Questions–yields90% m
i m
i
Howcan Ihelpyou? Mystomach hurts
mi m
i mi
Doyouhaveanyothersymptomsorconcernswe
m
i I occasionallyfeel“bloated”although I’m notsure mybellyisactually mi ix m
i mi mi mi ix
shoulddiscuss?
ix ixbiggerwhen I feel that way. I…wellpass a lot of gas ix ix ix mi ix ix ix ix ix ix
and… evenbelch a lot compared to otherpeople I know. Sortof ix ix ix ix ix ix ix ix ix
embarrassing forawoman youknow.Doyouthinkthat’srelatedto ix mi mi mi m
i m
i m
i ix
allofthis? ix ix ix
Isyourpain affectedbywhat,when,orhow
mi Itseems tobeworse withrichfoods.Ihaven’t reallynoticeditas
mi m
i m
i mi mi m
i mi mi
muchyoueat?
ix associated withwhenorhowmuch.
mi ix mi mi ix
Doyounoworhaveyoueversmokedorchewed
m
i
No,Ineverhave. mi m
i m
i ix i
m
tobacco?
ix
Are youtakinganyoverthecounterorherbal
mi mi I take amultivitamindaily,and acetaminophenfromtimeto mi mi mi mi mi m
i mi
medications?
ix timeforstressheadaches ix m
i
Areyoutakinganyprescriptionmedications?
m
i m
i No prescription medications mi ix
Doyou have anyallergies?
m
i mi NotthatIknowof mi
Haveyoueverbeenhospitalized? Justforthe c-sectionand the bikeaccident thing
mi mi mi mi m
i mi mi mi mi
Anypreviousmedical,surgical,ordental I had a c-section at27withoutanycomplications. WhenI was 17, I had
m
i m
i mi mi mi mi mi mi mi i x mi
procedures?
ix abike accidentand had a complicatedfracture of myright ix ix ix mi ix mi mi ix
tibia.Theyhadtofixthat with surgery. ix m
i mi mi ix
Canyoutell me about anycurrentorpastmedical I don’tknowreallywhat’simportant. Theonlythingbesidesthis
mi mi mi ix m
i mi mi
problems youhavehad?
ix stomach problem isthat lately I’ve been getting occasional hot
mi ix ix ix ix mi ix ix ix mi ix mi
flashesandmy skinis sortof dry.Ialso getheadaches now and then ix ix mi ix mi ix ix mi ix ix ix mi ix
which isn’tnew and thatprobably isn’t importantanyway. ix ix ix mi ix ix
Is that thekind ofthingsyou wantto know? mi mi ix mi mi ix mi
Doyouhave diarrhea?
m
i m
i Occasionally.SometimesI’d saymybowelmovement isloose and
mi m
i mi i
m mi mi
watery.Doesthatcount? ix ix ix
Isthere anybloodinyourstools orwithyour
m
i mi Anything red?Not thatI have noticed mi mi mi mi mi mi
bowelmovement?
ix m
i
Doyouhave aproblem withconstipation?
m
i mi Definitely. For as long as I can recall in my adult life, I have
mi mi mi ix ix mi ix ix ix mi mi ix ix ix ix ix
alternatingperiodsofconstipation and justtheoppositeifyou know ix mi mi mi
what I mean that lasts several d ays. When I am constipated, I feel ix mi mi ix ix ix mi ix mi ix ix mi
like I cannotgeteverything out,evenaftera ix mi mi mi
BM.
Haveyoubeenhaving fevers?
m
i Idon’t think so,can you checkthat forme
m
i m
i m
i m
i mi mi mi mi m
i mi
Howoftendoesthis abdominalpainoccur? It’s been coming and going for years now. It never really goes mi mi mi mi ix ixmi ix ix ix ix ix ix ix ix ix
away entirely, but then it also doesn’t seem to be getting a lot ix ix ix ix ix ix ix ix ix ix ix ix ix
worse.It’sjustthereallthe time.Sofrustrating. mi ix ix ix ix ix mi ix ix ix
Howsevere(1-10scale)isyourabdominal Itvaries,sometimesit’sjustmildandannoying,othertimesit
mi mi mi mi
pain?
ix stopsmeinmytracks it’ssobad ix mi mi
Doesthe pain in yourabdomenradiate No,it’s
mi justinmystomach mi mi mi mi mi
someplace else?Where?
