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 n
o m
i mi mi mi n
o
shoulddiscuss?
no n
o biggerwhen I feel that way. I…wellpass a lot of gas no no no mi no no no no no no
and… evenbelch a lot compared to otherpeople I know. Sortof no no no no no no no no no
embarrassing forawoman youknow.Doyouthinkthat’srelatedto no m
i mi mi m
i m
i m
i n
o
all ofthis? no no n
o
Isyourpain affectedbywhat,when,orhow
mi Itseems tobeworse withrichfoods.Ihaven’t reallynoticeditas
mi m
i m
i mi mi m
i mi mi
muchyoueat?
no associated withwhenorhowmuch.
mi no mi mi n
o
Doyounoworhaveyoueversmokedorchewed
m
i
No,Ineverhave. mi m
i m
i n
o i
m
tobacco?
no
Are youtakinganyoverthecounterorherbal
mi mi I take amultivitamindaily,and acetaminophenfromtimeto mi mi mi mi mi m
i mi
medications?
no timeforstressheadaches no mi
Areyoutakinganyprescriptionmedications?
m
i m
i No prescription medications mi no
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 n o mi
procedures?
no abike accidentand had a complicated fracture of my right no no no mi no mi mi no
tibia.Theyhadtofixthatwith surgery. no mi mi mi no
Canyoutell me about anycurrentorpastmedical I don’tknowreallywhat’simportant. Theonlythingbesidesthis
mi mi mi n
o m
i mi mi
problems youhavehad?
no stomach problem isthat lately I’ve been getting occasional hot
mi no no no no mi no no no mi no mi
flashesandmy skinis sort of dry. I also get headaches now and then no no mi no mi no no mi no no no mi no
which isn’tnew and thatprobably isn’t importantanyway. no no no mi no no
Is that thekind ofthingsyou wantto know? mi mi n
o mi mi n
o mi
Doyouhave diarrhea?
m
i m
i Occasionally.SometimesI’d saymybowelmovement isloose and
mi m
i mi i
m mi mi
watery. Doesthat count? no no no
Isthere anybloodinyourstools orwithyour
m
i mi Anything red?Not thatI have noticed mi mi mi mi mi mi
bowelmovement?
no i
m
Doyouhave aproblem withconstipation?
m
i mi Definitely. For as long as I can recall in my adult life, I have
mi mi mi no no mi no no no mi mi no no no no no
alternatingperiodsofconstipationand justtheoppositeifyou know no mi mi mi
what I mean that lasts several days. When I am constipated, I feel no mi mi no no no mi no mi no no mi
likeI cannotgeteverythingout,evenaftera no 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’s been coming and going for years now. It never really goes mi mi mi mi no nomi no no no no no no no no no
away entirely, but then it also doesn’t seem to be getting a lot no no no no no no no no no no no no no
worse.It’sjustthereallthe time.Sofrustrating. mi n
o n
o n
o n
o n
o mi no n
o n
o
Howsevere(1-10scale)isyourabdominal Itvaries,sometimesit’sjustmildandannoying,othertimesit
mi mi mi mi
pain?
no stopsmeinmytracks it’ssobad no mi mi
Doesthe pain in yourabdomenradiate No,it’s
mi justinmystomach mi mi mi mi mi
someplace else?Where?
no 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 n o
abdomenfeellike?(Cramping,burning,
no m
i m
i m
i
stabbing, aching, tingling, squeezing). no no no
Doesanythingmakethepaininyourabdomen
i
m “Havingabowelmovementsometimesmakesitbetter.Thenit m
i m
i m
i m
i m
i mi
betterorworse?
no startsupagain ifI’mstressed outoreatingthewrongstuff”. no mi mi mi n
o
Whendidyourabdominalpain start? Thisproblemstarted atleast10 yearsago.It’sreallybeengoingonfar m
i mi mi m
i mi mi mi mi mi n
o
toolong. no n
o
, Doyoursymptomsoccuraftereating rye, m
i m
i No
wheat,orbarley?
no mi
Whatare the events surrounding thestartof
mi mi mi mi mi Idon'trememberaparticularevent. m
i
yourabdominal pain?
no mi
Have youoranyfamilymemberhad ahistoryof
mi m
i mi mi n
o No,I’veneverheardthataboutanyone
m
i
IBD?
no
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?
no mi don’tfeelmuchlike eating. m
i mi
Doyou haveanyskinproblems? mi n
o Justalittledry.Ihaven’tnoticedanythingelse.
m
i m
i m
i
Doyouhaveahistoryofabowelobstruction?
