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Medical Record Documentation of Chronic Abdominal Pain

H. Shah MD

Name: Martha McCue1

Date of birth: June 24, 19842

Drug allergies: None known3

Immunizations: Complete4

Thursday, December 3, 1992

CHIEF COMPLAINT: "She's been having stomach aches since summer."

PRESENT ILLNESS: (without prospective diary) Stomach hurting off and on since end of summer. May have started on vacation. Says stomach hurts "lots of days." Many times too uncomfortable to go to school or mother has to get her. School nurse worried there is something wrong. Pain is usually "in middle." No obvious relation to meals; "can happen anytime." Not sure if it wakes her up, "but sometimes I have bad dreams." Pain lasts "a long time." Appetite normal for her; picky eater. No obvious relation to specific foods. Thinks bowel movements are normal; can't remember how often. No discomfort urinating. Has not had temperature taken. Remembers vomiting once. Mother thinks one bout was related to taking antibiotic.

PRESENT ILLNESS: (with prospective diary) Father had vomiting and diarrhea mid-August on vacation; better in 4 days. Martha caught it and had pronounced cramps. Not a week without abdominal pain since then. Several bouts a week. Diary shows pronounced pain on Sunday evenings, Monday mornings, Tuesday mornings, causing school absence 3 days. Milder discomfort on other days. No pain over Thanksgiving vacation until Sunday night.






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Copyright © 1993 by the American Academy of Pediatrics.