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NR 509 Focused abd exam.docx

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NR 509 Focused abd exam.docx Chief complaint: patient complains of abdominal pain, diarrhea for one day with 3-4 episodes during that day followed by no bowel movement in five days History of present illness: ...

NR 509 Focused abd exam.docx Chief complaint: patient complains of abdominal pain, diarrhea for one day with 3-4 episodes during that day followed by no bowel movement in five days History of present illness: patient states she started with abdominal pain that started 5 days ago. Patient complaining of diffuse abdominal pain the most painful area is the lower left quadrant and lower right quadrant. Patient states the pain is constant in nature. Patient states he pain is dull and crampy. Patient states pain is currently 6 out of 10. Patient states movement in eating exacerbates the pain. Alleviating factors include rest. Treatment includes rest and small sips of warm water. Current medications include accupril 10 mg PO daily. Allergies include latex which causes pruritic skin rash. Past medical history includes: hypertension diagnosed at age 54 3 pregnancies surgical history includes C-section at age 40 cholecystectomy at age 42 reports hospitalizations for 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 (More enquiries- [email protected])

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