How can I help you? My stomach hurts
Do you have any other symptoms or concerns
we should discuss?
I occasionally feel “bloated” although I’m not
... [Show More] sure my belly is
actually bigger when I feel that way. I…well pass a lot of gas and…
even belch a lot compared to other people I know. Sort of
embarrassing for a woman you know. Do you think that’s related
to all of this?
Is your pain affected by what, when, or how
much you eat?
It seems to be worse with rich foods. I haven’t really noticed it as
associated with when or how much.
Do you now or have you ever smoked or
chewed tobacco?
No, I never have.
Are you taking any over the counter or herbal
medications?
I take a multivitamin daily, and acetaminophen from time to
time for stress headaches
Are you taking any prescription medications? No prescription medications
Do you have any allergies? Not that I know of
Have you ever been hospitalized? Just for the c-section and the bike accident thing
Any previous medical, surgical, or dental
procedures?
I had a c-section at 27 without any complications. When I was 17, I
had a bike accident and had a complicated fracture of my right
tibia. They had to fix that with surgery.
Can you tell me about any current or past
medical problems you have had?
I don’t know really what’s important. The only thing besides this
stomach problem is that lately I’ve been getting occasional hot
flashes and my skin is sort of dry. I also get headaches now and
then which isn’t new and that probably isn’t important anyway.
Is that the kind of things you want to know?
Do you have diarrhea?
Is there any blood in your stools or with your
bowel movement?
Anything red? Not that I have noticed
Do you have a problem with constipation? Definitely. For as long as I can recall in my adult life, I have
alternating periods of constipation and just the opposite if you
know what I mean that lasts several days. When I am
constipated, I feel like I cannot get everything out, even after a
BM.
Have you been having fevers? I don’t think so, can you check that for me
How often does this abdominal pain occur? It’s been coming and going for years now. It never really goes
away entirely, but then it also doesn’t seem to be getting a lot
worse. It’s just there all the time. So frustrating.
Occasionally. Sometimes I’d say my bowel movement is loose and
watery. Does that count?
How severe (1-10 scale) is your abdominal
pain?
It varies, sometimes it’s just mild and annoying, other times it
stops me in my tracks it’s so bad
Does the pain in your abdomen radiate
someplace else? Where?
No, it’s just in my stomach
Where more precisely is your abdominal pain? All over, especially in the lower half of my belly.
What does the pain/discomfort in your
abdomen feel like? (Cramping, burning,
stabbing, aching, tingling, squeezing).
Usually like a bad cramp but sometimes it can be a stabbing
feeling.
Does anything make the pain in your abdomen
better or worse?
“Having a bowel movement sometimes makes it better. Then it
starts up again if I’m stressed out or eating the wrong stuff”.
When did your abdominal pain start? This problem started at least 10 years ago. It’s really been going
on far too long.
Do your symptoms occur after eating rye,
wheat, or barley?
No
What are the events surrounding the start of
your abdominal pain?
I don't remember a particular event.
Have you or any family member had a history
of IBD?
No, I’ve never heard that about anyone
Are you now or have you ever been anemic? No one has ever told me that
Do you avoid eating because you are worried
about pain?
Sometimes maybe I do. I mean when my stomach is hurting I
don’t feel much like eating.
Do you have any skin problems? Just a little dry. I haven’t noticed anything else.
Do you have a history of a bowel obstruction? No, nothing that dramatic.
Have you or any family member had a history
of colon polyps or colon cancer?
No, we do not.
Do you have black tar-like or foul-smelling
stools?
No, I’ve never had anything like that.
Have you lost weight? No
How long does the pain in your abdomen last? Sometimes a few minutes, sometimes up to an hour
Have you had the pain in your abdomen
before?
Yes, this same sort of pain on and off
Do you have arthritis? No, I’m lucky with that
Do you have heart disease and/or have you
ever had a heart attack? No, I do not have
heart problems.
No, I do not have heart problems.
Questions to fill out the EHR
Tell me about your work
Have you had a recent endoscopy, colonoscopy,
or biopsy?
Uh… No.
When and what was the result of your last
mammogram?
I haven’t had one yet. Too busy.
Physical Exam
Blood pressure 120/60, normal, normotensive
Cognitive Alert and oriented x 4
Pulse 60, regular, normal
RR 14, regular, unlabored
Temp 98.6
Inspect skin overall Dry skin, otherwise unremarkable
I am a manager at a local restaurant. I have very long workdays…
I usually work late into the night.
Inspect hair color, distribution,
thickness
Thickness and distribution pattern typical for patient gender and age
Inspect nails Nails without ridging, pitting, or peeling
Test capillary refill Normal capillary reflow
Inspect eyes Normal
Inspect face Normal expression. No lesions, scars, or abnormal pigmentation.
Ocular motor test Normal
Examine pupils R – NR, L – NR
Inspect/Palpate Head Normocephalic, atraumatic. No deformities. Facial features symmetric.
Temporal arteries non-tender to palpation. Frontal and maxillary sinuses nontender.
Inspect/Palpate scalp No visible scaliness, edema, masses, lumps, deformities, scars, rashes, nevi, or
other lesions. Non-tender.
Inspect neck No visible scars, deformities, or other lesions. Trachea is midline and freely
mobile.
Inspect mouth/pharynx Oropharynx not injected, clear mucosa, tonsils without exudate. Tongue pink,
symmetrical. No swelling or ulcerations.
Smell breath No unusual odor
Palpate neck Thyroid firm, an acceptable size for patient gender and age. No nodules
palpated.
Ask patient to swallow Normal exam. Thyroid moves with swallowing.
Palpate all lymph nodes No pathologically enlarged lymph nodes in the cervical, supraclavicular,
axillary, or inguinal lymph chains.
Lung sounds Normal
Heart sounds Normal
Visual inspection of the abdomen Abdomen is flat and symmetric with no scars, deformities, striae, or lesions
Auscultate abdomen Normal
Auscultate femoral/abdominal
arteries
Done
Palpate abdomen Mild tenderness with deep palpation of the lower abdomen on both sides.
Percuss abdomen Normal
Measure girth Appropriate girth for age and gender
Visual inspection of the
extremities
No swelling or deformity. No cyanosis, clubbing, or edema.
Palpate extremities There is no tenderness, muscular resistance, rigidity, or deformity.
Visual inspection of the rectal area No visible fissures, induration, or lesions [Show Less]