Gastrointestinal System – Analyzing a Progress Note

Part 1

Using the following progress note, define the highlighted terms within the chart provided.

This patient was assessed by an Urgent Care physician.

Progress Note

40 y. o. female presents with a 3 day history of stabbing pain and cramping in the lower abdomen. Patient complains of anorexia, vomiting, and diarrhea with fever. She feels week and dehydrated. Patient notes having this before one year prior. She had a colonoscopy and endoscopy at the time and was diagnosed with diverticulitis along with GERD.

Past Medical History: Diverticulitis, GERD, Cholecystitis in 2011.

Meds: Nexium 20mg every day

Allergies: Sulfa, PCN

Assessment: Vital Signs: T 101 degrees, P 110, R 18, B/P 144/92, occult blood test negative.

GEN: Appear to be in acute distress, dehydrated, bowel sounds hyperactive x4, tenderness to left and right lower quadrant with guarding.

Impression: Acute Diverticulitis of the colon, possible gastritis

Discussed with patient and planning transfer to University Hospital for direct admission.

C. Bolling, CNP

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