Esther Parks abdominal pain - EHR documentation Esther Parks abdominal pain - EHR documentation Esther Parks abdominal pain - EHR documentation Esther Parks abdominal pain - EHR documentation Esther P

********* ******** NotesStudent ****************** ************************* ***** ******* **** ********* discomfort and **** over *** last **** **** ******** in the **** **** *** last *** **** She rates *** ********* pain ** *** ********** ** ** "dull *** crampy" ** **** lower ******* *** states *** *** a ******** 3 **** *** and since **** she *** no bowel ******** *** ****** *** ********* **** ********* She ****** *** ****** **** ** ******** ***** ****** ******* ********* ** ********** ******* ********* ** *** other ******* ******** She denies any **** ******* ** ****** ******* of GI ******** *** ****** **************** *** cholecystomy ** ***** 40s *** has *** * ******** ** appetite over the **** few ***** ****** *** ****** small amount ** water and ****** *** denies ****** any *********** for ********* **** ** ************ *** ****** ******* gass *** ****** ** is regular **** *** ***** ** ***** ***** 1-2 **** **** no ***** problems ** ***** ***** with ******** Daughter does the ******** *** ******* ***** herselfMs Park ******* **** *** is ********* **** ** *** belly” *** experienced **** ******** three **** *** *** *** not *** a bowel ******** ***** *** reports **** *** *** been ******* **** ********* ********** *** ***** ** a **** *** *** **** has increased ** *** **** 2-3 **** *** *** rates *** pain ** * *** ** ** *** describes it as **** *** crampy *** ******* *** pain ***** ** the ***** ** 3 out ** ** She ** **** ************ ******** *** *** not **** *** ******** warranted a **** ** *** ****** *** *** daughter ******** *** **** *** ********* *** ******** primarily as *********** ********** in *** ******* *** states that *** ***** ******* ** the location ** *** pain *** ****** ****** *** vomiting ***** ** mucus ** ***** rectal **** or ******** ** ****** ***** She ****** ******* ******** ** discharge Reports ** ******* ** inflammatory ***** disease ** **** ****** ****** ******* ** GI ********* *** appetite has decreased **** *** last *** **** *** she ** taking ***** ******* ** water *** ****** ********** *** reports ******* brown soft ****** every day ** ***** ***** ******************* ***** ******* ** ** *** **** with grimace ** *** **** ** ********** ******* * ****** bit distressed *** ****** **** to ****** all ********* *** ** goog ********* ****** **** and ***** **** ***** **** mucouse ********* ****** **** ****** with ** tenting Cardio: S1 ** ** gallops **** ** ******* noted ** ***** ** ***** *********** ************ *********** ********* *** quiet **** ** ***** **** ********* **** ** *** **** breath sounds *** ** all ***** ********** 10 ** **** ** midline ** ********** ****** and 6 ** **** ** *** **** ******* ** ************* bowel ****** WNL ** *** quadrants; ** ******** ****** **** ****** ** ***** ** bruits in *** ****** ******* ********* ***** span ** * *** Guarding ** light touch ** LLQ; *** mass ** *** with **** ********** ****** ********* **** ***** **** ******** ** ****** ***** *** ********* kindey nontender; ***** ***** and **** ****** ****** **** ** nitrites **** RBCs or keatones ** ** ** 1017• ******* ******* ************* *** flushed appearing ******* ***** seated ** **** ***** ********* ** ***** ******* stable *** mildly distressed • ****** Mucus membranes are ***** Normal **** ******* ** tenting *** Cardiovascular: ** S2 no ******* ******* or ***** ** ** S4 **** ** ***** extremity ***** *** ************ ************ ***** *** ********* able to ***** ** **** ********* ****** ****** clear ** ************ *** ********** * ** **** ** *** *** 10 ** scar ** ******* ** ********** ****** ** abdominal **** ******* ** discoloration; normoactive ***** ****** in *** ********** ** ******* ** ******** sounds **** ****** or ****** tympany presides **** ********* dullness over **** abdomen **** in all ********** ** oblong **** ** noted ** *** LLQ with **** ******** distension; no organomegaly; ** *** *********** ***** **** 7 ** @ **** ** ******* • ******* ** hemorrhoids ** ******** or ulceration; ****** ********* **** fecal mass ** ****** vault • Pelvic: ** ************ or ********** of ***** ******** ********* ** ********* ** ****** ******* ** tenderness **** ********* *** *********** ***** ***** **** ****** ****** **** ** ******** WBCs RBCs ** ******* detected; ** ** SG ********************** Constipation ********** Small ***** ************** ******** ***** sounds *** *********** ** *** ********* **** no ****** or friction ****** Scattered dullness ** LLQ ****** percussion ** ********** ** feces ** *** ****** ********* *** ******* is ******** *** ******* ** soft ** ********** mild guarding *** ****** **** ********** ***** **** ********** ** *** ** *** tenderness; liver span 7 cm * **** ** splenic ******** ******* rectal exam revealed * ***** mass ** *** ****** ***** No abnormalities **** ***** ****** *** ****** **** ** ****** inflammatory ******* ** *** ********* ** Park’s ********** *** normal ***** rules out a ******* ***** ********* ** ***** ** dehydration ** cardiovascular ************* Mrs ******** ******** *** health ******* ******* *** *** ************ ************ ********* *** ************ ************** and ********** obstructionPlanEncourage to ***** **** ****** ** ****** **** glasses ***** * *** ********* ** ***** ***** ***** Prescription *** ***** ******** ******* *** ** *** ** ********* ***** ********* *** **** Blood **** CBC *** ******* ******** **** ****** receive ********** ***** ** rule out differentials: *** ** ****** for ******** WBCs ********** **** ************** electrolyte ******* ** ******** *********** *** fluid ****** *** * CT **** ** ****** *** *********** If *** Park *** ************** I ********* IV fluids *** bowel **** If *** has ***** obstruction * recommend *** ** ****** and general ******** ******* If *** *** constipation I recommend **** she increase ****** increase ***** *** ******** activity ** *********

Click here to download attached files: Esther-Parks-abdominal-pain---EHR-documentation.docx