© Question Patient Response O Chief complaint Abdominal pain. O Onsee ‘Two weeks ago. © Constant/intermittent Well, I don’t have the pain all the time. It comes and goes. 0 Frequency At least once every day. Progression, Itis getting worse. O Severity ona scale When I have the pain, it is 7/10, and then it can go down to 0. isi Teeter ere eres C Radiation’ No. Quality, Burning. 1 Alleviating factors Food, antacids, and milk. 1D Exacerbating factors Heavy meals and hunger. 1 Types of food that exacerhate pain Heavy, fatty meals, like pizza. CO Relationship of food to pain Well, usually the pain will decrease or stop completely when I eat, but it comes back after 2-3 hours. Gi Previous episodes of similar pain’ No. © Nausea/vomiting Sometimes | feel nauseated when I am in pain. Yesterday I vomited for the first time. CO Description of vomitus Te was a sour, yellowish fluid. 1D Blood in vomitus No. G Diarrhea/constipation No. 1 Weight changes No. DD Appetite changes No. 1 Change in stool color No. Current medications Maalox, ibuprofen (2 pills 23 times a day if asked). © Past medical history Thad a urinary tract infection 1 year ago, treated with amoxicillin, and arthritis in both knees, for which I take ibuprofen.eee Thad 2 C-sections. My father died at 55 of pancreatic cancer. My mother is alive and healthy. Housewife. With my husband (laughs) No. Connecting with the Patient CO Examinee recognized the SP’s emotions and responded with PEARLS. Physical Examination Ci Examinee washed his/her hands. CO Examine: ion to start the exam. asked perm C Examinee used respectful draping. 1 Examinee did not repeat painful maneuvers. Bree eas ees 0 CV exam Auscultation C Pulmonary exam Auscultation 1 Abdominal exam Inspection, auscultation, palpation (including Murphy's sign), percussiontie Thaven't had a period in 3 months. used to have regular periods every month lasting for 4-5 days, but over the past year I started having them less frequently—every 5-6 weeks, lasting for 7 days. Ic was 2-3 a day, bur the blood flow is becoming less, and I use only Laday now. Age 14. Thave gained 15 pounds over the past year: No. Actually, I recently noticed some hair on my chin that I have been. plucking. No. No. Thave a good appetite No, I've been a vegetarian for 10 years. No. C1 Depression/anxiety/stress No. C1 Hot flashes No. CJ Vaginal drynessfitching No. 1 Sleeping problems (falling asleep, stay- No. ing asleep, early waking, snoring) Cl Urinary frequency No. 1 Nipple discharge Yes, just last week I noticed some milky discharge from my left breast. 1 Visual changes No. CO Headache No. C1 Abdominal pain, No. Sexual activity ‘Once a week on average with my husband. C Contraceptives: The same pills for 8 years. O Pregnancies: Thave 1 child; he is 10 years old.cen I Problems during pregnancy/delivery No, it was a normal delivery, and my child is healthy. n cue Oi Miscarriggesfabortions No. | 1 tase Papsmear “Ten months ago. Ie was normal C0 History of abnormal Pap smears No. Ui Current medications None. Gi Past medical history None. Ci Past surgical history None. CU Family history. My father and mother are healthy; my mother began menopause at age 55. © Occupation Nurse. Ci Alcohol tise None. O Mice drug use Never. Ci Tobacco No. O Exercise Trun 2 miles 3 times a week. Gi Drugallergies: No,ee see eis OI Neck exam O CV exam Oi Pulmonary exam 0 Extremities 1 Neurologic exam Ent Inspection ‘(Visual fields, extraocular movements, checked DTRs