SHADOW HEALTH ABDOMINAL PAIN ESTHER PARK LATEST SOLUTION GUIDE

SHADOW HEALTH ABDOMINAL PAIN ESTHER PARK LATEST SOLUTION GUIDE chief complaint - -reports abdominal pain -reports difficulty with bowel movement asked about orientation - -oriented to own person -oriented to 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