Shadow Health Abdominal Pain Esther
Park (Focused Exam: Abdominal Pain)
chief complaint ✔️ -reports abdominal pain -reports difficulty with bowel movement asked about orientation ✔️ -oriented to own person -oriented to place -oriented to situation -oriented to time asked about onset, frequency, and duration of pain ✔️ -reports discomfort for the past 5 days -reports pain with gradual onset that worsened 2-3 days ago asked about location of pain ✔️ -reports pain in lower abdomen -reports pain is not localized asked about pain rating on scale ✔️ -reports 6/10 pain asked about characteristics of pain ✔️ -describes pain a dull and cramping -pain fluctuates in severity asked about non-pharmacological relieving factors ✔️ -denies taking pain medication -denies taking laxatives asked about aggravating factors ✔️ -reports pain is aggravated by eating -aggravated by physical activity asked about impact on daily life ✔️ -recent difficulty participating in usual activities -reports low energy followed up on constipation ✔️ -constipation most of last 5 days -denies any attempt to treat constipation 1 / 2
asked about diarrhea ✔️ recent diarrhea followed up about diarrhea ✔️ -about 6 months ago -sudden onset -lasted one day -loose and water asked about substances in stool ✔️ -denies mucus and blood in stool asked about urination ✔️ -recent, slight decrease in frequency of urination -darker urine recently -denies blood in urine asked about fluid intake ✔️ -decreased thirst -decreased fluid intake for last few days -typical fluid intake is 1-2 glasses water/day -denies drinking caffeine asked about contact with illnesses ✔️ -denies recent travel and exposure to food poisoning asked about history of constipation ✔️ denies history asked about typical bowel movements ✔️ -typically has BM almost every day -stools usually brown, formed, soft asked about allergies ✔️ -reports latex allergy -denies med allergies -denies food allergies asked about pre-existing health conditions ✔️ -reports high BP -diagnosed at 54 asked about relevant history of surgery ✔️ -c section at 40 -gall bladder removal at 42 -no post op complications
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