Comprehessive Shadowhealth abnominal pain by Esther park

1. chief complaint: -reports abdominal pain -reports difficulty with bowel movement 2. asked about orientation: -oriented to own person -oriented to place -oriented to situation -oriented to time 3. asked about onset, frequency, and duration of pain: -reports discomfort for the past 5 days -reports pain with gradual onset that worsened 2-3 days ago 4. asked about location of pain: -reports pain in lower abdomen -reports pain is not localized 5. asked about pain rating on scale: -reports 6/10 pain 6. asked about characteristics of pain: -describes pain a dull and cramping -pain fluctuates in severity 7. asked about non-pharmacological relieving factors: -denies taking pain med- ication -denies taking laxatives 8. asked about aggravating factors: -reports pain is aggravated by eating -aggravated by physical activity 9. asked about impact on daily life: -recent difficulty participating in usual activities -reports low energy 10. followed up on constipation: -constipation most of last 5 days -denies any attempt to treat constipation 11. asked about diarrhea: recent diarrhea 12. followed up about diarrhea: -about 6 months ago -sudden onset -lasted one day -loose and water 13. asked about substances in stool: -denies mucus and blood in stool 14. asked about urination: -recent, slight decrease in frequency of urination -darker urine recently -denies blood in urine 15. asked about fluid intake: -decreased thirst -decreased fluid intake for last few days -typical fluid intake is 1-2 glasses water/day -denies drinking caffeine 16. asked about contact with illnesses: -denies recent travel and exposure to food poisoning 17. asked about history of constipation: denies history