Orientation +1
Please verify your name and birthday
Chief Complaint +1
Do you have any pain today?
History of Presenting Illness +1
Can
... [Show More] you rate your current pain level on a scale of 0-10?
History of Presenting Illness +1
Where is your pain?
History of Presenting Illness +1
Can you describe your pain?
History of Presenting Illness +1
Does anything make your pain any better?
History of Presenting Illness +2
Does anything make your pain worse?
History of Presenting Illness +1
Have you taken anything for your pain?
History of Presenting Illness +1
When did you first notice the pain?
Social History +1
What was the last thing you ate?
History of Presenting Illness +1
Do you have difficulty going to the bathroom?
History of Presenting Illness +2
How often do you go to the bathroom?
Past Medical History +1
How is your diet?
Home Medications +1
Do you take any medications?
Home Medications +1
Do you take any antibiotics?
Social History +1
Do you eat a lot of fiber?
Review of Symptoms +1
How many meals a day do you eat?
Past Medical History +1
Have you ever had abdominal surgery?
Review of Systems +1
How many times do you urinate?
Social History +1
Do you have trouble walking?
Social History +1
Do you live alone?
Social History +1
Do you drink alcohol?
Social history +1
How many time do you drink alcohol?
Review of Systems +1
Do you exercise?
Review of Systems +1
Does your pain affect your daily activities?
History of Presenting Illness +2
Have you had any diarrhea?
Review of Systems +1
Have you ever had an appendectomy?
History of Presenting Illness +1
Do you have any bloody stool?
Review of Systems +1
Do you have problems swallowing?
Inspect-Head and Face
Skull: Symmetric
Facial: Symmetric
Appearance: No visible abnormal findings
Inspect-Nasal Mucosa
Appearance: moist and pink
Inspect-Mouth
Oral Mucosa: moist and pink
Insepct-Abdomen
Symmetry: Symmetric
Contour: Flat
Appearance: scarring
laceration, lesion, wound, redness
Inspect: Lower Extremity Edema
Right: No edema
Left: No edem
Auscultate: Heart Sounds
Heart Sounds: S1, S2, S3, S4 are audible
Extra Heart Sounds: No extra sounds
Auscultate-Breath Sounds
Breath Sounds: Present in all area
Adventitious Sounds: None
Location: All Clear
Auscultate-Abdominal Aorta
No bruit
Auscultate- Bowel Sounds
Bowel Sounds-Normoactive
Location: All are normal
Auscultate- Abdominal Arteries
All are no bruit
Percuss: Abdomen
Observations: some dull, some tympanic
Percuss: CVA Tenderness
patient did not react
Percuss-Spleen
Tympany
Percuss-Liver
Between 6-12 cm
Palpate-Light
Tenderness: some tenderness reported
Location: LLQ
Observations: no additional
Palpate-Deep
Palpable Mass
LLQ
Palpate-Liver
Palpable mass
Palpate-Spleen
not palpable
Palpate-Bladder
not palpable [Show Less]