Questions–yields90% m
i m
i
Howcan Ihelpyou? Mystomach hurts
mi m
i mi
Doyouhaveanyothersymptomsorconcernswe
m
i I occasionallyfeel“bloated”although I’m notsure mybellyisactually mi .r m
i mi mi mi .r
shoulddiscuss?
.r biggerwhenIfeel thatway. I…wellpass alot ofgas
.r .r .r .r mi .r .r .r .r .r .r
and…evenbelcha lotcompared to otherpeople Iknow. Sortof .r .r .r .r .r .r .r .r .r
embarrassing forawoman youknow.Doyouthinkthat’srelatedto .r mi mi mi m
i m
i m
i .r
allofthis? .r .r .r
Isyourpain affectedbywhat,when,orhow
mi Itseems tobeworse withrichfoods.Ihaven’t reallynoticeditas
mi m
i m
i mi mi m
i mi mi
muchyoueat?
.r associated withwhenorhowmuch.
mi .r mi mi .r
Doyounoworhaveyoueversmokedorchewed m
i
No,Ineverhave. mi m
i m
i .r
i
m
tobacco?
.r
Are youtakinganyoverthecounterorherbal
mi mi I take amultivitamindaily,and acetaminophenfromtimeto mi mi mi mi mi m
i mi
medications?
.r time forstressheadaches .r mi
Areyoutakinganyprescriptionmedications?
m
i No prescriptionmedications
m
i mi .r
Doyou have anyallergies?
m
i mi NotthatIknowof mi
Haveyoueverbeenhospitalized? Justforthe c-sectionand the bikeaccident thing
mi mi mi mi m
i mi mi mi mi
Anypreviousmedical,surgical,ordental I had a c-section at27withoutanycomplications. WhenI was 17, I had
m
i m
i mi mi mi mi mi mi mi . r mi
procedures?
.r abikeaccidentandhada complicatedfracture of myright .r .r .r mi .r mi mi .r
tibia.Theyhadtofixthatwith surgery. .r mi mi mi.r
Canyoutell me about anycurrentorpastmedical I don’tknowreallywhat’simportant. Theonlythingbesidesthis
mi mi mi .r m
i mi mi
problems youhavehad?
.r stomachproblem isthatlately I’vebeen getting occasional hot
mi .r .r .r .r mi .r .r .r mi .r mi
flashesandmyskinis sortof dry.Ialso getheadachesnowand then .r .r mi .r mi .r .r mi .r .r .r m i .r
whichisn’tnewand thatprobablyisn’timportantanyway. .r .r .r mi .r .r
Is that thekind ofthingsyou wantto know? mi mi .r mi mi .r mi
Doyouhave diarrhea?
m
i m
i Occasionally.SometimesI’d saymybowelmovement isloose and
mi m
i mi i
m mi mi
watery.Doesthatcount? .r .r .r
Isthere anybloodinyourstools orwithyour
m
i mi Anything red?Not thatI have noticed mi mi mi mi mi mi
bowelmovement?
.r i
m
Doyouhave aproblem withconstipation?
m
i mi Definitely. Foras long asIcan recall inmyadult life,Ihave
mi mi mi .r .r mi .r .r .r mi mi .r .r .r .r .r
alternatingperiodsofconstipationand justtheoppositeifyou know .r mi mi mi
what I mean that lasts several d ays.When Iamconstipated, I feel .r mi mi .r .r .r mi .r mi .r .r mi
like I cannotgeteverythingout,evenaftera .r mi mi mi
BM.
Haveyoubeenhaving fevers? m
i Idon’t think so,can you checkthat forme
m
i m
i m
i m
i mi mi mi mi m
i mi
Howoftendoesthis abdominalpainoccur? It’sbeen comingand going foryearsnow.Itneverreally goes away mi mi mi mi .r .rmi .r .r .r .r .r .r .r .r .r .r
entirely,butthen it alsodoesn’t seemtobegettinga lot .r .r .r .r .r .r .r .r .r .r .r .r
worse.It’sjustthereallthe time.Sofrustrating. mi .r .r .r .r .r mi.r .r .r
Howsevere(1-10scale)isyourabdominal Itvaries,sometimesit’sjustmildandannoying,othertimesit
mi mi mi mi
pain?
.r stopsmeinmytracks it’ssobad .r mi mi
Doesthe pain in yourabdomenradiate No,it’s
mi justinmystomach mi mi mi mi mi
someplace else?Where?
