Questions–yields90% m
i m
i
Howcan I help you? mi mi mi mi My stomach hurts m
i mi
Doyouhave any other symptomsor concerns we
m
i mi mi mi mi mi mi mi I occasionally feel “bloated” although I’m not sure my belly is actually
mi mi mi mi mi mi mi mi mi mi mi
should discuss?
mi mi bigger when I feel that way. I…well pass a lot of gas
mi mi mi mi mi mi mi mi mi mi mi mi
and… even belch a lot compared to other people I know. Sort of
mi mi mi mi mi mi mi mi mi mi mi mi
embarrassing for a woman you know.Do you think that’s related to
mi mi mi mi mi mi m
i mi mi mi mi mi
all of this?
mi mi mi
Is yourpain affectedbywhat, when,or how
mi mi mi mi m
i mi m
i mi It seems to be worse with rich foods. I haven’t really noticed it as
mi mi mi mi mi mi mi mi mi mi mi mi mi
muchyou eat? mi mi associated with when or how much. mi mi mi mi mi
Doyounow or have youever smokedor chewed
m
i mi mi mi mi mi mi mi mi No, Inever have. mi mi mi
tobacco?
mi
Are you taking any over the counter or herbal
mi mi mi mi mi mi mi mi I take a multivitamin daily, and acetaminophen from time to
mi mi mi mi mi mi mi mi mi
medications? time for stress headaches mi mi mi
Areyoutaking anyprescription medications?
m
i mi m
i m
i mi No prescription medications
mi m i
Doyou have any allergies?
m
i mi mi mi Not that I know of mi mi mi mi
Have you everbeen hospitalized?
mi mi mi mi Just for the c-section and the bike accident thing
mi mi mi mi mi mi mi mi
Any previousmedical,surgical,or dental
mi mi mi mi mi I had a c-section at 27 without any complications. When I was 17, I had
mi mi mi mi mi mi mi mi mi mi mi mi mi mi
procedures?
mi a bike accident and had a complicated fracture of my right
mi mi mi mi mi mi mi mi mi mi mi
tibia. They had to fix that with surgery. mi mi mi mi mi mi mi
Can you tell me about any current or past medical
mi mi mi mi mi mi mi mi mi I don’t know really what’s important. The only thing besides this
mi mi mi mi mi mi mi mi mi mi
problems you have had?
mi mi mi mi stomach problem is that lately I’ve been getting occasional hot
mi mi mi mi mi mi mi mi mi mi
flashes and my skin is sort of dry. I also get headaches now and then
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
which isn’t new and that probably isn’t important anyway.
mi mi mi mi mi mi mi mi mi
Is that the kind of things you want to know?
mi mi mi mi mi mi mi mi mi
Doyouhave diarrhea?
m
i mi mi Occasionally. SometimesI’d saymy bowelmovement is loose and m
i mi mi m
i mi m
i mi mi mi
watery. Does that count?
mi mi mi mi
Is there any blood in your stools or with your
mi mi m
i mi mi mi mi mi mi Anything red? Not that I have noticed mi mi mi mi mi mi
bowelmovement? m
i
Doyouhave a problem with constipation?
m
i mi mi mi mi mi Definitely. For as long as I can recall in my adult life, I have mi mi mi mi mi mi mi mi mi mi mi mi mi
alternating periods ofconstipation and just the opposite ifyou know
mi mi mi mi mi mi mi mi mi mi mi
what I mean that lasts several days. When I am constipated, I feel
mi mi mi mi mi mi mi mi mi mi mi mi mi
like I cannot get everything out, even after a
mi mi mi mi mi mi mi mi mi
BM.
Have youbeenhaving fevers? m
i mi mi mi Idon’t think so, can you checkthat for me
m
i mi mi mi mi mi mi mi mi
Howoften does this abdominal pain occur?
m
i mi mi mi mi mi It’s been coming and going for years now. It never really goes
mi mi mi mi mi mi mi mi mi mi mi
away entirely, but then it also doesn’t seem to be getting a lot
mi mi mi mi mi mi mi mi mi mi mi mi mi
worse. It’s just there all the time. So frustrating.
mi mi mi mi mi mi mi mi mi
Howsevere (1-10 scale) is your abdominal
mi mi mi mi mi mi It varies, sometimes it’s just mild and annoying, other timesit
mi mi mi mi mi mi mi mi mi mi
pain? stops me in my tracks it’s so bad mi mi mi mi mi mi mi
Does the pain in your abdomen radiate
mi mi mi mi mi mi No, it’s just in my stomach mi mi mi mi mi
someplace else? Where? mi mi
Where more preciselyis yourabdominalpain? mi mi m
i mi mi m
i All over, especially in the lower half of my belly.
