General Appearance: Patient presents with abdominal pain, or [1], and irregular stools. Stomach may be bloated but is not otherwise distended. When asked if she has also been experiencing N&V, which means [2], the patient responded that she has not. Visual and manual inspection of abdomen do not reveal any clear physical damage. Pain that is general and chronic rules out more emergent medical conditions, such as [3], or acute inflammation of the appendix. Normal temperature and lack of other symptoms help to rule out an infection. Heart: Rate at 80 bpm, with no abnormal sounds. Lungs: CTA AbD: Bowel sounds normal all four quadrants. MS: Joints and muscle symmetric. No swelling, masses, or deformity. UA: No blood present in urine, otherwise known as [4], or of blood in the stool. This rules out some more serious disorders. Glycosuria, or presence of [5] in the blood, was observed as well as the presence of ketone bodies, known as [6]. These symptoms indicate that diabetes treatment may need to be refined. Assessment: Most likely IBS, or irritable bowel syndrome, based on presenting symptoms and ruling out of other disorders. IBS is a [7] condition, meaning it persist and last a lifetime. Plan: 1. Lifestyle and diet changes. Monitor symptoms and avoid foods that seem to trigger symptoms. Maintain healthy diet and exercise routine. If symptoms do not improve or worsen over time, consult a specialist that can treat stomach and intestine issues specifically. This type of doctor is known as a [8]. Surgical procedures, such as a EGD, which stands for [9], are not deemed necessary at this time.
General Appearance: Patient presents with abdominal pain, or [1], and irregular stools. Stomach may be bloated but is not otherwise distended. When asked if she has also been experiencing N&V, which means [2], the patient responded that she has not. Visual and manual inspection of abdomen do not reveal any clear physical damage. Pain that is general and chronic rules out more emergent medical conditions, such as [3], or acute inflammation of the appendix. Normal temperature and lack of other symptoms help to rule out an infection.
Heart: Rate at 80 bpm, with no abnormal sounds.
Lungs: CTA
AbD: Bowel sounds normal all four quadrants.
MS: Joints and muscle symmetric. No swelling, masses, or deformity.
UA: No blood present in urine, otherwise known as [4], or of blood in the stool. This rules out some more serious disorders.
Glycosuria, or presence of [5] in the blood, was observed as well as the presence of
Assessment:
Most likely IBS, or irritable bowel syndrome, based on presenting symptoms and ruling out of other disorders. IBS is a [7] condition, meaning it persist and last a lifetime.
Plan:
1. Lifestyle and diet changes. Monitor symptoms and avoid foods that seem to trigger symptoms. Maintain healthy diet and exercise routine.
- If symptoms do not improve or worsen over time, consult a specialist that can treat stomach and intestine issues specifically. This type of doctor is known as a [8].
- Surgical procedures, such as a EGD, which stands for [9], are not deemed necessary at this time.
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