12/10/2018 Abdominal Pain Physical Assessment Assignment | Completed | Shadow Health
Abdominal Pain Physical Assessment Assignment Results | Completed
Advanced Health Assessment - Chamberlain, NR509-October-2018
Return to Assignment
Your Results Turn In Lab Pass
m
Overview
Documentation / Electronic Health Record
er as
Transcript
co
eH w
Subjective Data Collection Document: Vitals Document: Provider Notes
o.
Objective Data Collection
rs e
ou urc
Education & Empathy Document: Provider Notes
Documentation
Student Documentation Model Documentation
o
Self-Reflection
aC s
Subjective
vi y re
Ms. Park reports that she is “having pain in her
Patient Info: Esther Park, 78 years, Asian female belly.” She experienced mild diarrhea three days ago
and has not had a bowel movement since. She
CC: Patient states that they are "having pain in her reports that she has been feeling some abdominal
belly" and that she is having trouble "going to the discomfort for close to a week, but the pain has
ed d
bathroom." increased in the past 2-3 days. She now rates her
pain at 6 out of 10, and describes it as dull and
ar stu
HPI: The patient, Ms. Park, came into the office crampy. She reports her pain level at the onset at 3
complaing of abdominal pain and not being able to out of 10. She is also experiencing bloating. She did
have a bowel movement. She states that this pain not feel her symptoms warranted a trip to the clinic
started 5 days ago and has gotten worse over the but her daughter insisted she come. She describes
sh is
past 2 to 3 days. The pain is in the lower abdomen her symptoms primarily as generalized discomfort in
and does not radiate. She does not have pain the abdomen, and states that her lower abdomen is
the location of the pain. She denies nausea and
Th
anywhere else. She states that her current
abdominal pain could be rated a 6 out of 10. She vomiting, blood or mucus in stool, rectal pain or
describes the pain as "dull and crampy." She states bleeding, or recent fever. She denies vaginal
that it does get worse sometimes, especially after bleeding or discharge. Reports no history of
physical activity or eating. She states that resting inflammatory bowel disease or GERD. Denies family
does help, but the only treatment she has pursued is history of GI disorders. Her appetite has decreased
"taking small sips of warm water," a method her over the last few days and she is taking small
friend infromed her of. This has not been an effective amounts of water and fluids. Previously she reports
treatment. She states that she is not being able to go regular brown soft stools every day to every other
about her normal daily activities due to the pain. She day.
also reports a low energy level. She is currently
constipated, and issue that she has no history of.
She has been constipated for about 5 days, but has
not pursued any treatment. She had a bout of
diarrhea about 3 days ago that she described as
"loose and watery." It lasted for one day. Before the
onset of the abdominal pain 5 days ago, the patient
states that they had normal bowel habits, but has not
had a movement in 3 days. No mucus or blood in
https://www.coursehero.com/file/36352067/NR-509-Abdominal-Pain-Documentation-Shadowpdf/
stool. Patient states that the frequency of her
https://chamberlain.shadowhealth.com/assignment_attempts/4238251 1/5
, 12/10/2018 Abdominal Pain Physical Assessment Assignment | Completed | Shadow Health
Student Documentation Model Documentation
urination has had a small decrease, as well as a
darker yellow color. There is no blood in her urine.
Current Meds: Patient takes Accupril 10mg daily for
hypertension. She does not take any over the
counter medication.
Allergies: Patient has a latex allergy. No food,
medication, or environmental allergies noted.
Past Medical: Patient does have hypertension.
Patient has no history of gastro issues, heartburns,
or ulcers. She has not had appendicitis. She did
have Cholecystectomy at 42 and a caesarean
section at 40. No other major medical issues or
hospitilizations. Patient is up to date on vaccines
except for her seasonal flu shot.
Social History: Patient eats a failry healthy diet and
no fiber supplements. She drinks around 6 glasses
m
of water a day and has no changes in thirst level.
er as
She does not drink caffeinated beverages. Patient
co
denies any smoking or illicet drug use. She usually
eH w
has around 4 drinks per month, usually white wine.
She seems her doctor regularly and states that she
o.
is in good health for her age. Last colonoscopy was
10 years ago. She is generally physically active, but
rs e
not recently due to the abdominal pain. She attends
ou urc
fitness class, gardens, and considers herself
independent. She has had three pregnancies. She
has a strong support system as she lives with her
daughter. She is a widow. Her husband of 50 years
o
passed away 6 years ago. She currently dates a
man named Max who she is sexually active with. No
aC s
vaginal intercourse, though, just oral sex.
vi y re
Family History:
Mother: passed away at age 88 from strok. Had
hypertension and Type II diabetes.
Father: Passed away at age 82 and she had
ed d
hypertension and high cholesterol.
ar stu
Maternal grandparents: history of coronary artery
disease and Type II diabetes.
Paternal grandparents: History of obesity,
hypertension, and CVAs.
Siblings: 80 year old brother with hypertension, high
sh is
cholesterol, and prostate cancer. 81 year old brother
with hypertension.
Th
Son: 48 and healthy.
Daughter: 46 and healthy.
ROS:
General: Patient denies any fever or chills. She
notes feeling exhausted lately.
Gastro: Patient notes some bloating, increased gas,
loss of appetite. She denies any nausea or vomiting.
She denies any changes in weight.
