Name NR 509

Focused Note

Subjective:

Date of encounter: April 25, 2019

Patient Name or initials: Esther Park

Informant: 78-year-old woman who is a reliable historian.

Chief Complaint (CC): Abdominal pain.

History of present illness (HPI): Ms. Park reports that she is having abdominal pain for almost a

week now, beginning 5 days ago. She notes the pain is generalized across her entire abdomen,

however, hurts more along the left lower quadrant. The pain is increasingly getting worst in the

past 2-3 days. She rates her pain a 6 out of 10 and describes it as dull and cramping. She has not

tried any medications for pain relief. Ms. Park denies any recent travel. 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. 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 left abdomen is the location of the pain. She denies any radiating 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 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. Her pain is aggravated when she moves around and is

active. Staying still at rest lessens the pain but does not eliminate it completely. Ms. Park denies

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Name NR 509

taking any pain medications and instead drinks warm tea. As a result, she has experienced a

decline in her energy level and finds she is resting more often.

Allergies: Latex (contact dermatitis)

Immunizations: Up to date (declined influenza vaccination this season)

Medications: Accupril 10mg by mouth daily for high blood pressure.

Past History: Past medical history only includes hypertension.

Past Surgical History: Ms. Park has had a cesarean section (40-years-old) and a

Cholecystectomy (42-years-old) in the past.

Family History: Ms. Park notes her Mother had a history of hypertension and diabetes type II.

She passed away at the age of 88. Her Father passed away at the age of 82 and had a history of

hypertension and hypercholesterolemia. Her maternal grandparents have a history of coronary

artery disease and diabetes II. Her paternal grandparents have a history of obesity, CVA, and

hypertension. Her eldest brother is 81 years old and has a history of hypertension, and her

second oldest brother is 80 years old and has a history of hypertension, hypercholesterolemia,

and prostate cancer. She has one living son who is 48 years old and healthy, and one living

daughter who is 46 years old and healthy.

Personal and Social History:

Health Promotion/Maintenance Activities: Ms. Park does not currently smoke, nor has a history

of smoking, or using tobacco. Miss Park is up to date with her immunizations; however, she did

not receive an influenza vaccine this season. Sleep is adequate, and she notes performing water

aerobics and Pilates as well as walking. Miss Park denies recreational or illicit drug use, and

usually only drinks one glass of wine per week.

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