SOLVED992

ESTABLISHED PATIENT OFFICE VISIT HISTORY OF PRESENT ILLNESS: Patient follows up today after a CT scan of her abdomen for abdominal pain. She continues to have the same symptoms that she was having at her last clinic visit. I have interpreted the CT scan and went over the images with her. The only very subtle abnormality in her right inguinal region is that of a slight bowing of her transversalis fascia. Otherwise, I do not notice any abnormality. Trying to correlate this with where her symptoms are located on her abdominal wall, these are in two separate locations. Her abdominal wall pain is approximately 3 cm above her inguinal canal. ASSESSMENT/PLAN: She will continue to hold off on any significant core activities. I have told her to try and avoid activities that reproduce her pain. If this is an abdominal wall injury, it is going to take several weeks for it to heal and she will need to hold off on those activities for the next six to eight weeks. She will contact my office in three weeks to let me know how she is doing with her conservative management. If she continues to have symptoms at that time, then
SCIENCE
HEALTH SCIENCE
NURSING

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