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

********* ******** ************ DocumentationModel ************************* Parks ******* **** ********* ********** *** **** **** the **** **** with ******** ** the **** **** *** last *** **** *** rates *** ********* **** ** *** describing it as "dull and crampy" in left ***** abdomen *** ****** she *** a ******** 3 **** ago *** ***** **** *** *** ** ***** ******** *** denies *** ********* **** radiation She ****** *** ****** pain ** ******** ***** ****** ******* ********* or discomfort ******* sensation ** any ***** ******* ******** *** ****** *** **** medical or ****** ******* of ** ******** She ****** haveingc-section and cholecystomy ** ***** *** *** has had * ******** ** ******** **** the last few ***** states she ****** small ****** of ***** *** ****** *** denies ****** *** medications *** abdominal **** or ************ *** ****** ******* **** *** ****** ** ** ******* **** *** ***** in ***** ***** *** **** **** ** ***** problems ** ***** ***** with ******** ******** **** the shopping *** ******* cooks herselfMs **** ******* **** *** is “having **** ** her belly” She *********** mild ******** three **** *** and *** *** *** * bowel ******** ***** *** ******* that she has **** ******* some ********* ********** *** close ** * week but the **** *** increased ** the **** *** **** *** *** ***** *** **** ** * out of 10 *** ********* it ** **** *** crampy She ******* *** pain ***** ** the ***** ** * out ** ** *** is also ************ bloating *** did *** **** *** ******** warranted * trip to *** ****** *** *** daughter ******** *** **** *** ********* *** ******** ********* ** *********** ********** in *** ******* *** ****** that *** lower ******* ** the ******** ** *** **** *** denies nausea *** ******** ***** ** ***** ** stool ****** **** or ******** ** ****** fever She ****** ******* ******** ** ********* ******* ** history ** inflammatory ***** ******* ** **** ****** ****** ******* ** GI ********* Her ******** *** ********* over *** **** few days *** *** ** ****** ***** ******* ** water *** fluids Previously *** ******* regular ***** **** ****** ***** *** ** ***** ***** ******************* ***** sitting up in the **** **** ******* ** *** **** ** ********** ******* * ****** *** distressed but ****** **** ** answer *** inquiries *** ** **** ********* ****** **** *** ***** **** ***** **** mucouse membranes ****** **** ****** **** ** tenting ******* ** ** ** gallops rubs ** ******* ***** ** edema ** ***** extremities ************ respiration ********* *** ***** **** ** speak **** ********* **** no *** Lung ****** ****** CTA in all lobes Abdominal: ** cm **** at ******* ** ********** ****** and * cm **** ** *** Exam ******* ** ************* ***** sounds *** in all ********** no friction ****** **** spleen ** ***** ** bruits ** *** ****** ******* ********* Liver **** ** * cm; ******** to light ***** ** **** *** mass ** *** **** **** ********** ****** ********* **** ***** mass ******** ** ****** ***** *** ********* ****** ********** ***** ***** *** **** yellow normal **** ** ******** **** **** or keatones ** ** ** 1017• General ******* ************* *** ******* ********* ******* ***** seated ** exam ***** ********* at ***** ******* ****** *** mildly distressed • ****** ***** ********* *** ***** Normal skin ******* ** ******* *** *************** ** ** ** murmurs ******* ** ***** ** ** ** **** ** lower ********* ***** *** ************ ************ ***** *** unlabored **** ** ***** ** **** sentences ****** sounds ***** to ************ *** Abdominal: * ** scar ** RUQ *** ** ** **** ** ******* ** ********** ****** ** ********* **** ******* ** discoloration; *********** ***** ****** ** all quadrants; ** ******* ** friction ****** **** spleen ** ****** tympany ******** **** scattered ******** **** LLQ; abdomen **** ** all quadrants; ** oblong **** ** noted ** *** LLQ **** **** ******** *********** ** ************* ** *** *********** ***** span * ** * MCL; no ******* *** ******* ** hemorrhoids ** ******** ** *********** ****** ********* **** ***** mass in rectal vault *** Pelvic: No ************ ** ********** ** vulva ******** ********* or bleeding; ** ****** ******* ** ********** **** ********* *** *********** ***** clear **** ****** ****** odor ** ******** **** **** ** ketones ********* pH 65 SG 1017AssessmentPrimary: ************ ********** Small Bowel ObstructionMrs Park’s ***** sounds *** normoactive ** *** quadrants **** ** bruits ** ******** ****** ********* ******** ** LLQ during percussion ** ********** ** ***** ** *** colon; otherwise *** ******* is ******** *** ******* ** **** ** palpation; **** guarding and ****** **** ********** feces **** ********** ** *** No CVA tenderness; ***** span * ** * **** no ******* ******** ******* ****** **** revealed * ***** mass ** *** ****** ***** No abnormalities **** ***** ****** *** pelvic exam ** ****** inflammatory ******* is *** suspected Ms ******** ********** *** ****** ***** rules *** * ******* ***** ********* No signs ** *********** ** cardiovascular ************* *** ******** ******** and ****** ******* suggest she has ************ Differential diagnoses *** constipation ************** and ********** obstructionPlanEncourage ** drink **** ****** at ****** **** glasses ***** * *** ********* ** ***** ***** juice ************ for ***** softener ******* *** ** *** PO ********* x-ray Abdominal *** **** ***** **** *** *** ******* ******** **** should ******* diagnostic ***** ** rule out differentials: *** ** assess *** ******** **** ********** **** ************** *********** ******* ** ******** electrolyte and ***** ****** and * CT **** ** ****** for obstruction ** Mrs **** *** diverticulitis * ********* ** fluids *** ***** **** If she *** ***** obstruction * recommend *** ** fluids *** general ******** ******* ** *** *** constipation * ********* **** she ******** ****** ******** ***** and ******** ******** ** *********

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