solution
chief complaint
-reports abdominal pain
-reports difficulty with bowel movement
asked about orientation
-oriented to own person
-oriented to place
-oriented to situation
-oriented to time
asked about onset, frequency, and duration of pain
-reports discomfort for the past 5 days
-reports pain with gradual onset that worsened 2-3 days ago
asked about location of pain
-reports pain in lower abdomen
-reports pain is not localized
asked about pain rating on scale
-reports 6/10 pain
asked about characteristics of pain
-describes pain a dull and cramping
-pain fluctuates in severity
asked about non-pharmacological relieving factors
-denies taking pain medication
-denies taking laxatives
asked about aggravating factors
-reports pain is aggravated by eating
-aggravated by physical activity
asked about impact on daily life
-recent difficulty participating in usual activities
-reports low energy
followed up on constipation
-constipation most of last 5 days
-denies any attempt to treat constipation
asked about diarrhea
recent diarrhea
followed up about diarrhea
-about 6 months ago
-sudden onset
-lasted one day
-loose and water
asked about substances in stool
-denies mucus and blood in stool
asked about urination