ABDOMINAL PAIN ESTHER
PARK
[Document subtitle]
[DATE]
[COMPANY NAME]
[Company address]
, Shadow Health Abdominal Pain Case:
Chief Complaint
1. Reports abdominal pain
2. Reports difficulty with bowel movement
General Assessment
3. Asked about orientation
o Oriented to own person
o Oriented to place
o Oriented to situation
o Oriented to time
4. Asked about onset, frequency, and duration of pain
o Reports discomfort for the past 5 days
o Reports pain with gradual onset that worsened 2-3 days ago
5. Asked about location of pain
o Reports pain in lower abdomen
o Reports pain is not localized
6. Asked about pain rating on scale
o Reports 6/10 pain
7. Asked about characteristics of pain
o Describes pain as dull and cramping
o Pain fluctuates in severity
8. Asked about non-pharmacological relieving factors
o Denies taking pain medication
o Denies taking laxatives
9. Asked about aggravating factors
o Reports pain is aggravated by eating