Anthony Axelrod, RN Nurs 550
Focused Note
Subjective:
Date of encounter: July 19, 2018
Patient Name or initials: Esther Park
Informant: The informant is a 78-year-old woman who is a reliable historian.
Chief Complaint (CC): Abdominal pain. Ms. Park notes the pain began 5 days ago. She
notes the pain is generalized across her entire abdomen, however, hurts more along the
left lower quadrant. She also asserts that the pain is constant, and describes it as a dull,
and cramping sensation. Ms. Park reports that moving and eating aggravates her
symptoms, and notes that resting helps reduce the intensity. Ms. Park does not take any
medications for her pain, and notes only drinking warm tea. As a result she has
experienced a decline in her energy level and finds she is resting more often.
History of present illness (HPI): Ms. Park reports that she is having abdominal pain for
almost a week now. 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 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
Approved NP Faculty 3/2016
, Anthony Axelrod, RN Nurs 550
vaginal bleeding or discharge. Reports no history of inflammatory bowel disease or
GERD. Denies family 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.
Allergies: Latex (contact dermatitis)
Immunizations: Up to date (declined influenza vaccination this season)
Medications: Accupril 10mg by mouth daily for high blood pressure.
Past History: Past medical history only includes hypertension.
Past Surgical History: Ms. Park has had a cesarean section (40-years-old) and a
Cholecystectomy (42-years-old) in the past.
Family History: Miss Park notes her Mother had a history of hypertension and diabetes
type II. She passed away at the age of 88. Her Father passed away at the age of 82, and
had a history of hypertension and hypercholesterolemia. Her eldest brother is 81 years old
and has a history of hypertension, and her second oldest brother is 80 years old and has a
history of hypertension, hypercholesterolemia, and prostate cancer. She has one living
son who is 48 years old and healthy, and one living daughter who is 46 years old and
healthy.
Personal and Social History:
Ms. Park does not currently smoke, nor has a history of smoking, or using tobacco.
Health Promotion/Maintenance Activities: Miss Park is up to date with her
immunizations, however she did not receive an influenza vaccine this season. Sleep is
adequate, and she notes performing water aerobics and Pilates as well as walking. Miss
Approved NP Faculty 3/2016
Focused Note
Subjective:
Date of encounter: July 19, 2018
Patient Name or initials: Esther Park
Informant: The informant is a 78-year-old woman who is a reliable historian.
Chief Complaint (CC): Abdominal pain. Ms. Park notes the pain began 5 days ago. She
notes the pain is generalized across her entire abdomen, however, hurts more along the
left lower quadrant. She also asserts that the pain is constant, and describes it as a dull,
and cramping sensation. Ms. Park reports that moving and eating aggravates her
symptoms, and notes that resting helps reduce the intensity. Ms. Park does not take any
medications for her pain, and notes only drinking warm tea. As a result she has
experienced a decline in her energy level and finds she is resting more often.
History of present illness (HPI): Ms. Park reports that she is having abdominal pain for
almost a week now. 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 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
Approved NP Faculty 3/2016
, Anthony Axelrod, RN Nurs 550
vaginal bleeding or discharge. Reports no history of inflammatory bowel disease or
GERD. Denies family 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.
Allergies: Latex (contact dermatitis)
Immunizations: Up to date (declined influenza vaccination this season)
Medications: Accupril 10mg by mouth daily for high blood pressure.
Past History: Past medical history only includes hypertension.
Past Surgical History: Ms. Park has had a cesarean section (40-years-old) and a
Cholecystectomy (42-years-old) in the past.
Family History: Miss Park notes her Mother had a history of hypertension and diabetes
type II. She passed away at the age of 88. Her Father passed away at the age of 82, and
had a history of hypertension and hypercholesterolemia. Her eldest brother is 81 years old
and has a history of hypertension, and her second oldest brother is 80 years old and has a
history of hypertension, hypercholesterolemia, and prostate cancer. She has one living
son who is 48 years old and healthy, and one living daughter who is 46 years old and
healthy.
Personal and Social History:
Ms. Park does not currently smoke, nor has a history of smoking, or using tobacco.
Health Promotion/Maintenance Activities: Miss Park is up to date with her
immunizations, however she did not receive an influenza vaccine this season. Sleep is
adequate, and she notes performing water aerobics and Pilates as well as walking. Miss
Approved NP Faculty 3/2016
