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 no

******* NoteSubjective: Date ** ********** July ** *********** **** ** ********* Esther ***************** ********* ** * 78-year-old ***** who ** * reliable historianChief Complaint ***** Abdominal **** ** **** notes *** pain ***** * days *** *** ***** *** pain ** *********** ****** her ****** ******* ******* ***** more ***** *** left ***** ******** *** also ******* **** *** **** ** constant *** ********* ** as a **** and ******** ********* ** **** ******* **** ****** *** eating ********** *** ******** *** notes **** ******* ***** reduce the intensity ** Park **** *** **** any medications *** *** **** and ***** only drinking warm *** ** a result she *** experienced * decline in *** ****** ***** and finds she is resting **** ************ ** ******* illness ******** **** reports **** *** ** ****** ********* **** ********* * **** now The **** is ************ ************ ** *** **** *** days *** ***** her pain * * out ** ** *** ********* ** ** **** *** ******** *** *** nottried any *********** *** **** relief ** Park denies *** ****** ********* *********** **** ******** ***** **** ****** has not *** * ***** ******** ***** ********** **** she *** **** ******* **** ******************* for ***** to * **** *** is **** ************ ******** *** didnot feel *** ******** ********* * **** to *** ********* *** daughter ******** *** **** She ************ ******** ********* ** *********** discomfort inthe ******* *** ****** **** *** ***** abdomen isthe location ** *** **** *** ****** ****** *********** blood ** mucus ** ***** ****** **** ********** or recent ***** She ****** *************** or ********* Reports ** history ************** bowel ******* or GERD ****** ************* ** GI ********* Her ******** *** decreasedover *** last *** **** *** *** is ****** ************ of ***** *** ****** Previously *** ************** ***** **** ****** ***** day to ***** otherdayAllergies:Latex ******** dermatitis)Immunizations: ** ** **** ********* influenza vaccination **** *************************** 10mg ** ***** daily *** high ***** ************ ************ ******* ******* **** ******** **************** ******** ******** ** **** *** *** * ******** ******* ************** *** a *************** (42-years-old) ** *** pastFamily ************ **** notes *** Mother *** * ******* of hypertension *** ******** **** ** She ****** **** ** the *** of ** *** ****** passed **** ** *** *** ** 82 *** *** a ******* ** ************ *** ******************** *** ****** ******* is ** ***** *** *** *** a ******* of hypertension *** *** ****** ****** brother ** ** ***** *** and *** * ******* ** hypertension ******************** *** ******** ****** *** has *** living *** *** ** ** years old *** ******* *** *** ****** daughter *** is 46 years *** *** healthyPersonal *** ****** ********** **** **** not ********* smoke *** has a ******* of ******* ** ***** tobaccoHealth ********************* *********** **** Park is ** ** date **** her ************* ******* *** did *** receive an influenza vaccine **** season ***** is ******** *** *** ***** ********** ***** ******** *** ******* ** well ** walking **** **** ****** recreational ** ******* **** *** *** usually **** ****** *** glass ** **** ** Sundays *** weekPertinent ****** ** ******* ************ ****** **** ****** *** ****** *** ******** Notes ** ******* or ********** ************ ** **** ********** or ******* ***** ** ****** noted ******* ****** difficulty ***************** ****** *** ***** ********** ** ********** discomfortCV: ******* ** *********** or ***** ********* **** sensations Denies ********* of ****** with activityAbdomen: ******* **** note distension *** bloating ** *** ******* ********* points to left ***** ******** as *** **** ** **** pain **** **** ***** *** pain ** a * out of 10 ** * 10-point scaleGenitalia:Patient denies **** abnormal ******* ** ******* ** ******** *** internal ********* Miss **** ***** ** abnormal ********* *** ****** ******* ************** ************** **** *** use ******* protection during intimacy **** ******* ** ******* of sexually *********** ******* ********************* ****** ***** ********** ** ******** **** range ** ****** ******* however ***** * decreased ***** ** **************** *********** **** *** had * ****** ******** in *** ****** of ***** ***** ** **** **** *** have *** ******* *** ****** ** ***** *** **** ** **** ******* **** ***** help in identifying a change in ******* ****** ** foods **** in *** ie *** **** content *** * ******** ** fiber ****** ***** can ********** ** ************* **** *** *** a ****** ******** ** *** *** ** non-steroidal anti-inflammatory (NSAID’s) medications *** **** ********* *** *** of ********* ** also * contributory ****** *** * ********* ** constipation Chronic *** ** ********* can **** ***** ****** ****** renal ******* *** **** ********** you experiencing any ****** ****** or ************* ******* in **** *** **** ** decreased appetite *** ******* ********** ********* ****** and ********** ***** an *********** ********** *** lead to physical manifestations *** ******* to ****************** ************************** ****** ***** **** is ** ***** ******** ** ****** ************ are ** and ***** ******** is **** and *** *********** ** ** ******* ***************************** **** ****** 120 lbs and is ***** *** *** ** 219 ***** places *** in the healthy ****** range *** *** *** and ************** ExamGeneral: *** ******* ** ** ******* ***** ******* ** ** *** exam *** ******** grimacing at ***** appearing ************* and ******* *** appears ********* ********** *** ****** and **** ** ****** *** ********* *** ** oriented and ***************** **** *** ***** **** moist **** ****** membranes ****** **** ****** **** ** ******************* Respirations *** ********* and quiet **** to ***** **** sentences **** ** ********* ** breath **** *** breath ****** ***** ** ************ ***** ** *** lobesCV: ** ** ** ******* **** ** murmurs ***** No S3 ** ** **** ** ***** to ***** *********** *************** * ** **** ** *** *** ** cm **** ** midline ** ********** ****** An ********* **** ******* ** ************** ******* is ********** *** to ********* ********** in **** *********** bowel ****** ** *** ********** no bruits; ** friction ****** over ****** ** liver; ******* ******** **** scattered dullness over **** abdomen **** ** *** quadrants; an ****** **** ** ***** ** *** *** ********* ***** with **** ******** and ******* tenderness; no ************* ** CVA tenderness; ** ********* *********** ** ******** or ulceration; ****** ********* **** ***** **** ** rectal vault ************* clear **** ****** normal odor ** nitrites **** **** or ketones detected; ** ** ** ********** ******* ********* inflammation ** irritation of ***** ******** ********* or bleeding; ** ****** growths ** ********** **** ****************** ******** ******* * Para ********************** Mood ** *********** and memory ** ********* intact ************************* Constipation: *** patient’sdescription of * **** *** ******** **** ** *** left ***** ******* and * ********* in *** occurrence of *** ****** ***** ******** ** ********** of constipation2 ******* tract ********* ***** vs ******** *********** ********* ****** The *********** reduced ***** ****** and **** ******* ***** ** *********** **** *** abdominal pain can ** related ** a ********* of UTI *** ***** ** ** ****** ** ** *** *** ******** ******* **** ** **** ***** this may be ****** ** ******** ** ******* solutes *** ** ** addition to *** ******** ** ******** ***** ******* *********** and possible ********** ** UTI **** **** ***** *** ***** ********** **** ****** *********** ** *********** ** ********* ** ******* **** ****** Renal colic:The patient’s *********** ** a generalized ********* ********** **** is **** *** ******** *** * ********* *** ************ urine output *** also ** indicative ** ***** ***** *** **** ** **** ********** ** ******** *** ** ******** ** ***** and *** also notes * ******** ** ****** and fluid ****** ***** *** be ******* ** * ********* ** renal colicDiagnosis: Constipation **** **** ***** a ******** in ******** secondary ** **** ***** quadrant pain as well ** * decrease ** food and fluid ****** ******** to ***** ***** ** LLQ was noted ** *********** *** a 2x4cm **** *** ***** ** *** *** with **** palpation * ****** sphincter **** was ***** *** a *********** ***** mass *** ******** ** *** ****** ******************************************** No further ********** ***** *** required ** **** timePharmacology: ****** ***** *** ******* **** **** ** ** ********** * ****** *** rectum *** ** *** ** exceed * ************** ** * 24-hour ****** **** **** will **** ******** ** take *** ***** ******** medications ** orderedEducation/CounselingMiss **** **** ******** ** ****** in *** water *********** and ******* ******** ******* *** will increase her water intake *** will **** ******** ** *** ******** **** and increase the amount ** fiber *** ***** in *** ***************** Park **** call ** ******** * follow up ***** **** **** ****** within * weekSelf-Assessment: A ******* *********** ** **** ******* ********* pain *** performed **** ******** *** *********** palpated and ********* for normal *** ******** ******** * ***** **** ***** **** **** ***** her ****** ******* of gastrointestinal problems I would **** also ******* ** *** *** ** ********* ** ***** softeners for ***** ****************************** * * ******** * G ***** Hoffman R M (2017) ***** ***** ** ******** *********** *** ******* ****** Philadelphia: ******* KluwerMoll *** ******** **** * & ** ***** ****** * * ************** examination ** ******** with ***** abdominal **************************************** 155 *****

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