chief complaint
-reports abdominal pain
-reports difficulty with bowel movement
asked about orientation
-oriented to own person
-oriented to
... [Show More] place
-oriented to situation
-oriented to time
asked about onset, frequency, and duration of pain
-reports discomfort for the past 5 days
-reports pain with gradual onset that worsened 2-3 days ago
asked about location of pain
-reports pain in lower abdomen
-reports pain is not localized
asked about pain rating on scale
-reports 6/10 pain
asked about characteristics of pain
-describes pain a dull and cramping
-pain fluctuates in severity
asked about non-pharmacological relieving factors
-denies taking pain medication
-denies taking laxatives
asked about aggravating factors
-reports pain is aggravated by eating
-aggravated by physical activity
asked about impact on daily life
-recent difficulty participating in usual activities
-reports low energy
followed up on constipation
-constipation most of last 5 days
-denies any attempt to treat constipation
asked about diarrhea
recent diarrhea
followed up about diarrhea
-about 6 months ago
-sudden onset
-lasted one day
-loose and water
asked about substances in stool
-denies mucus and blood in stool
asked about urination
-recent, slight decrease in frequency of urination
-darker urine recently
-denies blood in urine
asked about fluid intake
-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
-denies recent travel and exposure to food poisoning
asked about history of constipation
denies history
asked about typical bowel movements
-typically has BM almost every day
-stools usually brown, formed, soft
asked about allergies
-reports latex allergy
-denies med allergies
-denies food allergies
asked about pre-existing health conditions
-reports high BP
-diagnosed at 54
asked about relevant history of surgery
-c section at 40
-gall bladder removal at 42
-no post op complications
asked about home meds
-meds for high BP
-10 mg accupril daily at 8 am
-no OTC meds
asked about access to healthcare
-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
-reports living with daughter and strong family support
asked about diet
-last meal was toast at breakfast
-typically eats 3 meals a day
-denies snacks
-typical breakfast is toast
-typical lunch is soup
-typical dinner is chicken or fish with rice
asked about fiber intake
-denies fiber supplements
-denies efforts to incorporate fiber in diet
-reports eating veggie every 1-2 days
-reports eating fruit ever 3-4 days
asked about typical activity level
-typically high level of mobility and independence
-reports typically having a moderated activity level
asked about substance abuse
-denies illicit drug use; smoking
-low alcohol consumption
followed up on alcohol
-drinks 1 night a week
-drinks 1 drink per sitting
-white wine [Show Less]