.r mi
Wheremorepreciselyisyourabdominalpain? Allover,especiallyinthelowerhalfofmybelly. m
i i
m
Whatdoesthepain/discomfortinyour Usuallylike a bad crampbutsometimesitcan be a stabbing feeling. m
i mi mi mi mi mi . r
abdomenfeellike?(Cramping,burning,
.r m
i m
i m
i
stabbing,aching,tingling,squeezing). .r .r .r
Doesanythingmakethepaininyourabdomen
i
m “Havingabowelmovementsometimesmakesitbetter.Thenit m
i m
i m
i m
i m
i mi
betterorworse?
.r startsupagain ifI’mstressed outoreatingthewrongstuff”. .r mi mi mi .r
Whendidyourabdominalpain start? Thisproblemstarted atleast10 yearsago.It’sreallybeengoingonfar m
i mi mi m
i mi mi mi mi mi .r
toolong. .r .r
, Doyoursymptomsoccuraftereating rye, m
i m
i No
wheat,orbarley?
.r mi
Whatare the events surrounding thestartof
mi mi mi mi mi Idon'trememberaparticularevent. m
i
yourabdominal pain?
.r mi
Have youoranyfamilymemberhad ahistoryof
mi m
i mi mi .r No,I’veneverheardthataboutanyone
m
i
IBD? .r
Areyounoworhaveyoueverbeenanemic? m
i Noonehasevertoldmethat
Doyouavoideating becauseyouareworried i
m m
i
SometimesmaybeI do.Imean whenmystomach ishurting I m
i mi mi m
i mi mi m
i mi
aboutpain?
.r mi don’tfeelmuchlike eating. m
i mi
Doyou haveanyskinproblems? mi .r Justalittledry.Ihaven’tnoticedanythingelse.
m
i m
i m
i
Doyouhaveahistoryofabowelobstruction?
mi .r m
i mi No,nothing that dramatic.
i
m m
i mi
Have youoranyfamilymemberhad ahistoryof
mi m
i mi mi .r No,wedonot. mi
colonpolyps orcoloncancer?
.r .r mi .r .r
Doyouhave blacktar-likeorfoul-smelling
i
m mi i
m i
m No,I’veneverhadanythinglike that.
m
i .r
stools?
.r
Have youlost weight?
mi m
i mi No
Howlongdoesthepain inyourabdomenlast? m
i mi Sometimesafewminutes,sometimesuptoan hour m
i mi mi m
i mi
Haveyouhad the pain in yourabdomen
m
i mi mi mi mi mi Yes,thissamesortofpainonand off m
i mi
before?
.r
Doyouhavearthritis? .r No,I’mluckywiththat
m
i m
i
Doyouhaveheartdisease and/orhave youever m
i m
i mi .r No,Idonothaveheart problems.
mi .r mi
hada heart attack?No,Idonot have heart
.r .r mi .r .r .r .r .r .r .r
problems.
.r
Questions to fill out the EHR mi mi mi mi mi
Tellme aboutyourwork mi
Iamamanagerata localrestaurant.I haveverylongworkdays…
mi
mi .r mi mi .r
Iusuallywork late intothenight. mi mi m
i
Have youhad arecent endoscopy,colonoscopy,
mi Uh…No.
mi mi mi mi mi
orbiopsy?
.r
Whenand whatwas the resultofyourlast
m
i Ihaven’thad oneyet.Toobusy.
mi mi mi mi mi i
m
mammogram?
.r
Physical Exam mi . r
Bloodpressure mi 120/60, normal,normotensive mi .r
Cognitive Alertandorientedx4 m
i
Pulse 60,regular,normal
RR 14,regular,unlabored
.r .r
Temp 98.6
Inspect skin overall mi mi Dryskin,otherwise unremarkable mi
Inspect haircolor,distribution, mi Thicknessand distributionpatterntypicalforpatientgenderand age mi mi mi m
i mi
thickness
.r
Inspect nails mi Nailswithout ridging,pitting, orpeeling
mi mi mi
Testcapillaryrefill Normalcapillary reflow .r .r
Inspect eyes mi Normal
Inspect face mi Normalexpression.Nolesions, scars,orabnormalpigmentation.
m
i mi m
i
Ocularmotortest Normal
Examinepupils R –NR,L–NRmi .r m
i .r .r
Inspect/Palpate Head . r Normocephalic, atraumatic. No deformities. Facial featuressymmetric. .r .r .r .r .r
Temporalarteriesnon-tendertopalpation.Frontalandmaxillarysinuses
.r m
i m
i
non-tender.
