Source And Reliability : Patient Alert And Oriented At Time, Place And Person, Reliable Historian Essay

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II. SOURCE AND RELIABILITY: Patient alert and oriented to time, place and person, reliable historian.
III. REASON FOR SEEKING CARE (CC): 38 y/o female c/o abdominal pain throughout the entire abdominal cavity, states that she has always had abdominal discomfort, but the past 3 days’ pain has become unbearable. She describes the pain as a burning, churning throughout 8/10. Pain is intermittent c/o of sour stomach after meals accompanied by nausea, denies vomiting, diarrhea or anorexia, last bowel movement 4 days ago. States she moved bowels 2-3 times a week. She states this happened about 2 years she went to the emergency room, CT was done, no blockage, she was sent home without medications, CT contrast helped her move bowels at the time, symptoms eventually resolved on their own. Patient c/o of waking up feeling unrested, had trouble falling asleep ever since she could remember, wakes up frequently with difficulty getting back to sleep. She reports sleep disorder sometimes coincide with inability to get comfortable due to shoulder and neck pain especially in the winter months. Patient states the head and shoulder pain are the result of an MVI in 1995 where she had spinal nerve damage and bulging disc.
Abdominal pain 8/10
O. Started 3 days ago after eating large meal.
P. Pain is intermittent and worst when lying down on the back or sitting down, relief felt when lying on stomach.
Q. Pain is severe, churning and feeling of sour

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