solution
ian njuguna
[COMPANY NAME] [Company address]
, ShadowHealth Abdominal Pain Esther Park with complete
solution
chief complaint Ans- -reports abdominal pain
-reports difficulty with bowel movement
asked about orientation Ans- -oriented to own person
-oriented to place
-oriented to situation
-oriented to time
asked about onset, frequency, and duration of pain Ans- -reports discomfort for the past
5 days
-reports pain with gradual onset that worsened 2-3 days ago
asked about location of pain Ans- -reports pain in lower abdomen
-reports pain is not localized
asked about pain rating on scale Ans- -reports 6/10 pain
asked about characteristics of pain Ans- -describes pain a dull and cramping
-pain fluctuates in severity
asked about non-pharmacological relieving factors Ans- -denies taking pain medication
-denies taking laxatives
asked about aggravating factors Ans- -reports pain is aggravated by eating
-aggravated by physical activity
asked about impact on daily life Ans- -recent difficulty participating in usual activities
-reports low energy
followed up on constipation Ans- -constipation most of last 5 days
-denies any attempt to treat constipation
asked about diarrhea Ans- recent diarrhea
followed up about diarrhea Ans- -about 6 months ago
-sudden onset
-lasted one day
-loose and water