.r
i m
i
Howcan Ihelpyou? Mystomach hurts
mi m
i mi
Doyouhaveanyothersymptomsorconcernswe
m
i I occasionallyfeel“bloated”although I’m notsure mybellyisactually mi .r m
i mi mi mi .r
shoulddiscuss?
.r biggerwhenIfeel thatway. I…wellpass alot ofgas
.r .r .r .r mi .r .r .r .r .r .r
and…evenbelcha lotcompared to otherpeople Iknow. Sortof .r .r .r .r .r .r .r .r .r
embarrassing forawoman youknow.Doyouthinkthat’srelatedto .r mi mi mi m
i m
i m
i .r
allofthis? .r .r .r
Isyourpain affectedbywhat,when,orhow
mi Itseems tobeworse withrichfoods.Ihaven’t reallynoticeditas
mi m
i m
i mi mi m
i mi mi
muchyoueat?
.r associated withwhenorhowmuch.
mi .r mi mi .r
Doyounoworhaveyoueversmokedorchewed m
i
No,Ineverhave. mi m
i m
i .r
i
m
tobacco?
.r
Are youtakinganyoverthecounterorherbal
mi mi I take amultivitamindaily,and acetaminophenfromtimeto mi mi mi mi mi m
i mi
medications?
.r time forstressheadaches .r mi
Areyoutakinganyprescriptionmedications?
m
i No prescriptionmedications
m
i mi .r
Doyou have anyallergies?
m
i mi NotthatIknowof mi
Haveyoueverbeenhospitalized? Justforthe c-sectionand the bikeaccident thing
mi mi mi mi m
i mi mi mi mi
Anypreviousmedical,surgical,ordental I had a c-section at27withoutanycomplications. WhenI was 17, I had
m
i m
i mi mi mi mi mi mi mi . r mi
procedures?
.r abikeaccidentandhada complicatedfracture of myright .r .r .r mi .r mi mi .r
tibia.Theyhadtofixthatwith surgery. .r mi mi mi.r
Canyoutell me about anycurrentorpastmedical I don’tknowreallywhat’simportant. Theonlythingbesidesthis
mi mi mi .r m
i mi mi
problems youhavehad?
.r stomachproblem isthatlately I’vebeen getting occasional hot
mi .r .r .r .r mi .r .r .r mi .r mi
flashesandmyskinis sortof dry.Ialso getheadachesnowand then .r .r mi .r mi .r .r mi .r .r .r m i .r
whichisn’tnewand thatprobablyisn’timportantanyway. .r .r .r mi .r .r
Is that thekind ofthingsyou wantto know? mi mi .r mi mi .r mi
Doyouhave diarrhea?
m
i m
i Occasionally.SometimesI’d saymybowelmovement isloose and
mi m
i mi i
m mi mi
watery.Doesthatcount? .r .r .r
Isthere anybloodinyourstools orwithyour
m
i mi Anything red?Not thatI have noticed mi mi mi mi mi mi
bowelmovement?
.r i
m
Doyouhave aproblem withconstipation?
m
i mi Definitely. Foras long asIcan recall inmyadult life,Ihave
mi mi mi .r .r mi .r .r .r mi mi .r .r .r .r .r
alternatingperiodsofconstipationand justtheoppositeifyou know .r mi mi mi
what I mean that lasts several d ays.When Iamconstipated, I feel .r mi mi .r .r .r mi .r mi .r .r mi
like I cannotgeteverythingout,evenaftera .r mi mi mi
BM.
Haveyoubeenhaving fevers? m
i Idon’t think so,can you checkthat forme
m
i m
i m
i m
i mi mi mi mi m
i mi
Howoftendoesthis abdominalpainoccur? It’sbeen comingand going foryearsnow.Itneverreally goes away mi mi mi mi .r .rmi .r .r .r .r .r .r .r .r .r .r
entirely,butthen it alsodoesn’t seemtobegettinga lot .r .r .r .r .r .r .r .r .r .r .r .r
worse.It’sjustthereallthe time.Sofrustrating. mi .r .r .r .r .r mi.r .r .r
Howsevere(1-10scale)isyourabdominal Itvaries,sometimesit’sjustmildandannoying,othertimesit
mi mi mi mi
pain?
.r stopsmeinmytracks it’ssobad .r mi mi
Doesthe pain in yourabdomenradiate No,it’s
mi justinmystomach mi mi mi mi mi
someplace else?Where?
