Focused Exam- Abdominal Pain | documentation provider notes
Miss Park is a 78 year old female of Korean to send
date of birth Jan 17.
CC Miss Park
... [Show More] States" I have some pain in my belly
and I am having difficulty going to the bathroom my
daughter was worried about me."
C: pain in belly with difficulties going to the
bathroom, dull crampy feeling. 6/10 on pain sacele
O: 5 days ago, gradual, constant and bloating
L: lower belly, entire bellly
D: constant pain
E: moivng and eating , has missed both of her
exercise classes and states " never misses her
exercise classes."
R: resting helps a little but no real relief, sips of
warm water a friend suggested not helping
R: patient has not tried any medication, aggravated
with eating and physical activity also reports low
energy level, a dull crampy feeling a 6 out of 10 on
the Pain Scale.
A: Bowel movement noted a few days ago was
diarrhea, denies any history of constipation. Reports
having diarrhea about 2 to 3 days ago sudden onset
lasting one day, record very loose and watery:
normal normal bowel movements description of
brown formed and soft are usually every day until 5
days ago. Reports recent slight decrease in
frequency of urination do to decrease water intake.
Urine darker than usual. Denies blood in urine.
Denies any GI history disorders. Denies history of
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.
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