Brenda James gastrointestinal issues
1. What bring you in today?
2. Where is abdominal pain?
3. How severe is the pain on your stomach?
4. How long have you had the pain?
5. When did the pain start? Does the pain ra
...
Brenda James gastrointestinal issues
1. What bring you in today?
2. Where is abdominal pain?
3. How severe is the pain on your stomach?
4. How long have you had the pain?
5. When did the pain start? Does the pain radiate someplace else?
6. Is the pain constant or intermittent?
7. Any recent hospitalization or surgeries?
8. Have you ever had abdominal surgery?
9. Have you ever had this pain before?
10. Anything makes the pain better or worse?
11. Do you have nausea or vomiting?
12. Do you have black or bloody stool?
13. Do you have diarrhea or change in bowel habits?
14. Do you have Any allergy?
15. Anything food trigger pain?
16. Do you have a history of diverticulitis, pancreatitis, kidney failure, gallstones
inflammatory bowel disease?
17. Are you taking antibiotics or steroids?
18. How is your appetite? Any wight gain or lost?
19. Do you use any antiacids medication?
20. How is your diet?
21. Any fever?
22. Do you drink any alcohol or smoke?
23. Do you have a history of vascular or heart disease, hypertension, or atrial fibrillation?
24. How is your parents’ health?
25. Have you had any more stress in your life lately?
26. When is last period?
27. Do you have your immunization up to date?
28. Do you have any other symptoms or concerns we should discuss?
CC: “Stomach hurting last two days, haven’t able to go to work.”
HPI: Lt Col Brenda James is a 48-year-old female presenting with a chief complaint of crampy,
gnawing, achiness for two days. She started her pain and discomfort localized at her right upper
anterior abdomen under her lower ribs. The pain exacerbated when she take deep breathing. She
states that she has had a similar pain start a few months ago that discomfort has come and gone.
However, her abdomen pain has been constant for the last two days. She reports that the pain
radiates to her right shoulder but did not recall any inciting event when this pain began, but the
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