Orientation +1 - Please verify your name and birthday Chief Complaint +1 - Do you have any pain today? History of Presenting Illness +1 - Can you rate your current pain level on a scale of 0-10? History of Presenting Illness +1 - Where is your pain? History of Presenting Illness +1 - Can you describe your pain? History of Presenting Illness +1 - Does anything make your pain any better? History of Presenting Illness +2 - Does anything make your pain worse? History of Presenting Illness +1 - Have you taken anything for your pain? History of Presenting Illness +1 - When did you first notice the pain? Social History +1 - What was the last thing you ate? History of Presenting Illness +1 - Do you have difficulty going to the bathroom? History of Presenting Illness +2 - How often do you go to the bathroom? Past Medical History +1 - How is your diet? Home Medications +1 - Do you take any medications? Home Medications +1 - Do you take any antibiotics? Social History +1 - Do you eat a lot of fiber? Review of Symptoms +1 - How many meals a day do you eat? Past Medical History +1 - Have you ever had abdominal surgery? Review of Systems +1 - How many times do you urinate? Social History +1 - Do you have trouble walking? Social History +1 - Do you live alone? Social History +1 - Do you drink alcohol? Social history +1 - How many time do you drink alcohol? Review of Systems +1 - Do you exercise? Review of Systems +1 - Does your pain affect your daily activities? History of Presenting Illness +2 - Have you had any diarrhea? Review of Systems +1 - Have you ever had an appendectomy? History of Presenting Illness +1 - Do you have any bloody stool? Review of Systems +1 - Do you have problems swallowing? Inspect-Head and Face - Skull: Symmetric

 

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