ix mi
Wheremorepreciselyisyourabdominalpain? Allover,especiallyinthelowerhalfofmybelly. m
i i
m
Whatdoesthepain/discomfortinyour Usuallylike a bad crampbutsometimesitcan be a stabbing feeling. m
i mi mi mi mi mi i x
abdomenfeellike?(Cramping,burning,
ix m
i m
i m
i
stabbing, aching, tingling, squeezing). ix ix ix
Doesanythingmakethepaininyourabdomen
i
m “Havingabowelmovementsometimesmakesitbetter.Thenit m
i m
i m
i m
i m
i mi
betterorworse?
ix startsupagain ifI’mstressed outoreatingthewrongstuff”. ix mi mi mi ix
Whendidyourabdominalpain start? Thisproblemstarted atleast10 yearsago.It’sreallybeengoingonfar m
i mi mi m
i mi mi mi mi mi ix
toolong. ix ix
, Doyoursymptomsoccuraftereating rye, m
i m
i No
wheat,orbarley?
ix m
i
Whatare the events surrounding thestartof
mi mi mi mi mi Idon'trememberaparticularevent. m
i
yourabdominal pain?
ix mi
Have youoranyfamilymemberhad ahistoryof
mi m
i mi mi ix No,I’veneverheardthataboutanyone
m
i
IBD?
ix
Areyounoworhaveyoueverbeenanemic? m
i Noonehasevertoldmethat
Doyouavoideating becauseyouareworried i
m m
i
SometimesmaybeI do.Imean whenmystomach ishurting I m
i mi mi m
i mi mi m
i mi
aboutpain?
ix mi don’tfeelmuchlike eating. m
i mi
Doyou haveanyskinproblems? mi ix Justalittledry.Ihaven’tnoticedanythingelse.
m
i m
i m
i
Doyouhaveahistoryofabowelobstruction?
mi ix m
i mi No,nothing that dramatic.
i
m m
i mi
Have youoranyfamilymemberhad ahistoryof
mi m
i mi mi ix No,wedonot. mi
colonpolyps or coloncancer?
ix ix mi ix ix
Doyouhave blacktar-likeorfoul-smelling
i
m mi i
m i
m No,I’veneverhadanythinglike that.
m
i ix
stools?
ix
Have youlost weight?
mi m
i mi No
Howlongdoesthepain inyourabdomenlast? m
i mi Sometimesafewminutes,sometimesuptoan hour m
i mi mi m
i mi
Haveyouhad the pain in yourabdomen
m
i mi mi mi mi mi Yes,thissamesortofpainonand off m
i mi
before?
ix
Doyouhavearthritis? ix No,I’mluckywiththat
m
i m
i
Doyouhaveheartdisease and/orhave youever m
i m
i mi ix No,Idonothaveheart problems.
mi ix mi
hada heart attack? No, I do not have heart
ix ix mi ix ix ix ix ix ix ix
problems.
ix
Questions to fill out the EHR mi mi mi mi mi
Tellme aboutyourwork mi
Iamamanagerata localrestaurant.I haveverylongworkdays…
mi
mi ix mi mi ix
Iusuallywork late intothenight. mi mi m
i
Have youhad arecent endoscopy,colonoscopy,
mi Uh…No.
mi mi mi mi mi
orbiopsy?
ix
Whenand whatwas the resultofyourlast
m
i Ihaven’thad oneyet.Toobusy.
mi mi mi mi mi i
m
mammogram?
ix
Physical Exam mi ix
Bloodpressure mi 120/60, normal,normotensive mi ix
Cognitive Alertandorientedx4 m
i
Pulse 60,regular,normal
RR 14,regular,unlabored
ix ix
Temp 98.6
Inspect skin overall mi mi Dryskin,otherwise unremarkable mi
Inspect haircolor,distribution, mi Thicknessand distributionpatterntypicalforpatientgenderand age
mi mi mi m
i mi
thickness
ix
Inspect nails mi Nailswithout ridging,pitting, orpeeling
mi mi mi
Testcapillaryrefill Normal capillary reflow ix ix
Inspect eyes mi Normal
Inspect face mi Normalexpression.Nolesions, scars,orabnormalpigmentation.
m
i mi m
i
Ocularmotortest Normal
Examinepupils R –NR,L–NRmi ix m
i ix ix
Inspect/Palpate Head i x Normocephalic, atraumatic. No deformities. Facial featuressymmetric. ix ix ix ix ix
Temporalarteriesnon-tendertopalpation.Frontalandmaxillarysinuses
ix m
i m
i
non-tender.