mi mi mi mi mi mi mi mi mi
What does the pain/discomfort in your
mi mi mi mi mi Usually like a bad cramp but sometimes it can be a stabbing feeling. mi mi mi mi mi mi mi mi mi mi mi mi
abdomenfeellike?(Cramping,burning, m
i m
i m
i m
i
stabbing, aching, tingling, squeezing).
mi mi mi mi
Doesanything make the pain in your abdomen
m
i mi mi mi mi mi m
i “Having a bowel movement sometimesmakes it better. Then it mi mi mi mi mi mi mi mi mi
better or worse? mi mi starts up again if I’m stressed out or eating the wrong stuff”.
mi mi mi mi mi mi mi mi mi mi mi
Whendid yourabdominalpain start? mi mi mi m
i mi This problemstarted at least 10 years ago. It’s really been going on far
mi mi mi mi mi mi mi mi mi mi mi mi mi
too long.
mi mi
, Do yoursymptoms occur after eating rye,
mi mi mi mi mi mi No
wheat,or barley? mi mi
What are the events surrounding the start of
mi mi mi mi mi mi mi I don't remembera particular event.
m
i mi mi mi mi
yourabdominal pain? m
i mi
Have youor any family memberhad a history of
mi mi mi mi mi mi mi mi mi No, I’ve never heard that about anyone
mi mi mi mi mi mi
IBD?
mi
Are you now or have you ever been anemic?
mi mi mi mi mi mi mi mi Noone has ever told me that
mi mi mi mi mi mi
Doyouavoid eating because you are worried
m
i mi mi mi mi mi mi Sometimesmaybe I do. I mean when my stomach is hurting I mi mi mi mi mi mi mi mi mi mi mi
about pain? mi don’t feel much like eating. mi mi mi mi
Doyou have any skin problems?
m
i mi mi mi mi Just a little dry.I haven’t noticed anything else.
mi mi mi m
i mi mi mi mi
Do you have a history of a bowel obstruction?
mi mi mi mi mi mi mi mi No,nothing that dramatic.m
i mi mi
Have youor any family memberhad a history of
mi mi mi mi mi mi mi mi mi No, we do not. mi mi mi
colon polyps or colon cancer?
mi mi mi mi mi
Doyouhave blacktar-like or foul-smelling
m
i m
i mi m
i mi mi No, I’ve never had anything like that.
mi mi mi mi mi mi
stools?
mi
Have youlost weight? mi mi mi No
Howlong does the pain in your abdomen last?
mi mi mi mi mi mi mi mi Sometimesa few minutes, sometimesup to an hour mi mi mi mi mi mi mi mi
Have you had the pain in your abdomen
mi mi mi mi mi mi mi Yes, this same sort ofpain on and off
m
i mi mi mi m
i mi mi mi
before?
Doyou have arthritis?
m
i mi mi No, I’m lucky withthat mi mi mi mi
Doyouhave heart disease and/or have you ever
m
i mi mi mi m
i mi mi mi No, Ido not have heart problems.
mi mi mi mi mi mi
had a heart attack? No, I do not have heart
mi mi mi mi mi mi mi mi mi mi
problems.
mi
Questions to fill out the EHR mi mi mi mi mi
Tell me about yourwork
mi I am a manager at a local restaurant. I have very long workdays…
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
I usually work late into the night. m
i mi mi mi mi mi
Have you had a recent endoscopy, colonoscopy,
mi Uh… No. mi mi mi mi mi mi
or biopsy?
mi
Whenand what was the result of yourlast I haven’t had one yet. Too busy.
mi mi mi mi mi mi mi mi m
i mi mi mi mi mi
mammogram?
mi
Physical Exam mi
Bloodpressure mi 120/60, normal, normotensive mi mi
Cognitive Alert and oriented x 4 mi mi mi mi
Pulse 60,regular,normal m
i m
i
RR 14, regular, unlabored mi mi
Temp 98.6
Inspect skin overall mi mi Dryskin,otherwise unremarkable m
i m
i mi
Inspect hair color,distribution, mi mi mi Thicknessand distribution pattern typicalfor patient genderand age m
i mi mi mi m
i mi mi i
m mi
thickness
Inspect nails mi Nails without ridging,pitting, orpeeling mi mi m
i mi m
i
Test capillary refill mi m
i Normal capillary reflow mi mi
Inspect eyes mi Normal
Inspect face mi Normalexpression. Nolesions, scars,or abnormal pigmentation.
m
i m
i m
i mi m
i m
i m
i
Ocularmotortest m
i m
i Normal
Examine pupils mi R – NR, L – NR
mi mi mi mi mi
Inspect/Palpate Head m i Normocephalic, atraumatic. No deformities. Facial features symmetric. mi mi mi mi mi mi
Temporalarteries non-tendertopalpation. Frontal and maxillary sinuses
mi m
i mi m
i m
i m
i m
i mi m
i
non-tender.
