Exam (elaborations) NUR 500 ESTHER PARKS ABDOMINAL PAIN EHR Documentation

Document: Provider Notes Student Documentation Model Documentation Subjective Ms. Parks reports some abdominal discomfort and pain over the last week with increase in the pain over the last 2-3 days. She rates her abdominal pain at 6/1, describing it as "dull and crampy" in left lower abdomen. She states she had a diarrhea 3 days ago and since than she had no bowel movement. She denies any abdominal pain radiation. She denies any rectal pain or bleeding, fever, nasuea, vaginal discharge or discomfort, burning sensation or any other urinary symptoms. She denies any past medical or family history of GI problems. She states haveing c-section and cholecystomy in early 40s. She has had a decrease in appetite over the last few days; states she drinks small amount of water and fluids. She denies taking any medications for abdominal pain or constipation. She states passing gass. The normal BM is regular, soft and brown in color, every 1-2 days with no other problems. Ms. Parks lives with daughter. Daughter does the shopping and Ms.Parks cooks herself Ms. Park reports that she is “having pain in her belly.” She experienced mild diarrhea three days ago and has not had a bowel movement since. She reports that she has been feeling some abdominal discomfort for close to a week, but the pain has increased in the past 2-3 days. She now rates her pain at 6 out of 10, and describes it as dull and crampy. She reports her pain level at the onset at 3 out of 10. She is also experiencing bloating. She did not feel her symptoms warranted a trip to the clinic but her daughter insisted she come. She describes her symptoms primarily as generalized discomfort in the abdomen, and states that her lower abdomen is the location of the pain. She denies nausea and vomiting, blood or mucus in stool, rectal pain or bleeding, or recent fever. She denies vaginal bleeding or discharge. Reports no history of inflammatory bowel disease or GERD. Denies family history of GI disorders. Her appetite has decreased over the last few days and she is taking small amounts of water and fluids. Previously she reports regular brown soft stools every day to every other day. Objective Elderly womes sitting up in the exam with grimace at the time of discomfort. Appears a liitle bit distressed but stable, able to answer all inquiries and is goog historian. HEENT: nose and mouth with moist pink mucouse membranes, normal skin turgor with no tenting. Cardio: S1, S2, no gallops, rubs, or murmurs noted. No edema to lower extremities. Respiratory: respiration unlabored and quiet, abel to speak full sentences with no SOB. Lung breath sounds CTA in all lobes. Abdominal: 10 cm scar at midline in suprapubic region and 6 cm scar in RUQ, Exam reveals no discoloration, • General Survey: Uncomfortable and flushed appearing elderly woman seated on exam table grimacing at times. Appears stable but mildly distressed. • HEENT: Mucus membranes are moist. Normal skin turgor; no tenting. • Cardiovascular: S1, S2, no murmurs, gallops or rubs; no S3, S4 rubs. No lower extremity edema. • Respiratory: Respirations quiet and unlabored, able to speak in full sentences. Breath sounds clear to auscultation. • Abdominal: 6 cm scar in RUQ and 10 cm scar at midline in suprapubic region. An abdominal exam reveals no discoloration; normoactive bowel sounds in all quadrants; no bruits; no friction sounds over spleen or liver; tympany