Looking for the best study guides, study notes and summaries about comprehensive health assessment. Advanced Practice Care of Adults? This document will take you through the template of conducting health assessment and writing SOAP Notes.
CC: “I have a burning abdominal pain that gets worse when the stomach is empty.”
HPI: An African American female aged 55 comes to the office with complaints of
burning abdominal pain that gets worse when she is on an empty stomach. The patient
reports that she also feels nausea, bloating, burping, unintentional weight loss and loss of
appetite. The patient states that her symptoms started about four days ago and they have
been getting worse with the passing of time. The patient also states that her abdominal
pain does not radiate to other parts of the body. The patient rates her abdominal pain as
6/10 and states that the abdominal burning sensation is episodic and it usually lasts for
more than 45 minutes. The patient states that she does not really know what relieves her
pain and she just knows they usually disappear on their own. The patient reports that an
empty stomach usually makes her symptoms worse. The patient denies past diagnosis of
any health condition. The patient denies chills, fever, fatigue and malaise. The patient
denies taking any form of medication to relieve her symptoms.
Medications:
None.
PMH:
Medication Intolerances: None.
Allergies: NKDA.
Chronic Illnesses: None.
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