Esther Park-Shadow Health-Abdominal Pain Questions and Answers

Esther Park-Shadow Health-Abdominal Pain Questions and Answers Orientation +1 Please verify your name and birthday Chief Complaint +1 Do you have any pain today? History of Presenting Illness +1 Can you rate your current pain level on a scale of 0-10? History of Presenting Illness +1 Where is your pain? History of Presenting Illness +1 Can you describe your pain? History of Presenting Illness +1 Does anything make your pain any better? History of Presenting Illness +2 Does anything make your pain worse? History of Presenting Illness +1 Have you taken anything for your pain? History of Presenting Illness +1 When did you first notice the pain? Social History +1 What was the last thing you ate? History of Presenting Illness +1 Do you have difficulty going to the bathroom? History of Presenting Illness +2 How often do you go to the bathroom? Past Medical History +1 How is your diet? Home Medications +1 Do you take any medications? Home Medications +1 Do you take any antibiotics? Social History +1 Do you eat a lot of fiber? Review of Symptoms +1 How many meals a day do you eat? Past Medical History +1 Have you ever had abdominal surgery? Review of Systems +1 How many times do you urinate? Social History +1 Do you have trouble walking? Social History +1 Do you live alone? Social History +1 Do you drink alcohol? Social history +1 How many time do you drink alcohol? Review of Systems +1 Do you exercise? Review of Systems +1 Does your pain affect your daily activities? History of Presenting Illness +2 Have you had any diarrhea? Review of Systems +1 Have you ever had an appendectomy? History of Presenting Illness +1 Do you have any bloody stool? Review of Systems +1 Do you have problems swallowing? Inspect-Head and Face Skull: Symmetric Facial: Symmetric Appearance: No visible abnormal findings Inspect-Nasal Mucosa Appearance: moist and pink Inspect-Mouth Oral Mucosa: moist and pink Insepct-Abdomen Symmetry: Symmetric Contour: Flat Appearance: scarring laceration, lesion, wound, redness Inspect: Lower Extremity Edema Right: No edema Left: No edem Auscultate: Heart Sounds Heart Sounds: S1, S2, S3, S4 are audible Extra Heart Sounds: No extra sounds Auscultate-Breath Sounds Breath Sounds: Present in all area Adventitious Sounds: None Location: All Clear Auscultate-Abdominal Aorta No bruit Auscultate- Bowel Sounds Bowel Sounds-Normoactive Location: All are normal Auscultate- Abdominal Arteries All are no bruit Percuss: Abdomen Observations: some dull, some tympanic Percuss: CVA Tenderness patient did not react Percuss-Spleen Tympany Percuss-Liver Between 6-12 cm Palpate-Light Tenderness: some tenderness reported Location: LLQ Observations: no additional Palpate-Deep Palpable Mass LLQ Palpate-Liver Palpable mass Palpate-Spleen not palpable Palpate-Bladder not palpable Palpate-Kidneys not palpable Test-Skin Tugor no tenting Past Medical History +1 Any allergies? Past Medical History +1 Are you sexually active? Past Medical History +1 Do you have any sexually transmitted infections?