of.
1/5
, 12/10/201
8 states that her lower abdomen is the location
Ms. Park reports that she is “having pain in her belly.” She experienced of the pain. She denies nausea and vomiting,
mild diarrhea three days ago and has not had a bowel movement since. blood or mucus in stool, rectal pain or
She reports that she has been feeling some abdominal discomfort for bleeding, or recent fever. She denies vaginal
close to a week, but the pain has increased in the past 2-3 days. She bleeding or discharge. Reports no history of
now rates her pain at 6 out of 10, and describes it as dull and crampy. inflammatory bowel disease or GERD. Denies
She reports her pain level at the onset at 3 out of 10. She is also family history of GI disorders. Her appetite has
experiencing bloating. She did not feel her symptoms warranted a trip decreased over the last few days and she is
to the clinic but her daughter insisted she come. She describes her taking small amounts of water and fluids.
symptoms primarily as generalized discomfort in the abdomen, and Previously she reports regular brown soft
stools every day to every other day.
hTthtpiss:s/t/uwdwywso.cuorucerswehaesrod.ocwomnl/ofaildee/3d6b3y521006070
DtHhoeecroufr.mceoqemnuteaontnico0yn4-oS-1fh4ah-de2o0rw22pd1f3/ :44:53 s/0GMT
tNo0R8 o2l-.51P0897a-7tAi8e7n4tofsmrtoaimnteaCs-Pothuairanste-
-05:00
2/5
8
Abdominal Pain Physical Assessment Assignment Results |
Completed
Advanced Health Assessment - Chamberlain, NR509-October-2018
Return to Assignment
Your
Turn In Lab Pass
Results
Overvie
w
shared
This study via
resource
Documentation / Electronic Health Record
CourseHero.com
was
Transcri Document: Vitals Document: Provider Notes
pt
Subjective Data Document: Provider Notes
Collection Objective
Student Documentation Model Documentation
Data Collection
Subjective She has been
Education & Empathy constipated for
Patient Info: Esther Park, 78 years, Asian about 5 days, but
female has not pursued any
treatment. She had
CC: Patient states that they are "having pain a bout of diarrhea
in her belly" and that she is having trouble about 3 days ago
"going to the bathroom." that she described
as "loose and
HPI: The patient, Ms. Park, came into the office watery." It lasted for
complaing of abdominal pain and not being one day. Before the
able to have a bowel movement. She states onset of the
that this pain started 5 days ago and has abdominal pain 5
gotten worse over the past 2 to 3 days. The days ago, the
pain is in the lower abdomen and does not patient states that
radiate. She does not have pain anywhere they had normal
else. She states that her current abdominal bowel habits, but
pain could be rated a 6 out of 10. She has not had a
describes the pain as "dull and crampy." She movement in 3
states that it does get worse sometimes, days. No mucus or
especially after physical activity or eating. She blood in
states that resting does help, but the only
treatment she has pursued is "taking small
sips of warm water," a method her friend
infromed her of. This has not been an
effective treatment. She states that she is not
being able to go about her normal daily
activities due to the pain. She also reports a
low energy level. She is currently constipated,
and issue that she has no history of.
1/5
, 12/10/201
8 states that her lower abdomen is the location
Ms. Park reports that she is “having pain in her belly.” She experienced of the pain. She denies nausea and vomiting,
mild diarrhea three days ago and has not had a bowel movement since. blood or mucus in stool, rectal pain or
She reports that she has been feeling some abdominal discomfort for bleeding, or recent fever. She denies vaginal
close to a week, but the pain has increased in the past 2-3 days. She bleeding or discharge. Reports no history of
now rates her pain at 6 out of 10, and describes it as dull and crampy. inflammatory bowel disease or GERD. Denies
She reports her pain level at the onset at 3 out of 10. She is also family history of GI disorders. Her appetite has
experiencing bloating. She did not feel her symptoms warranted a trip decreased over the last few days and she is
to the clinic but her daughter insisted she come. She describes her taking small amounts of water and fluids.
symptoms primarily as generalized discomfort in the abdomen, and Previously she reports regular brown soft
stools every day to every other day.
hTthtpiss:s/t/uwdwywso.cuorucerswehaesrod.ocwomnl/ofaildee/3d6b3y521006070
DtHhoeecroufr.mceoqemnuteaontnico0yn4-oS-1fh4ah-de2o0rw22pd1f3/ :44:53 s/0GMT
tNo0R8 o2l-.51P0897a-7tAi8e7n4tofsmrtoaimnteaCs-Pothuairanste-
-05:00
2/5