Genitourinary: Patient denies any pain while
urinating, no incontinence, no history of UTIs, no
history of gyno issues, no vaginal bleeding or
abnormal discharge. Started menopause at 45. No
bladder or kidney issues.
https://www.coursehero.com/file/36352067/NR-509-Abdominal-Pain-Documentation-Shadowpdf/
https://chamberlain.shadowhealth.com/assignment_attempts/4238251 2/5
Abdominal Pain Physical Assessment Assignment Results | Completed
Advanced Health Assessment - Chamberlain, NR509-October-2018
Return to Assignment
Your Results Turn In Lab Pass
m
Overview
Documentation / Electronic Health Record
er as
Transcript
co
eH w
Subjective Data Collection Document: Vitals Document: Provider Notes
o.
Objective Data Collection
rs e
ou urc
Education & Empathy Document: Provider Notes
Documentation
Student Documentation Model Documentation
o
Self-Reflection
aC s
Subjective
vi y re
Ms. Park reports that she is “having pain in her
Patient Info: Esther Park, 78 years, Asian female belly.” She experienced mild diarrhea three days ago
and has not had a bowel movement since. She
CC: Patient states that they are "having pain in her reports that she has been feeling some abdominal
belly" and that she is having trouble "going to the discomfort for close to a week, but the pain has
ed d
bathroom." increased in the past 2-3 days. She now rates her
pain at 6 out of 10, and describes it as dull and
ar stu
HPI: The patient, Ms. Park, came into the office crampy. She reports her pain level at the onset at 3
complaing of abdominal pain and not being able to out of 10. She is also experiencing bloating. She did
have a bowel movement. She states that this pain not feel her symptoms warranted a trip to the clinic
started 5 days ago and has gotten worse over the but her daughter insisted she come. She describes
sh is
past 2 to 3 days. The pain is in the lower abdomen her symptoms primarily as generalized discomfort in
and does not radiate. She does not have pain the abdomen, and states that her lower abdomen is
the location of the pain. She denies nausea and
Th
anywhere else. She states that her current
abdominal pain could be rated a 6 out of 10. She vomiting, blood or mucus in stool, rectal pain or
describes the pain as "dull and crampy." She states bleeding, or recent fever. She denies vaginal
that it does get worse sometimes, especially after bleeding or discharge. Reports no history of
physical activity or eating. She states that resting inflammatory bowel disease or GERD. Denies family
does help, but the only treatment she has pursued is history of GI disorders. Her appetite has decreased
"taking small sips of warm water," a method her over the last few days and she is taking small
friend infromed her of. This has not been an effective amounts of water and fluids. Previously she reports
treatment. She states that she is not being able to go regular brown soft stools every day to every other
about her normal daily activities due to the pain. She day.
also reports a low energy level. She is currently
constipated, and issue that she has no history of.
She has been constipated for about 5 days, but has
not pursued any treatment. She had a bout of
diarrhea about 3 days ago that she described as
"loose and watery." It lasted for one day. Before the
onset of the abdominal pain 5 days ago, the patient
states that they had normal bowel habits, but has not
had a movement in 3 days. No mucus or blood in
https://www.coursehero.com/file/36352067/NR-509-Abdominal-Pain-Documentation-Shadowpdf/
stool. Patient states that the frequency of her
https://chamberlain.shadowhealth.com/assignment_attempts/4238251 1/5
, 12/10/2018 Abdominal Pain Physical Assessment Assignment | Completed | Shadow Health
Student Documentation Model Documentation
urination has had a small decrease, as well as a
darker yellow color. There is no blood in her urine.
Current Meds: Patient takes Accupril 10mg daily for
hypertension. She does not take any over the
counter medication.
Allergies: Patient has a latex allergy. No food,
medication, or environmental allergies noted.
Past Medical: Patient does have hypertension.
Patient has no history of gastro issues, heartburns,
or ulcers. She has not had appendicitis. She did
have Cholecystectomy at 42 and a caesarean
section at 40. No other major medical issues or
hospitilizations. Patient is up to date on vaccines
except for her seasonal flu shot.
Social History: Patient eats a failry healthy diet and
no fiber supplements. She drinks around 6 glasses
m
of water a day and has no changes in thirst level.
er as
She does not drink caffeinated beverages. Patient
co
denies any smoking or illicet drug use. She usually
eH w
has around 4 drinks per month, usually white wine.
She seems her doctor regularly and states that she
o.
is in good health for her age. Last colonoscopy was
10 years ago. She is generally physically active, but
rs e
not recently due to the abdominal pain. She attends
ou urc
fitness class, gardens, and considers herself
independent. She has had three pregnancies. She
has a strong support system as she lives with her
daughter. She is a widow. Her husband of 50 years
o
passed away 6 years ago. She currently dates a
man named Max who she is sexually active with. No
aC s
vaginal intercourse, though, just oral sex.
vi y re
Family History:
Mother: passed away at age 88 from strok. Had
hypertension and Type II diabetes.
Father: Passed away at age 82 and she had
ed d
hypertension and high cholesterol.
ar stu
Maternal grandparents: history of coronary artery
disease and Type II diabetes.
Paternal grandparents: History of obesity,
hypertension, and CVAs.
Siblings: 80 year old brother with hypertension, high
sh is
cholesterol, and prostate cancer. 81 year old brother
with hypertension.
Th
Son: 48 and healthy.
Daughter: 46 and healthy.
ROS:
General: Patient denies any fever or chills. She
notes feeling exhausted lately.
Gastro: Patient notes some bloating, increased gas,
loss of appetite. She denies any nausea or vomiting.
She denies any changes in weight.
Genitourinary: Patient denies any pain while
urinating, no incontinence, no history of UTIs, no
history of gyno issues, no vaginal bleeding or
abnormal discharge. Started menopause at 45. No
bladder or kidney issues.
https://www.coursehero.com/file/36352067/NR-509-Abdominal-Pain-Documentation-Shadowpdf/
https://chamberlain.shadowhealth.com/assignment_attempts/4238251 2/5