mi
i m
i
Howcan I help you? mi mi mi mi My stomach hurts m
i mi
Doyouhave any other symptomsor concerns we
m
i mi mi mi mi mi mi mi I occasionally feel “bloated” although I’m not sure my belly is actually
mi mi mi mi mi mi mi mi mi mi mi
should discuss?
mi mi bigger when I feel that way. I…well pass a lot of gas
mi mi mi mi mi mi mi mi mi mi mi mi
and… even belch a lot compared to other people I know. Sort of
mi mi mi mi mi mi mi mi mi mi mi mi
embarrassing for a woman you know.Do you think that’s related to
mi mi mi mi mi mi m
i mi mi mi mi mi
all of this?
mi mi mi
Is yourpain affectedbywhat, when,or how
mi mi mi mi m
i mi m
i mi It seems to be worse with rich foods. I haven’t really noticed it as
mi mi mi mi mi mi mi mi mi mi mi mi mi
muchyou eat? mi mi associated with when or how much. mi mi mi mi mi
Doyounow or have youever smokedor chewed
m
i mi mi mi mi mi mi mi mi No, Inever have. mi mi mi
tobacco?
mi
Are you taking any over the counter or herbal
mi mi mi mi mi mi mi mi I take a multivitamin daily, and acetaminophen from time to
mi mi mi mi mi mi mi mi mi
medications? time for stress headaches mi mi mi
Areyoutaking anyprescription medications?
m
i mi m
i m
i mi No prescription medications
mi m i
Doyou have any allergies?
m
i mi mi mi Not that I know of mi mi mi mi
Have you everbeen hospitalized?
mi mi mi mi Just for the c-section and the bike accident thing
mi mi mi mi mi mi mi mi
Any previousmedical,surgical,or dental
mi mi mi mi mi I had a c-section at 27 without any complications. When I was 17, I had
mi mi mi mi mi mi mi mi mi mi mi mi mi mi
procedures?
mi a bike accident and had a complicated fracture of my right
mi mi mi mi mi mi mi mi mi mi mi
tibia. They had to fix that with surgery. mi mi mi mi mi mi mi
Can you tell me about any current or past medical
mi mi mi mi mi mi mi mi mi I don’t know really what’s important. The only thing besides this
mi mi mi mi mi mi mi mi mi mi
problems you have had?
mi mi mi mi stomach problem is that lately I’ve been getting occasional hot
mi mi mi mi mi mi mi mi mi mi
flashes and my skin is sort of dry. I also get headaches now and then
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
which isn’t new and that probably isn’t important anyway.
mi mi mi mi mi mi mi mi mi
Is that the kind of things you want to know?
mi mi mi mi mi mi mi mi mi
Doyouhave diarrhea?
m
i mi mi Occasionally. SometimesI’d saymy bowelmovement is loose and m
i mi mi m
i mi m
i mi mi mi
watery. Does that count?
mi mi mi mi
Is there any blood in your stools or with your
mi mi m
i mi mi mi mi mi mi Anything red? Not that I have noticed mi mi mi mi mi mi
bowelmovement? m
i
Doyouhave a problem with constipation?
m
i mi mi mi mi mi Definitely. For as long as I can recall in my adult life, I have mi mi mi mi mi mi mi mi mi mi mi mi mi
alternating periods ofconstipation and just the opposite ifyou know
mi mi mi mi mi mi mi mi mi mi mi
what I mean that lasts several days. When I am constipated, I feel
mi mi mi mi mi mi mi mi mi mi mi mi mi
like I cannot get everything out, even after a
mi mi mi mi mi mi mi mi mi
BM.
Have youbeenhaving fevers? m
i mi mi mi Idon’t think so, can you checkthat for me
m
i mi mi mi mi mi mi mi mi
Howoften does this abdominal pain occur?
m
i mi mi mi mi mi It’s been coming and going for years now. It never really goes
mi mi mi mi mi mi mi mi mi mi mi
away entirely, but then it also doesn’t seem to be getting a lot
mi mi mi mi mi mi mi mi mi mi mi mi mi
worse. It’s just there all the time. So frustrating.
mi mi mi mi mi mi mi mi mi
Howsevere (1-10 scale) is your abdominal
mi mi mi mi mi mi It varies, sometimes it’s just mild and annoying, other timesit
mi mi mi mi mi mi mi mi mi mi
pain? stops me in my tracks it’s so bad mi mi mi mi mi mi mi
Does the pain in your abdomen radiate
mi mi mi mi mi mi No, it’s just in my stomach mi mi mi mi mi
someplace else? Where? mi mi
Where more preciselyis yourabdominalpain? mi mi m
i mi mi m
i All over, especially in the lower half of my belly.