ix
i m
i
Howcan Ihelpyou? Mystomach hurts
mi m
i mi
Doyouhaveanyothersymptomsorconcernswe
m
i I occasionallyfeel“bloated”although I’m notsure mybellyisactually mi ix m
i mi mi mi ix
shoulddiscuss?
ix ixbiggerwhen I feel that way. I…wellpass a lot of gas ix ix ix mi ix ix ix ix ix ix
and… evenbelch a lot compared to otherpeople I know. Sortof ix ix ix ix ix ix ix ix ix
embarrassing forawoman youknow.Doyouthinkthat’srelatedto ix mi mi mi m
i m
i m
i ix
allofthis? ix ix ix
Isyourpain affectedbywhat,when,orhow
mi Itseems tobeworse withrichfoods.Ihaven’t reallynoticeditas
mi m
i m
i mi mi m
i mi mi
muchyoueat?
ix associated withwhenorhowmuch.
mi ix mi mi ix
Doyounoworhaveyoueversmokedorchewed
m
i
No,Ineverhave. mi m
i m
i ix i
m
tobacco?
ix
Are youtakinganyoverthecounterorherbal
mi mi I take amultivitamindaily,and acetaminophenfromtimeto mi mi mi mi mi m
i mi
medications?
ix timeforstressheadaches ix m
i
Areyoutakinganyprescriptionmedications?
m
i m
i No prescription medications mi ix
Doyou have anyallergies?
m
i mi NotthatIknowof mi
Haveyoueverbeenhospitalized? Justforthe c-sectionand the bikeaccident thing
mi mi mi mi m
i mi mi mi mi
Anypreviousmedical,surgical,ordental I had a c-section at27withoutanycomplications. WhenI was 17, I had
m
i m
i mi mi mi mi mi mi mi i x mi
procedures?
ix abike accidentand had a complicatedfracture of myright ix ix ix mi ix mi mi ix
tibia.Theyhadtofixthat with surgery. ix m
i mi mi ix
Canyoutell me about anycurrentorpastmedical I don’tknowreallywhat’simportant. Theonlythingbesidesthis
mi mi mi ix m
i mi mi
problems youhavehad?
ix stomach problem isthat lately I’ve been getting occasional hot
mi ix ix ix ix mi ix ix ix mi ix mi
flashesandmy skinis sortof dry.Ialso getheadaches now and then ix ix mi ix mi ix ix mi ix ix ix mi ix
which isn’tnew and thatprobably isn’t importantanyway. ix ix ix mi ix ix
Is that thekind ofthingsyou wantto know? mi mi ix mi mi ix mi
Doyouhave diarrhea?
m
i m
i Occasionally.SometimesI’d saymybowelmovement isloose and
mi m
i mi i
m mi mi
watery.Doesthatcount? ix ix ix
Isthere anybloodinyourstools orwithyour
m
i mi Anything red?Not thatI have noticed mi mi mi mi mi mi
bowelmovement?
ix m
i
Doyouhave aproblem withconstipation?
m
i mi Definitely. For as long as I can recall in my adult life, I have
mi mi mi ix ix mi ix ix ix mi mi ix ix ix ix ix
alternatingperiodsofconstipation and justtheoppositeifyou know ix mi mi mi
what I mean that lasts several d ays. When I am constipated, I feel ix mi mi ix ix ix mi ix mi ix ix mi
like I cannotgeteverything out,evenaftera ix mi mi mi
BM.
Haveyoubeenhaving fevers?
m
i Idon’t think so,can you checkthat forme
m
i m
i m
i m
i mi mi mi mi m
i mi
Howoftendoesthis abdominalpainoccur? It’s been coming and going for years now. It never really goes mi mi mi mi ix ixmi ix ix ix ix ix ix ix ix ix
away entirely, but then it also doesn’t seem to be getting a lot ix ix ix ix ix ix ix ix ix ix ix ix ix
worse.It’sjustthereallthe time.Sofrustrating. mi ix ix ix ix ix mi ix ix ix
Howsevere(1-10scale)isyourabdominal Itvaries,sometimesit’sjustmildandannoying,othertimesit
mi mi mi mi
pain?
ix stopsmeinmytracks it’ssobad ix mi mi
Doesthe pain in yourabdomenradiate No,it’s
mi justinmystomach mi mi mi mi mi
someplace else?Where?
