Medical Record Documentation of Chronic Abdominal Pain

1993 ◽  
Vol 14 (2) ◽  
pp. 68-69
Author(s):  
H. Shah
Keyword(s):  
Abdominal Pain ◽  
Medical Record ◽  
School Nurse ◽  
Chronic Abdominal Pain ◽  
Chief Complaint ◽  
School Absence ◽  
Bowel Movements ◽  
Long Time ◽  
Obvious Relation ◽  
Medical Record Documentation

Name: Martha McCue1 Date of birth: June 24, 19842 Drug allergies: None known3 Immunizations: Complete4 Thursday, December 3, 1992 CHIEF COMPLAINT: "She's been having stomach aches since summer." PRESENT ILLNESS: (without prospective diary) Stomach hurting off and on since end of summer. May have started on vacation. Says stomach hurts "lots of days." Many times too uncomfortable to go to school or mother has to get her. School nurse worried there is something wrong. Pain is usually "in middle." No obvious relation to meals; "can happen anytime." Not sure if it wakes her up, "but sometimes I have bad dreams." Pain lasts "a long time." Appetite normal for her; picky eater. No obvious relation to specific foods. Thinks bowel movements are normal; can't remember how often. No discomfort urinating. Has not had temperature taken. Remembers vomiting once. Mother thinks one bout was related to taking antibiotic. PRESENT ILLNESS: (with prospective diary) Father had vomiting and diarrhea mid-August on vacation; better in 4 days. Martha caught it and had pronounced cramps. Not a week without abdominal pain since then. Several bouts a week. Diary shows pronounced pain on Sunday evenings, Monday mornings, Tuesday mornings, causing school absence 3 days. Milder discomfort on other days. No pain over Thanksgiving vacation until Sunday night.

Medical Record Documentation of Seizures

1992 ◽  
Vol 13 (2) ◽  
pp. 76-77
Keyword(s):  
Medical Record ◽  
Chief Complaint ◽  
Total Loss ◽  
Loss Of Consciousness ◽  
Pertinent Data ◽  
Sample Record ◽  
Medical Record Documentation

This sample record is meant to demonstrate comprehensive recording of pertinent data. Actual records will vary in format; many will be written in a more abbreviated style. Name: Sharon DiStefano1 Date of birth: December 8, 19832 Drug allergies: None; cramps from erythromycin3 Immunizations: Fully immunized4 Thursday, February 6, 1992 Telephone Teacher called parents — Sharon "suddenly gets a blank look" for brief periods. Has done this several times. Parents will get further information from teacher, watch carefully over weekend, bring in for visit next week. Tuesday, February 11, 1992 CHIEF COMPLAINT: "We think she's having spells." PRESENT ILLNESS: (See letter from teacher). He has noted over the last week, on 5 or 6 occasions, that Sharon will develop "blank stare" suddenly. When talked to, will not respond at first but will after several repetitions. Once did this in the middle of talking; paused noticeably for a number of seconds, then resumed talking. Eyes always stay open; blinking noted; no total loss of consciousness. No jerking, twitching, slumping, drooling, incontinence. Seems normal afterwards; not aware of any lapse. Over the weekend parents saw similar spells: three times at meals, twice when watching television, once after she had been running around backyard and had just sat down. "Like a shade was drawn behind her eyes."

MEDICAL RECORD DOCUMENTATION OF ACUTE PHARYNGITIS

1990 ◽  
Vol 12 (5) ◽  
pp. 134-135
Keyword(s):  
Lymph Node ◽  
Physical Examination ◽  
Medical Record ◽  
Sore Throat ◽  
Soft Palate ◽  
Chief Complaint ◽  
Birth Date ◽  
Mandibular Angle ◽  
Acute Pharyngitis ◽  
Medical Record Documentation

Name: Charles Whitcomb1 Birth date: May 3, 19762 Drug allergies: Hives with sulfonamides3 Immunizations: 5 DTP injections recorded4 Monday, September 24, 1990 CHIEF COMPLAINT: Sore throat. HISTORY: Throat started to hurt late Friday and has worsened gradually over the weekend. Hurts to swallow. Took temperature once: 100°F last night. Nose stuffy. Thinks he has swollen glands. PHYSICAL EXAMINATION: Fairly comfortable; complaining of throat pain. Temperature: 101°F orally. Tympanic membranes: clear. Nose: No discharge but sounds stuffy. Pharynx: Small tonsils; mildly erythematous; no exudate. Posterior soft palate and uvula mildly swollen; no petechiae. Neck: 1.0 cm mildly tender lymph node at each mandibular angle. A few smaller anterior and a number of 0.5 cm posterior cervical nodes. Neck fully supple.

scholarly journals Gallbladder diaphragm: about a case

2021 ◽  
Vol 8 (7) ◽  
pp. 2159
Author(s):  
Baiss Marouane ◽  
Hicham El Majdoubi ◽  
Rabbani Mohammed ◽  
Anwar Rahali ◽  
Rahal Massrouri ◽  
...  
Keyword(s):  
Abdominal Pain ◽  
Laparoscopic Cholecystectomy ◽  
Blood Count ◽  
Histological Study ◽  
Chronic Abdominal Pain ◽  
Radiological Examination ◽  
Rare Anomaly ◽  
Long Time ◽  
Work Up ◽  
Hepatic Cytolysis

Diaphragm gallbladder is a very rare anomaly of gallbladder embryogenesis. This malformation is very rare in adults and represents 0.1% of gallbladder anomalies. It can remain asymptomatic for a long time and be discovered fortuitously during a radiological examination for another pathology or be revealed by chronic abdominal pain or by a complication such as cholecystitis or biliary peritonitis. We report the observation of a 34 years old woman with chronic hepatic colic. The biological work-up including a blood count, a hepatic cytolysis and cholestas and CRP determination did not reveal any abnormality, whose morphological examinations concluded to an uncomplicated diaphragm gallbladder. A laparoscopic cholecystectomy was performed. The post-operative course was unremarkable. The intraoperative finding by opening the cholecystectomy specimen confirmed the diagnosis of a diaphragm gallbladder. Histological study confirms the diagnosis of diaphragm vesicle cholecystitis. In this document, we described the clinical and radiological characteristics of this rare anomaly.

Assessment of clinical outcomes among CT scan in the diagnosis of chronic abdominal pain

2019 ◽  
Vol 10 (3) ◽  
pp. 15-18
Author(s):  
Anant Madhukarrao Bhuibhar ◽  
◽  
Challa Anil Kumar ◽  
Lalwani Shyam Tekchand ◽  
◽  
...  
Keyword(s):  
Abdominal Pain ◽  
Ct Scan ◽  
Clinical Outcomes ◽  
Chronic Abdominal Pain
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