mi mi mi mi mi mi mi mi mi
What does the pain/discomfort in your
mi mi mi mi mi Usually like a bad cramp but sometimes it can be a stabbing feeling. mi mi mi mi mi mi mi mi mi mi mi mi
abdomenfeellike?(Cramping,burning, m
i m
i m
i m
i
stabbing, aching, tingling, squeezing).
mi mi mi mi
Doesanything make the pain in your abdomen
m
i mi mi mi mi mi m
i “Having a bowel movement sometimesmakes it better. Then it mi mi mi mi mi mi mi mi mi
better or worse? mi mi starts up again if I’m stressed out or eating the wrong stuff”.
mi mi mi mi mi mi mi mi mi mi mi
Whendid yourabdominalpain start? mi mi mi m
i mi This problemstarted at least 10 years ago. It’s really been going on far
mi mi mi mi mi mi mi mi mi mi mi mi mi
too long.
mi mi
, Do yoursymptoms occur after eating rye,
mi mi mi mi mi mi No
wheat,or barley? mi mi
What are the events surrounding the start of
mi mi mi mi mi mi mi I don't remembera particular event.
m
i mi mi mi mi
yourabdominal pain? m
i mi
Have youor any family memberhad a history of
mi mi mi mi mi mi mi mi mi No, I’ve never heard that about anyone
mi mi mi mi mi mi
IBD?
mi
Are you now or have you ever been anemic?
mi mi mi mi mi mi mi mi Noone has ever told me that
mi mi mi mi mi mi
Doyouavoid eating because you are worried
m
i mi mi mi mi mi mi Sometimesmaybe I do. I mean when my stomach is hurting I mi mi mi mi mi mi mi mi mi mi mi
about pain? mi don’t feel much like eating. mi mi mi mi
Doyou have any skin problems?
m
i mi mi mi mi Just a little dry.I haven’t noticed anything else.
mi mi mi m
i mi mi mi mi
Do you have a history of a bowel obstruction?
mi mi mi mi mi mi mi mi No,nothing that dramatic.m
i mi mi
Have youor any family memberhad a history of
mi mi mi mi mi mi mi mi mi No, we do not. mi mi mi
colon polyps or colon cancer?
mi mi mi mi mi
Doyouhave blacktar-like or foul-smelling
m
i m
i mi m
i mi mi No, I’ve never had anything like that.
mi mi mi mi mi mi
stools?
mi
Have youlost weight? mi mi mi No
Howlong does the pain in your abdomen last?
mi mi mi mi mi mi mi mi Sometimesa few minutes, sometimesup to an hour mi mi mi mi mi mi mi mi
Have you had the pain in your abdomen
mi mi mi mi mi mi mi Yes, this same sort ofpain on and off
m
i mi mi mi m
i mi mi mi
before?
Doyou have arthritis?
m
i mi mi No, I’m lucky withthat mi mi mi mi
Doyouhave heart disease and/or have you ever
m
i mi mi mi m
i mi mi mi No, Ido not have heart problems.
mi mi mi mi mi mi
had a heart attack? No, I do not have heart
mi mi mi mi mi mi mi mi mi mi
problems.
mi
Questions to fill out the EHR mi mi mi mi mi
Tell me about yourwork
mi I am a manager at a local restaurant. I have very long workdays…
mi mi mi mi mi mi mi mi mi mi mi mi mi mi mi
I usually work late into the night. m
i mi mi mi mi mi
Have you had a recent endoscopy, colonoscopy,
mi Uh… No. mi mi mi mi mi mi
or biopsy?
mi
Whenand what was the result of yourlast I haven’t had one yet. Too busy.
mi mi mi mi mi mi mi mi m
i mi mi mi mi mi
mammogram?
mi
Physical Exam mi
Bloodpressure mi 120/60, normal, normotensive mi mi
Cognitive Alert and oriented x 4 mi mi mi mi
Pulse 60,regular,normal m
i m
i
RR 14, regular, unlabored mi mi
Temp 98.6
Inspect skin overall mi mi Dryskin,otherwise unremarkable m
i m
i mi
Inspect hair color,distribution, mi mi mi Thicknessand distribution pattern typicalfor patient genderand age m
i mi mi mi m
i mi mi i
m mi
thickness
Inspect nails mi Nails without ridging,pitting, orpeeling mi mi m
i mi m
i
Test capillary refill mi m
i Normal capillary reflow mi mi
Inspect eyes mi Normal
Inspect face mi Normalexpression. Nolesions, scars,or abnormal pigmentation.
m
i m
i m
i mi m
i m
i m
i
Ocularmotortest m
i m
i Normal
Examine pupils mi R – NR, L – NR
mi mi mi mi mi
Inspect/Palpate Head m i Normocephalic, atraumatic. No deformities. Facial features symmetric. mi mi mi mi mi mi
Temporalarteries non-tendertopalpation. Frontal and maxillary sinuses
mi m
i mi m
i m
i m
i m
i mi m
i
non-tender.
mi