ix mi
Wheremorepreciselyisyourabdominalpain? Allover,especiallyinthelowerhalfofmybelly. m
i i
m
Whatdoesthepain/discomfortinyour Usuallylike a bad crampbutsometimesitcan be a stabbing feeling. m
i mi mi mi mi mi i x
abdomenfeellike?(Cramping,burning,
ix m
i m
i m
i
stabbing, aching, tingling, squeezing). ix ix ix
Doesanythingmakethepaininyourabdomen
i
m “Havingabowelmovementsometimesmakesitbetter.Thenit m
i m
i m
i m
i m
i mi
betterorworse?
ix startsupagain ifI’mstressed outoreatingthewrongstuff”. ix mi mi mi ix
Whendidyourabdominalpain start? Thisproblemstarted atleast10 yearsago.It’sreallybeengoingonfar m
i mi mi m
i mi mi mi mi mi ix
toolong. ix ix
, Doyoursymptomsoccuraftereating rye, m
i m
i No
wheat,orbarley?
ix m
i
Whatare the events surrounding thestartof
mi mi mi mi mi Idon'trememberaparticularevent. m
i
yourabdominal pain?
ix mi
Have youoranyfamilymemberhad ahistoryof
mi m
i mi mi ix No,I’veneverheardthataboutanyone
m
i
IBD?
ix
Areyounoworhaveyoueverbeenanemic? m
i Noonehasevertoldmethat
Doyouavoideating becauseyouareworried i
m m
i
SometimesmaybeI do.Imean whenmystomach ishurting I m
i mi mi m
i mi mi m
i mi
aboutpain?
ix mi don’tfeelmuchlike eating. m
i mi
Doyou haveanyskinproblems? mi ix Justalittledry.Ihaven’tnoticedanythingelse.
m
i m
i m
i
Doyouhaveahistoryofabowelobstruction?
mi ix m
i mi No,nothing that dramatic.
i
m m
i mi
Have youoranyfamilymemberhad ahistoryof
mi m
i mi mi ix No,wedonot. mi
colonpolyps or coloncancer?
ix ix mi ix ix
Doyouhave blacktar-likeorfoul-smelling
i
m mi i
m i
m No,I’veneverhadanythinglike that.
m
i ix
stools?
ix
Have youlost weight?
mi m
i mi No
Howlongdoesthepain inyourabdomenlast? m
i mi Sometimesafewminutes,sometimesuptoan hour m
i mi mi m
i mi
Haveyouhad the pain in yourabdomen
m
i mi mi mi mi mi Yes,thissamesortofpainonand off m
i mi
before?
ix
Doyouhavearthritis? ix No,I’mluckywiththat
m
i m
i
Doyouhaveheartdisease and/orhave youever m
i m
i mi ix No,Idonothaveheart problems.
mi ix mi
hada heart attack? No, I do not have heart
ix ix mi ix ix ix ix ix ix ix
problems.
ix
Questions to fill out the EHR mi mi mi mi mi
Tellme aboutyourwork mi
Iamamanagerata localrestaurant.I haveverylongworkdays…
mi
mi ix mi mi ix
Iusuallywork late intothenight. mi mi m
i
Have youhad arecent endoscopy,colonoscopy,
mi Uh…No.
mi mi mi mi mi
orbiopsy?
ix
Whenand whatwas the resultofyourlast
m
i Ihaven’thad oneyet.Toobusy.
mi mi mi mi mi i
m
mammogram?
ix
Physical Exam mi ix
Bloodpressure mi 120/60, normal,normotensive mi ix
Cognitive Alertandorientedx4 m
i
Pulse 60,regular,normal
RR 14,regular,unlabored
ix ix
Temp 98.6
Inspect skin overall mi mi Dryskin,otherwise unremarkable mi
Inspect haircolor,distribution, mi Thicknessand distributionpatterntypicalforpatientgenderand age
mi mi mi m
i mi
thickness
ix
Inspect nails mi Nailswithout ridging,pitting, orpeeling
mi mi mi
Testcapillaryrefill Normal capillary reflow ix ix
Inspect eyes mi Normal
Inspect face mi Normalexpression.Nolesions, scars,orabnormalpigmentation.
m
i mi m
i
Ocularmotortest Normal
Examinepupils R –NR,L–NRmi ix m
i ix ix
Inspect/Palpate Head i x Normocephalic, atraumatic. No deformities. Facial featuressymmetric. ix ix ix ix ix
Temporalarteriesnon-tendertopalpation.Frontalandmaxillarysinuses
ix m
i m
i
non-tender.
ix
