SHADOW HEALTH FOCUSED
EXAM:ABDOMINAL PAIN -
WEEK 9 (ESTHER PARK)
[Document subtitle]
[DATE]
[COMPANY NAME]
[Company address]
, SUBJECTIVE DATA COLLECTION
Patient Data
1. Chief Complaint
o Established chief complaint: Abdominal pain & difficulty with bowel
movements
o Empathy statement: "I'm sorry you're having these symptoms. It's good
you came in today."
2. Orientation
o Asked: "Do you know where you are?"
o Patient oriented to person, place, situation, time
3. History of Present Illness
o Onset/Duration: Discomfort ×5 days, worsened 2-3 days ago
o Location: Lower abdomen, non-localized
o Pain Rating: 6/10
o Characteristics: Dull, cramping, fluctuates
o Relieving Factors: No pain meds/laxatives
o Aggravating Factors: Eating, activity
o Impact: Reduced daily activities, low energy
4. Bowel Habits
o Constipation ×5 days (no treatment attempted)
o Diarrhea episode 6mo ago (1 day, watery)
o No blood/mucus in stool
5. Urinary Symptoms
o Slightly decreased frequency, dark urine
o No blood in urine
6. Fluid Intake
o 1-2 glasses water/day (recent decrease)
o No caffeine
o Education: Encouraged increased water intake
EXAM:ABDOMINAL PAIN -
WEEK 9 (ESTHER PARK)
[Document subtitle]
[DATE]
[COMPANY NAME]
[Company address]
, SUBJECTIVE DATA COLLECTION
Patient Data
1. Chief Complaint
o Established chief complaint: Abdominal pain & difficulty with bowel
movements
o Empathy statement: "I'm sorry you're having these symptoms. It's good
you came in today."
2. Orientation
o Asked: "Do you know where you are?"
o Patient oriented to person, place, situation, time
3. History of Present Illness
o Onset/Duration: Discomfort ×5 days, worsened 2-3 days ago
o Location: Lower abdomen, non-localized
o Pain Rating: 6/10
o Characteristics: Dull, cramping, fluctuates
o Relieving Factors: No pain meds/laxatives
o Aggravating Factors: Eating, activity
o Impact: Reduced daily activities, low energy
4. Bowel Habits
o Constipation ×5 days (no treatment attempted)
o Diarrhea episode 6mo ago (1 day, watery)
o No blood/mucus in stool
5. Urinary Symptoms
o Slightly decreased frequency, dark urine
o No blood in urine
6. Fluid Intake
o 1-2 glasses water/day (recent decrease)
o No caffeine
o Education: Encouraged increased water intake
