ocused_Exam__Abdominal_Pain___Documentation.pdf

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Student Documentation Model Documentation Model Documentation Ms. Park usually does water aerobics and pilates but the pain this week has made her skip her classes. PMI: Ms. Park was diagnosed wit... h hypertension at the age of 54. She does not monitor her blood pressure at home and only gets a check annually during her physical. Surgeries: Ms. Park has had two surgeries in her life. A C-section at the age of 40 and a cholecystectomy at the age of 42. Medications: Accupril 10mg q Daily. She takes it in the morning with her breakfast. Allergies: Ms Park has an allergy to latex which causes a rash. Family History: Ms. Park states that her father had occasional heartburn but no one else in her family has stomach issues. She denies family history of colon cancer, liver disease, cholecystitis, irritable bowel syndrome, kidney problems or bladder issues but she nites that her extended family is still in Korea so she cannot be certain. ROS: HEENT: Ms. Park denies any dizziness. She states but she has no problems with her vision. She did state that her hearing is not as good as it used to be but she feels that she still hears pretty well. Ms. Park does not have any sinus problems and state that she hasn't "gad a cold or any congestion all year". She denies any pain in her mouth or teeth. Ms. Park notes that she had a root canal 1 year ago. Cardiac: Ms. Park was diagnosed with hypertension at the age of 54. Respiratory: Ms. Park denies any breathing problems or shortness of breath. Gastrointestinal: Ms. Park denies a history of GERD, ulcers, appendicitis or hernia. She states that she has not had any digestive or gastrointestinal issues until now. She had her gall bladder removed 26 years ago. Ms Park has not had a normal bowel movement in almost five days. She notes that her last bowel movement was diarrhea. Ms. Park states that she is normally regular having one bowel movement a day. She denies vomiting recently but states that she feels bloated. Gynecological: Ms. Park went through menopause at the age of 54. Urinary: Ms. Park denies any issues with her kidneys, problems urinating for incontinence. She knows that her urine has been where's my mom's house a bit darker than usual and that she has not been urinating as often. Musculoskeletal: Ms. Park denies any pain in her arms or legs. This study source was downloaded by 100000816392744 from CourseHero.com on 04-22-2021 06:18:11 GMT -05:00 https://www.coursehero.com/file/50721353/Focused-Exam-Abdominal-Pain-Documentationpdf/ [Show More]

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