.r mi
Wheremorepreciselyisyourabdominalpain? Allover,especiallyinthelowerhalfofmybelly. m
i i
m
Whatdoesthepain/discomfortinyour Usuallylike a bad crampbutsometimesitcan be a stabbing feeling. m
i mi mi mi mi mi . r
abdomenfeellike?(Cramping,burning,
.r m
i m
i m
i
stabbing,aching,tingling,squeezing). .r .r .r
Doesanythingmakethepaininyourabdomen
i
m “Havingabowelmovementsometimesmakesitbetter.Thenit m
i m
i m
i m
i m
i mi
betterorworse?
.r startsupagain ifI’mstressed outoreatingthewrongstuff”. .r mi mi mi .r
Whendidyourabdominalpain start? Thisproblemstarted atleast10 yearsago.It’sreallybeengoingonfar m
i mi mi m
i mi mi mi mi mi .r
toolong. .r .r
, Doyoursymptomsoccuraftereating rye, m
i m
i No
wheat,orbarley?
.r mi
Whatare the events surrounding thestartof
mi mi mi mi mi Idon'trememberaparticularevent. m
i
yourabdominal pain?
.r mi
Have youoranyfamilymemberhad ahistoryof
mi m
i mi mi .r No,I’veneverheardthataboutanyone
m
i
IBD? .r
Areyounoworhaveyoueverbeenanemic? m
i Noonehasevertoldmethat
Doyouavoideating becauseyouareworried i
m m
i
SometimesmaybeI do.Imean whenmystomach ishurting I m
i mi mi m
i mi mi m
i mi
aboutpain?
.r mi don’tfeelmuchlike eating. m
i mi
Doyou haveanyskinproblems? mi .r Justalittledry.Ihaven’tnoticedanythingelse.
m
i m
i m
i
Doyouhaveahistoryofabowelobstruction?
mi .r m
i mi No,nothing that dramatic.
i
m m
i mi
Have youoranyfamilymemberhad ahistoryof
mi m
i mi mi .r No,wedonot. mi
colonpolyps orcoloncancer?
.r .r mi .r .r
Doyouhave blacktar-likeorfoul-smelling
i
m mi i
m i
m No,I’veneverhadanythinglike that.
m
i .r
stools?
.r
Have youlost weight?
mi m
i mi No
Howlongdoesthepain inyourabdomenlast? m
i mi Sometimesafewminutes,sometimesuptoan hour m
i mi mi m
i mi
Haveyouhad the pain in yourabdomen
m
i mi mi mi mi mi Yes,thissamesortofpainonand off m
i mi
before?
.r
Doyouhavearthritis? .r No,I’mluckywiththat
m
i m
i
Doyouhaveheartdisease and/orhave youever m
i m
i mi .r No,Idonothaveheart problems.
mi .r mi
hada heart attack?No,Idonot have heart
.r .r mi .r .r .r .r .r .r .r
problems.
.r
Questions to fill out the EHR mi mi mi mi mi
Tellme aboutyourwork mi
Iamamanagerata localrestaurant.I haveverylongworkdays…
mi
mi .r mi mi .r
Iusuallywork late intothenight. mi mi m
i
Have youhad arecent endoscopy,colonoscopy,
mi Uh…No.
mi mi mi mi mi
orbiopsy?
.r
Whenand whatwas the resultofyourlast
m
i Ihaven’thad oneyet.Toobusy.
mi mi mi mi mi i
m
mammogram?
.r
Physical Exam mi . r
Bloodpressure mi 120/60, normal,normotensive mi .r
Cognitive Alertandorientedx4 m
i
Pulse 60,regular,normal
RR 14,regular,unlabored
.r .r
Temp 98.6
Inspect skin overall mi mi Dryskin,otherwise unremarkable mi
Inspect haircolor,distribution, mi Thicknessand distributionpatterntypicalforpatientgenderand age mi mi mi m
i mi
thickness
.r
Inspect nails mi Nailswithout ridging,pitting, orpeeling
mi mi mi
Testcapillaryrefill Normalcapillary reflow .r .r
Inspect eyes mi Normal
Inspect face mi Normalexpression.Nolesions, scars,orabnormalpigmentation.
m
i mi m
i
Ocularmotortest Normal
Examinepupils R –NR,L–NRmi .r m
i .r .r
Inspect/Palpate Head . r Normocephalic, atraumatic. No deformities. Facial featuressymmetric. .r .r .r .r .r
Temporalarteriesnon-tendertopalpation.Frontalandmaxillarysinuses
.r m
i m
i
non-tender.
.r
