Asked review of systems for genitourinary
Denies....
-hx of bladder problems
-painful urination
-burning with urination
-urinary incontinence
-hx of
... [Show More] UTIs
-holding urine unneccessarily
-gynecological problems
-vaginal bleeding
-vaginal discharge
-hx of kidney problems
Reports....
-onset of menopause, was age 54
Establish cheif complaint
-Reports abdominal pain
-Reports difficulty with bowel movements
Asked about orientation
Oriented to...
-own person
-place
-situation
-time
Asked about the onset of pain
Reports...
-discomfort for the past five days
- pain worsened intensely 2-3 days ago
Asked about location of the pain
Reports...
- pain in lower abdomen
-pain is not localized
Denies...
-flank pain
Asked about pain rating on a scale
Reports...
-current pain rating of 2/10
-lowest pain is 2/10
-worst pain is 8/10
Asked about characteristics of the pain
Describes pain as...
-dull
-cramping
-constant
-fluctuating in severity
Asked about non-pharmacological relieving factors
Reports...
-resting helps relieve pain
-drinking warm water to relieve pain was ineffective
Asked about pharmacological relieving factors
Denies...
-taking pain medication
-taking laxatives
Asked about aggravating factors
Reports pain is aggravated by...
- eating
- physical activity
Asked about impact of pain on daily life
Reports...
- recent difficulty participating in usual activities
- low energy
Followed up on constipation
Reports...
- current constipation
- constipation all of last 5 days
Asked about diarrhea
- Reports recent diarrhea
Followed up on diarrhea
Reports diarrhea...
- about 6 months ago
- had a sudden onset
- lasted one day
Asked about substance of stool
Denies...
- mucus in stool
- blood in stool
Asked about urination
Reports...
- slight decrease in frequency of urination
- darker urine recently
- blood in urine
Asked about fluid intake
Reports decreased...
- thirst
- fluid intake
- typical fluid intake, 1-2 glasses of water a day
- Denies drinking caffeinated drinks such as coffee or soda
Asked about substance use
Denies...
-illicit drug use
-cigarette smoking
Reports...
-low alcohol consumption
Followed-up on alcohol consumption
Reports...
-drinking 1 night a week
-1 drink per siting
-typical drink is white wine
Asked about psychological hx
Reports...
-living with her daughter
-strong familial support system
Denies...
-recent travel
Asked about experience of abuse
Denies being...
-physically abused
-emotionally abused
-financially abused
-verbally abused
Asked about constitutional health
Denies...
-recent wt changes
-recent fever
-chills
-night sweats
-swelling
-sleep issues
Reports...
-short-term feeling of exhaustion
Asked about hx of gastrointestinal disorders
Denies hx of...
- GERD or ulcer
- appendicitis
- stomach cancer
- liver disease
Asked about cardiovascular health
Denies...
-palpitations
-chest discomfort
-racing heartbeat
Asked about throat irritation
-Denies sore throat
Asked about respiratory health
Denies...
- coughing
- difficulty swallowing
- difficulty breathing
Asked additional review of systems for gastrointestinal
Reports...
- bloating
- slight increase in gas
- loss of appetite in the past few days
Denies...
- nausea
- vomiting
- food poisoning
Asked about hx of constipation
Denies hx of constipation
Asked about typical bowel movements
Reports typical...
- bowel movement every day
- stools are brown
- stools are formed
- stools are soft [Show Less]