mi n
o m
i mi No,nothing that dramatic.
i
m m
i mi
Have youoranyfamilymemberhad ahistoryof
mi m
i mi mi n
o No,wedonot. mi
colon polyps or colon cancer?
no no mi no no
Doyouhave blacktar-likeorfoul-smelling
i
m mi i
m i
m No,I’veneverhadanythinglike that.
m
i no
stools?
no
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?
no
Doyouhavearthritis? n
o No,I’mluckywiththat
m
i m
i
Doyouhaveheartdisease and/orhave youever m
i m
i mi n
o No,Idonothave heart problems.
mi no mi
hada heart attack? No, I do not have heart
no no mi no no no no no no no
problems.
no
Questions to fill out the EHR mi mi mi mi mi
Tellme aboutyourwork mi
Iamamanagerata localrestaurant.I haveverylongworkdays…
mi
mi n
o mi mi n
o
Iusuallywork late intothenight. mi mi m
i
Have youhad arecent endoscopy,colonoscopy,
mi Uh…No.
mi mi mi mi mi
orbiopsy?
no
Whenand whatwas the resultofyourlast
m
i Ihaven’thad oneyet.Toobusy.
mi mi mi mi mi i
m
mammogram?
no
Physical Exam mi no
Bloodpressure mi 120/60, normal, normotensive mi n
o
Cognitive Alertandorientedx4 m
i
Pulse 60,regular,normal
RR 14,regular,unlabored
n
o n
o
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
no
Inspect nails mi Nailswithout ridging,pitting, orpeeling
mi mi mi
Testcapillaryrefill Normal capillary reflow no no
Inspect eyes mi Normal
Inspect face mi Normalexpression.Nolesions, scars,orabnormalpigmentation.
m
i mi m
i
Ocularmotortest Normal
Examinepupils R –NR,L–NR
mi n
o mi n
o n
o
Inspect/Palpate Head no Normocephalic, atraumatic. No deformities. Facial featuressymmetric.
no no no no no
Temporalarteriesnon-tendertopalpation.Frontalandmaxillarysinuses
no m
i m
i
non-tender.
no
i m
i
Howcan Ihelpyou? Mystomach hurts
mi m
i mi
Doyouhaveanyothersymptomsorconcernswe
m
i I occasionallyfeel“bloated”although I’m notsure mybellyisactually mi n
o m
i mi mi mi n
o
shoulddiscuss?
no n
o biggerwhen I feel that way. I…wellpass a lot of gas no no no mi no no no no no no
and… evenbelch a lot compared to otherpeople I know. Sortof no no no no no no no no no
embarrassing forawoman youknow.Doyouthinkthat’srelatedto no m
i mi mi m
i m
i m
i n
o
all ofthis? no no n
o
Isyourpain affectedbywhat,when,orhow
mi Itseems tobeworse withrichfoods.Ihaven’t reallynoticeditas
mi m
i m
i mi mi m
i mi mi
muchyoueat?
no associated withwhenorhowmuch.
mi no mi mi n
o
Doyounoworhaveyoueversmokedorchewed
m
i
No,Ineverhave. mi m
i m
i n
o i
m
tobacco?
no
Are youtakinganyoverthecounterorherbal
mi mi I take amultivitamindaily,and acetaminophenfromtimeto mi mi mi mi mi m
i mi
medications?
no timeforstressheadaches no mi
Areyoutakinganyprescriptionmedications?
m
i m
i No prescription medications mi no
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 n o mi
procedures?
no abike accidentand had a complicated fracture of my right no no no mi no mi mi no
tibia.Theyhadtofixthatwith surgery. no mi mi mi no
Canyoutell me about anycurrentorpastmedical I don’tknowreallywhat’simportant. Theonlythingbesidesthis
mi mi mi n
o m
i mi mi
problems youhavehad?
no stomach problem isthat lately I’ve been getting occasional hot
mi no no no no mi no no no mi no mi
flashesandmy skinis sort of dry. I also get headaches now and then no no mi no mi no no mi no no no mi no
which isn’tnew and thatprobably isn’t importantanyway. no no no mi no no
Is that thekind ofthingsyou wantto know? mi mi n
o mi mi n
o mi
Doyouhave diarrhea?
m
i m
i Occasionally.SometimesI’d saymybowelmovement isloose and
mi m
i mi i
m mi mi
watery. Doesthat count? no no no
Isthere anybloodinyourstools orwithyour
m
i mi Anything red?Not thatI have noticed mi mi mi mi mi mi
bowelmovement?
