Exam (elaborations) NUR 500 ESTHER PARKS ABDOMINAL PAIN EHR Documentation
Document: Provider Notes
Student Documentation Model
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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
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NUR 500 ESTHER PARKS ABDOMINAL
PAIN EHR Documentation
Student Documentation Model Documentation
bowel sounds WNL in all quadrants; no friction
sounds over spleen or liver, no bruits in any
areas; tympany presides; Liver span at 7 cm;
Guarding to light touch at LLQ; 2x4 mass in
LLQ with deep palpation; strong sphincter tone,
fecal mass detected in rectal vault. GU: bilateral
kindey nontender; urine clear and dark yellow,
normal odor, no nitrites, WBCs, RBCs, or
keatones, pH 6.5, SG 1.017.
presides with scattered dullness over LLQ;
abdomen soft in all quadrants; an oblong mass
is noted in the LLQ with mild guarding,
distension; no organomegaly; no CVA
tenderness; liver span 7 cm @ MCL; no
hernias. • Rectal: No hemorrhoids, no fissures
or ulceration; strong sphincter tone, fecal mass
in rectal vault. • Pelvic: No inflammation or
irritation of vulva, abnormal discharge, or
bleeding; no masses, growths, or tenderness
upon palpation. • Urinalysis: Urine clear, dark
yellow, normal odor. No nitrites, WBCs, RBCs,
or ketones detected; pH 6.5, SG 1.017.
Assessment
Primary: Constipation Secondary: Small Bowel
Obstruction
Mrs. Park’s bowel sounds are normoactive in all
quadrants, with no bruits or friction sounds.
Scattered dullness in LLQ during percussion is
suggestive of feces in the colon; otherwise, her
abdomen is tympanic. Her abdomen is soft to
palpation; mild guarding and oblong mass
suggesting feces were discovered in LLQ. No
CVA tenderness; liver span 7 cm @ MCL; no
splenic dullness. Digital rectal exam revealed a
fecal mass in the rectal vault. No abnormalities
were noted during the pelvic exam, so pelvic
inflammatory disease is not suspected. Ms.
Park’s urinalysis was normal, which rules out a
urinary tract infection. No signs of dehydration
or cardiovascular abnormalities. Mrs. Park’s
symptoms and health history suggest she has
constipation. Differential diagnoses are
constipation, diverticulitis, and intestinal
obstruction.
Plan
Encourage to drink more fluids at tleast 8-10
glasses wat [Show Less]