ShadowHealth Abdominal Pain Esther Park
chief complaint Correct Answer: -reports abdominal pain
-reports difficulty with bowel movement
asked
... [Show More] about orientation Correct Answer: -oriented to own person
-oriented to place
-oriented to situation
-oriented to time
asked about onset, frequency, and duration of pain Correct Answer: -reports discomfort for the past 5 days
-reports pain with gradual onset that worsened 2-3 days ago
asked about location of pain Correct Answer: -reports pain in lower abdomen
-reports pain is not localized
asked about pain rating on scale Correct Answer: -reports 6/10 pain
asked about characteristics of pain Correct Answer: -describes pain a dull and cramping
-pain fluctuates in severity
asked about non-pharmacological relieving factors Correct Answer: -denies taking pain medication
-denies taking laxatives
asked about aggravating factors Correct Answer: -reports pain is aggravated by eating
-aggravated by physical activity
asked about impact on daily life Correct Answer: -recent difficulty participating in usual activities
-reports low energy
followed up on constipation Correct Answer: -constipation most of last 5 days
-denies any attempt to treat constipation
asked about diarrhea Correct Answer: recent diarrhea
followed up about diarrhea Correct Answer: -about 6 months ago
-sudden onset
-lasted one day
-loose and water
asked about substances in stool Correct Answer: -denies mucus and blood in stool
asked about urination Correct Answer: -recent, slight decrease in frequency of urination
-darker urine recently
-denies blood in urine
asked about fluid intake Correct Answer: -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 Correct Answer: -denies recent travel and exposure to food poisoning
asked about history of constipation Correct Answer: denies history
asked about typical bowel movements Correct Answer: -typically has BM almost every day
-stools usually brown, formed, soft
asked about allergies Correct Answer: -reports latex allergy
-denies med allergies
-denies food allergies
asked about pre-existing health conditions Correct Answer: -reports high BP
-diagnosed at 54
asked about relevant history of surgery Correct Answer: -c section at 40
-gall bladder removal at 42
-no post op complications
asked about home meds Correct Answer: -meds for high BP
-10 mg accupril daily at 8 am
-no OTC meds
asked about access to healthcare Correct Answer: -annual checkup with HCP
-last pap smear over 10 years
-level of health and activity is good
-denies STI testing
-last colonoscopy over 10 years
-denies finances as a barrier
-denies transportation as a barrier
asked about family and support system Correct Answer: -reports living with daughter and strong family support
asked about diet Correct Answer: -last meal was toast at breakfast
-typically eats 3 meals a day [Show Less]