HISTORY:
Abdominal pain for
Location:
Radiation:
Severity: , / 10
Type:
Onset: , following
Pattern: , worse during the
Episode duration:
Worsening factors or triggers:
Alleviating factors: ,
, episodes ,
, episodes ,
, up to °, over
, over ,
Additional symptoms:
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Pelvic: vulva , vagina , cervix , uterus , adnexa ,
Genital: , testicles , penis
Extremities: , , cap refill , pulses ,
ASSESSMENT:
DDx:
PLAN:
- Blood work: , , , , , , ,
- Urinalysis
- Abdominal X-ray
- Abdominal ultrasound
- CT scan of abdomen and pelvis
- Upper GI endoscopy
- Colonoscopy
-
-
-
-
- Referral to gastroenterologist
- Referral to surgeon
- Follow-up in
- Return if pain worsens or if new symptoms develop such as fever, vomiting, or blood in stools