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78 y/o 5’3 125 lbs Vitals T: 100.76F PO P: 90 BP: 126/72 RR; 16 O2: 97% RA CC: Diarrhea 1. How can I help u today? – having a lot of watery diarrhea and stomach has been too upset. Caretaker at rehab sent her here to see whats wrong. The sent my chart over for you to review 2. Any other symptoms or concerns we should discuss? – yes appetitie is way off and having tummy pain. Feel woozy, lightheaded when standing. Feel worn out 3. When did ur diarrhea start – 2 days ago 4. What are the events surrounding the start of ur diarrhea – don’t know 5. How often do u have diarrhea like this - never 6. What tx have u had for ur diarrhea – none 7. Is there any blood in ur stool or with BM – no 8. Do u have black tar-like or foul smelling stool – no 9. How often do u feel that u need to move ur bowels – normally 2x/day. But when diarrhea started it happened 2x first night, 5x yesterday, and already 2x this AM 10. When did ur abd pain start - when diarrhea did 11. Does anything make the abd pain better or worse – taking it easy and resting makes better. A little better once get off toilet 12. What doesthe pain/discomfort in your abd feel like? – crampy 13. Where more precisely is your abd pain – all over belly 14. Do u have any abd bloating? – yes. 15. How severe (1-10) is your abd pain – 6 at its worse 16. How long doesthe pain in your abdomen last? – com
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