Health Abdominal Pain Esther Park
Marking Scheme
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
Marking Scheme
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
