Abdominal Pain History

  • CC
    • Site: where? Does it radiate anywhere else?
    • Onset: first time? when? Sudden\gradual? Continuous\intermittent? Getting better\worse?
    • Duration: how long does it last?
    • Timing: specific time of day\night? How frequent?
    • Character of pain: sharp, dull, cramping?
    • Character of stool: Amount? Watery? Blood? Mucous? Greasy\difficult to flush?
    • Relieving\aggravating factors: certain foods (gluten, lactose)? Medication?
    • Severity: 1-10 scale? Wakes you up from sleep? Interfering w\ ADL?
    • Food hx: recent suspect food? Food poisoning?
  • Associated sx:
    • Constitutional: fever, wt loss, loss of appetite, night sweats, chills?
    • GI: abdominal pain, diarrhea\constipation, N\V, heartburn, jaundice?
    • GU: dysuria, hematuria?
    • Anemia: fatigue, dizziness, palpitation, headache?
    • IBS: relieved after defecation, abdominal pain, diarrhea\constipation, flatulence\bloating, associated with stress\spicy food\menstruation?
    • IBD: bloody diarrhea, rash, mouth ulcer, joint pain?
  • PMHx:
    • Diseases:
      • Chronic ds (HTN, DM, DLP)
      • GI ds
    • Medications: NSAIDs, abx, laxatives, herbals
    • Surgery, hospitalization, trauma
    • Blood transfusions, IV drug use, tattoos
    • Allergies
  • FMHx:
    • Similar complaint?
    • Same diseases as in PMHx?
  • Social Hx:
    • Occupation, marital status, children?
    • Smoking, alcohol, recreational drugs?
    • Travel Hx, contact with sick pts
    • Diet, exercise

 


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