Week Eight I-Human Karen Floyd Case Study UPDATED

Week Seven-Karen Floyd Reason: Abdominal pain 45 y/o 5’4” (163 cm) 141 lb (64.1 kg) Thanks for seeing me today. I hope you can get to the bottom of my problems Observations: skin warm and dry Good Questions 93% 1. How can I help you? 2. Do you have any other symptoms or concerns we should discuss? 3. Is your pain affected by what? When or how much you eat? 4. Do you now or have you ever smoked or chewed tobacco? 5. Are you taking any over-the counter or herbal medications? 6. Are you taking any prescriptions medications? 7. Do you have any allergies? 8. Have you ever been hospitalized? 9. Any previous medical, surgical, or dental procedures? 10. Can you tell me about any current or past medical problems you have had? 11. Do you have diarrhea? 12. Is there any blood in your stools or with your bowel movement? 13. Do you have any problem with constipation? 14. Have you been having fevers? 15. How often does this abdominal pain occur? 16. How severe (1-10) is your abdominal pain? 17. Does the pain in your abdomen radiate someplace else? Where? 18. Where more precisely is your abdominal pain? 19. What does the pain discomfort in your abdomen feel like? (cramping, burning, stabbing, aching, tingling, squeezing)? 20. Does anything make the pain in your abdomen better or worse? 21. When did your abdominal pain start? 22. How long does the pain in your abdomen last? 23. Does the symptoms occur after eating rye, wheat, or barley? 24. What are the events surrounding the start of your abdominal pain? 25. Have you had any family member had a history of inflammatory bowel disease? 26. Are you now or have you ever been anemic? 27. Do you avoid eating because you are worries about the pain? 28. Do you have any skin problems? 29. Do you have a history of bowel obstruction? 30. Have you or any family member had a history of colon polyps or colon cancer? 31. Do you have tar like or foul-smelling stools? 32. Have you lost weight? 33. Do you have heart disease and/or have you ever had a heart attack? 34. Have you had the pain in your abdomen before? 35. Do you have arthritis? Extra Questions 1. Do you have night sweats? 2. Have you had any significant traumatic injuries or accidents? 3. Have you had a recent endoscopy, colonoscopy, or biopsy? 4. What was the results of your last mammogram? 5. Are your immunizations UTD 6. Tell me about your work? 7. Tell me about the health of your parents? 8. Where do you live? 9. Alcohol use 10. Do you eat raw or undercooked meat? 11. Have you been vomiting anything that looks like blood or coffee grounds? 12. What treatments have you had for your abdominal pain? 13. Does the pain awaken you from sleep? 14. Do you have a problem swallowing? 15. Do you have nausea or vomiting? 16. Do you presently have heartburn, a food or acid taste in your mouth? 17. Do you have difficulty breathing? 18. Do you feel dizzy, faint, or lightheaded? 19. Have you been feeling sad, depressed, or hopeless? 20. Do you have any tingling and/or numbness anywhere? 21. Do you have any difficulty urinating? 22. What childhood illnesses have you had? 23. What laxatives, enemas, or suppositories do you use? 24. Any changes in your abdominal pain since it began? 25. How quickly does the pain in your abdomen come on? 26. Is your pain relieved after a bowel movement? 27. Do you have any abdominal bloating? 28. Have you gained or lost weight unintenitally, despite normal appetite and exercise 29. Do you or have you had any stomach, intestinal or bowel problems? 30. Have you been eating anything out of the ordinary lately? 31. Do you have a problem with fatigue or tiredness? 32. Have you had any recent acute or chronic infections? 33. Have you traveled? Where did you go. 34. Do you have high cholesterol EHR-Subjective Reason for encounter: Abdominal pain HPI: KF is a 45 y/o female who presents with a ten-year history of intermittent lower abdominal pain. She says the abdominal pain never goes away and is not getting worse. Rates pain from mild and annoying cramping to stabbing in nature lasting a few minutes to an hour, worse after consuming rich foods. Better after a bowel movement; however, the pain returns with stress or eating poorly. Avoids eating when stomach is sore. Denies any events surrounding the start of abdominal pain or weight changes. Denies any treatments. Hx is positive for alternating bowel patterns from loose and watery stools to periods of constipation lasting for several days. Denies difficulty with swallowing, pain radiating elsewhere, or blood in stool. ROS-Subjective General: Pleasant, well-nourished female. Alert and oriented x 4. Afebrile. Denies fatigue, night sweats, or recent travel. HEENT/Neck: Admits to occasional headaches. Denies difficulties with swallowing. Denies nausea and/or vomit. Denies heartburn, food or acid taste in mouth. Denies feeling dizzy, faint or lightheaded. Cardiovascular: Denies history of heart disease or heart attack. Respiratory: Denies difficulty breathing. Gastrointestinal: Admits to lower abdominal pain. Occurring for ten years. Admits pain is constant and never goes away. Rates abdominal pain as varying from mild and annoying cramping to very bad stabbing feeling that last a few minutes to sometimes an hour. Reports feeling bloating and belching. Worse with rich foods. Better with after a