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
Asked about substances in stool Ans- -denies mucus and blood in stool
Asked about urination Ans- -recent, slight decrease in frequency of urination
-darker urine recently
-denies blood in urine
Asked about fluid intake Ans- -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 Ans- -denies recent travel and exposure to food poisoning
Asked about history of constipation Ans- denies history
Asked about typical bowel movements Ans- -typically has BM almost every day
-stools usually brown, formed, soft
-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
Asked about substances in stool Ans- -denies mucus and blood in stool
Asked about urination Ans- -recent, slight decrease in frequency of urination
-darker urine recently
-denies blood in urine
Asked about fluid intake Ans- -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 Ans- -denies recent travel and exposure to food poisoning
Asked about history of constipation Ans- denies history
Asked about typical bowel movements Ans- -typically has BM almost every day
-stools usually brown, formed, soft
