Exam (elaborations) NR 509 FOCUSED EXAM SHADOW HEALTH Abdominal Pain Results

Student Documentation Model Documentation 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 some sort of fruit usually a banana. Typical lunch is usually soup 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