Focused Exam: Abdominal Pain Results | Turned In Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1
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Miss Park is a pleasant Korean 78 year old woman who presents to the clinic with complaints of abdominal pain for the past 5 days. She is oriented to person place and time. She answers the questions appropriately and maintains eye contact during the interview and exam. This with her daughter who assist with her Care at home. Pains are described as crampy, dull at her lower abdomen, with a pain scale of 6/10, mostly constant. Has had difficulty using the bathroom this past 5 days, which has affected her daily activites. She has been feeling more tired than usual, denies feeling fever chills or rectal pain. She drinks two glasses of water a day and eats well, although has had a decrease in appetite since her abdominal pain started. Her abominal pain Is aggravated with food and activity, pain is relieved with rest. Her stool is soft and brown, no current diarrhea. She has history of colonoscopy that was negative. She denies any vaginal bleeding or urinary difficulty. She denies any GERD, colon cancer or stomach issues. PMHx: HTN on accupril 10 mg daily Immunizations: updated: declines flu vaccination today. Surgical hx: choleystectomy at 42yo Cesarean delivery at 40yo: OB/GYN: G3P3L2: one stillbirth for cord accident. No hx of STI. Pap WNL 2010 Social hx: has a friend who she is intimate with, no tobacco use, no illicit drugs. Drinks once a week with white wine. Has stong family support. Visits her Son in Houston occasionally. Family Hx: Mother: DM and HTN: Deceased @ 88yo Father: HTN and hypercholestremia: deceased at 82yo MGP: HTN PGM: HTN/ CVA/obesity Brothers: HTN SOn: healthy daughter: Healthy
Ms. Park reports that she is “having pain in her belly.” She experienced mild diarrhea three days ago and has not had a bow 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 o 10, and describes it as dull and crampy. She reports her pain lev the onset at 3 out of 10. She is also experiencing bloating. She d not feel her symptoms warranted a trip to the clinic but her daug insisted she come. She describes her symptoms primarily as generalized discomfort in the abdomen, and states that her lowe abdomen is the location of the pain. She denies nausea and vomiting, blood or mucus in stool, rectal pain or bleeding, or rece fever. She denies vaginal bleeding or discharge. Reports no histo of inflammatory bowel disease or GERD. Denies family history of 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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