no i
m
Doyouhave aproblem withconstipation?
m
i mi Definitely. For as long as I can recall in my adult life, I have
mi mi mi no no mi no no no mi mi no no no no no
alternatingperiodsofconstipationand justtheoppositeifyou know no mi mi mi
what I mean that lasts several days. When I am constipated, I feel no mi mi no no no mi no mi no no mi
likeI cannotgeteverythingout,evenaftera no 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’s been coming and going for years now. It never really goes mi mi mi mi no nomi no no no no no no no no no
away entirely, but then it also doesn’t seem to be getting a lot no no no no no no no no no no no no no
worse.It’sjustthereallthe time.Sofrustrating. mi n
o n
o n
o n
o n
o mi no n
o n
o
Howsevere(1-10scale)isyourabdominal Itvaries,sometimesit’sjustmildandannoying,othertimesit
mi mi mi mi
pain?
no stopsmeinmytracks it’ssobad no mi mi
Doesthe pain in yourabdomenradiate No,it’s
mi justinmystomach mi mi mi mi mi
someplace else?Where?
no 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 n o
abdomenfeellike?(Cramping,burning,
no m
i m
i m
i
stabbing, aching, tingling, squeezing). no no no
Doesanythingmakethepaininyourabdomen
i
m “Havingabowelmovementsometimesmakesitbetter.Thenit m
i m
i m
i m
i m
i mi
betterorworse?
no startsupagain ifI’mstressed outoreatingthewrongstuff”. no mi mi mi n
o
Whendidyourabdominalpain start? Thisproblemstarted atleast10 yearsago.It’sreallybeengoingonfar m
i mi mi m
i mi mi mi mi mi n
o
toolong. no n
o
, Doyoursymptomsoccuraftereating rye, m
i m
i No
wheat,orbarley?
no mi
Whatare the events surrounding thestartof
mi mi mi mi mi Idon'trememberaparticularevent. m
i
yourabdominal pain?
no mi
Have youoranyfamilymemberhad ahistoryof
mi m
i mi mi n
o No,I’veneverheardthataboutanyone
m
i
IBD?
no
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?
no mi don’tfeelmuchlike eating. m
i mi
Doyou haveanyskinproblems? mi n
o Justalittledry.Ihaven’tnoticedanythingelse.
m
i m
i m
i
Doyouhaveahistoryofabowelobstruction?
mi n
o m
i mi No,nothing that dramatic.
i
m m
i mi
Have youoranyfamilymemberhad ahistoryof
mi m
i mi mi n
o No,wedonot. mi
colon polyps or colon cancer?
no no mi no no
Doyouhave blacktar-likeorfoul-smelling
i
m mi i
m i
m No,I’veneverhadanythinglike that.
m
i no
stools?
no
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?
no
Doyouhavearthritis? n
o No,I’mluckywiththat
m
i m
i
Doyouhaveheartdisease and/orhave youever m
i m
i mi n
o No,Idonothave heart problems.
mi no mi
hada heart attack? No, I do not have heart
no no mi no no no no no no no
problems.
no
Questions to fill out the EHR mi mi mi mi mi
Tellme aboutyourwork mi
Iamamanagerata localrestaurant.I haveverylongworkdays…
mi
mi n
o mi mi n
o
Iusuallywork late intothenight. mi mi m
i
Have youhad arecent endoscopy,colonoscopy,
mi Uh…No.
mi mi mi mi mi
orbiopsy?
no
Whenand whatwas the resultofyourlast
m
i Ihaven’thad oneyet.Toobusy.
mi mi mi mi mi i
m
mammogram?
no
Physical Exam mi no
Bloodpressure mi 120/60, normal, normotensive mi n
o
Cognitive Alertandorientedx4 m
i
Pulse 60,regular,normal
RR 14,regular,unlabored
n
o n
o
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
no
Inspect nails mi Nailswithout ridging,pitting, orpeeling
mi mi mi
Testcapillaryrefill Normal capillary reflow no no
Inspect eyes mi Normal
Inspect face mi Normalexpression.Nolesions, scars,orabnormalpigmentation.
m
i mi m
i
Ocularmotortest Normal
Examinepupils R –NR,L–NR
mi n
o mi n
o n
o
Inspect/Palpate Head no Normocephalic, atraumatic. No deformities. Facial featuressymmetric.
no no no no no
Temporalarteriesnon-tendertopalpation.Frontalandmaxillarysinuses
no m
i m
i
non-tender.
no
