LARRY ORLANDER PAIN
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12 Does the pain in your abdomen radiate someplace else?
13 Is the pain in your abdomen affected
... [Show More] by what, when, or how much you eat?
14 Any change in the frequency of your bowel movements?
15 Any previous medical, surgical, or dental procedures?
16 Are you unable to pass gas?
17 Can you tell me about any current or past medical problems you’ve had?
18 Do you have a history of bowel obstruction?
19 Have you or any family member had a history of inflammatory bowel disease?
20 Have you had the pain in your abdomen before?
21 Do you have heart disease and/or have you ever had a heart attack?
22
Have you lost weight?
23 Have you been vomiting anything that looks like blood orcoffee grounds?
24 Do you have any black tar or foul-smelling stools?
25 Have you ever been hospitalized?
26 Do you have diarrhea?
27 Do you have a history of volvulus?
28 Do you avoid eating because you are worried about the pain?
29 How long does the pain in your abdomen last?
30 Is there any blood in your stools or with your bowel movements?
31 How often does this abdominal pain occur?
32 Have you been diagnosed with chronic mesenteric ischemia?
33 Do you now, or have you ever had cancer?
FYI – The electronic health record is not listed on the rubric as being graded, check with your
professor before spending the time completing the EHR. Some professors still wanted to see that it
was completed, some did not require it – the EHR information is here for you just in case.
Electronic Health Record – History
Reason for Encounter Abdominal Pain
HPI Patient presents with a progressive 3-day history of severe cramping
abdominal pain 5/10 with associated nausea, vomiting on undigested food
Neck: Patient denies any stiffness, no pain, no tenderness, no noted masses.
cramps, or weakness
and inability to pass gas or have a BM. Denies any hematochezia or melena in
stool, diarrhea, fever, chills, or night sweats. Last BM: 2 days ago.
General Patient deniesfever/chills, unexplained weight loss, fatigue, nightsweats HEENT/Neck
Head: Patient denie headaches, no vertigo, no injury.
Eyes: Normal vision, no tearing, no scotomata, no pain.
Ears: Patient denies any change in hearing, no tinnitus, no bleeding, no
vertigo.
Nose: Patient denies any epistaxis, no coryza, no obstruction, no discharge.
Cardiovascular Patient denieschest pain, palpitations, edema, syncope, decrease in exercise
Respiratory
tolerance
Patient denies expectoration, dyspnea with rest or exertion, orthopnea, PND,
wheezing
GI Patient endorses abdominal pain, nausea, vomiting, constipation, decreased
appetite, and inability to pass gas. Last BM:2 days ago. Denies dyspepsia,
belching, melena or bloody stools.
GU Patient denies dysuria, frequency, urgency, hematuria, nocturia,
MS
incontinence, dribbling, hesitancy, retention, flank pain
Patient denies new weakness, arthralgias, myalgias,swelling,stiffness [Show Less]