NR 509 Abdominal Pain Documentation Shadow

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Patient Info: Esther Park, 78 years, Asian female CC: Patient states that they are "having pain in her belly" and that she is having trouble "going to the bathroom." HPI: The patient, Ms. Park, ca me ... into the office complaing of abdominal pain and not being able to have a bowel movement. She states that this pain started 5 days ago and has gotten worse over the past 2 to 3 days. The pain is in the lower abdomen and does not radiate. She does not have pain anywhere else. She states that her current abdominal pain could be rated a 6 out of 10. She describes the pain as "dull and crampy." She states that it does get worse sometimes, especially after physical activity or eating. She states that resting does help, but the only treatment she has pursued is "taking small sips of warm water," a method her friend infromed her of. This has not been an effective treatment. She states that she is not being able to go about her normal daily activities due to the pain. She also reports a low energy level. She is currently constipated, and issue that she has no history of. She has been constipated for about 5 days, but has not pursued any treatment. She had a bout of diarrhea about 3 days ago that she described as "loose and watery." It lasted for one day. Before the onset of the abdominal pain 5 days ago, the patient states that they had normal bowel habits, but has not had a movement in 3 days. No mucus or blood in stool. Patient states that the frequency of her [Show More]

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