Shadow Health Abdominal Pain Esther Park with complete solution

Shadow Health Abdominal Pain Esther Park with complete solution chief complaint Ans- -reports abdominal pain -reports difficulty with bowel movement asked about orientation Ans- -oriented to own person -oriented to pl ...

Shadow Health Abdominal Pain Esther Park with complete solution chief complaint Ans- -reports abdominal pain -reports difficulty with bowel movement asked about orientation Ans- -oriented to own person -oriented to place -oriented to situation -oriented to time asked about onset, frequency, and duration of pain Ans- -reports discomfort for the past 5 days -reports pain with gradual onset that worsened 2-3 days ago asked about location of pain Ans- -reports pain in lower abdomen -reports pain is not localized asked about pain rating on scale Ans- -reports 6/10 pain asked about characteristics of pain Ans- -describes pain a dull and cramping -pain fluctuates in severity asked about non-pharmacological relieving factors Ans- -denies taking pain medication -denies taking laxatives asked about aggravating factors Ans- -reports pain is aggravated by eating -aggravated by physical activity asked about impact on daily life Ans- -recent difficulty participating in usual activities -reports low energy followed up on constipation Ans- -constipation most of last 5 days -denies any attempt to treat constipation asked about diarrhea Ans- recent diarrhea followed up about diarrhea Ans- -about 6 months ago -sudden onset -lasted one day -loose and water asked about substances in stool Ans- -denies mucus and blood in stool asked about urination Ans- -recent, slight decrease in frequency of urination -darker urine recently -denies blood in urine asked about fluid intake Ans- -decreased thirst -decreased fluid intake for last few days -typical fluid intake is 1-2 glasses water/day -denies drinking caffeine asked about contact with illnesses Ans- -denies recent travel and exposure to food poisoning asked about history of constipation Ans- denies history asked about typical bowel movements Ans- -typically has BM almost every day -stools usually brown, formed, soft asked about allergies Ans- -reports latex allergy -denies med allergies -denies food allergies asked about pre-existing health conditions Ans- -reports high BP -diagnosed at 54 asked about relevant history of surgery Ans- -c section at 40 -gall bladder removal at 42 -no post op complications asked about home meds Ans- -meds for high BP -10 mg accupril daily at 8 am -no OTC meds asked about access to healthcare Ans- -annual checkup with HCP -last pap smear over 10 years -level of health and activity is good -denies STI testing -last colonoscopy over 10 years -denies finances as a barrier -denies transportation as a barrier asked about family and support system Ans- -reports living with daughter and strong family support asked about diet Ans- -last meal was toast at breakfast -typically eats 3 meals a day -denies snacks -typical breakfast is toast -typical lunch is soup -typical dinner is chicken or fish with rice asked about fiber intake Ans- -denies fiber supplements -denies efforts to incorporate fiber in diet -reports eating veggie every 1-2 days -reports eating fruit ever 3-4 days asked about typical activity level Ans- -typically high level of mobility and independence -reports typically having a moderated activity level asked about substance abuse Ans- -denies illicit drug use; smoking -low alcohol consumption followed up on alcohol Ans- -drinks 1 night a week -drinks 1 drink per sitting -white wine asked about constitutional health Ans- -denies recent weight changes -denies fever, chills, night sweats -short term feeling of exhaustion ROS for GI system Ans- -reports bloating -reports slight increase in gassiness -reports loss of appetite -denies nausea, vomiting ROS for GU system Ans- -reports onset of menopause at age 54 -denies history of bladder problems -denies painful urination; burning; incontinence -denies hx of UTIs -denies GYN problems -denies vaginal bleeding/discharge ROS for cardiovascular system Ans- denies palpi