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NR 509 Week 5 Shadow Health Focused Exam Abdominal Pain-COMPLETE CONTENT: Chamberlain College Of Nursing

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NR 509 Week 5 Shadow Health Focused Exam Abdominal Pain-COMPLETE CONTENT: Chamberlain College Of NursingPre Brief: Ms. Esther Park is a 78-year-old woman who comes to the clinic complaining of abdominal pain. She reports that the pain isn’t severe, but that her daughter was concerned and brought her in. It is very important to determine whether or not the situation is an emergency and that the underlying cause of Esther’s discomfort. Be sure to inquire about a variety of psychosocial factors related to the GI system, including her diet, toilet habits, immunizations, recent travel, etc. This case study will offer you the opportunity to take a complete surgical, reproductive, and current sexual history. During her physical examination, take particular note as to where Mrs. Park verbalizes pain during palpation so that you may synthesize verbal and non-verbal cues. Be sure to apply the supportive information learned in this week’s concept lab to your critical thinking process in this case study. Reason for Visit: Patient presents complaining of abdominal pain. Results Included: | Overview | Transcript | Subjective Data Collection | Objective Data Collection | Education & Empathy | Documentation | Self-Reflection

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12/4/2020 Focused Exam: Abdominal Pain | Completed | Shadow Health

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Focused Exam: Abdominal Pain Results | Turned In
Physical Diagnosis - Fall 2020, CLSC 6103
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Overview
Transcript
Transcript
Started: Oct 29, 2020 | Total Time: 92 min
Subjective Data Collection
All Lines (212) Interview Questions (94) Statements (28) Exam Actions (90)
Objective Data Collection

Education & Empathy Gre
Hello. My name is Kevin and I will be doing your exam today.
10/29/20 12:11 AM C
Documentation

Program Competency Progress Hello.


Quest
Will you please state your name? (Clarified to what is your name and birthday.)
10/29/20 12:12 AM C


Esther Park.


Quest
When is your birthday?
10/29/20 12:12 AM C


My birthday is January 7th.


Quest
Please state your age.
10/29/20 12:13 AM C


Esther Park.


Quest
How old are you?
10/29/20 12:13 AM C


Seventy-eight.


Quest
What brought you into today?
10/29/20 12:13 AM C


I have some pain in my belly. . . and I'm having difficulty going to the bathroom. My
daughter was worried about me.

Support


https://app.shadowhealth.com/assignment_attempts/8303446 1/17

,12/4/2020 Focused Exam: Abdominal Pain | Completed | Shadow Health

Empath
I am sorry to hear that Esther.
10/29/20 12:14 AM C


Thank you.


Exam Act
Measured vitals
10/29/20 12:14 AM C


Quest
When did your pain start?
10/29/20 12:15 AM C


The pain started as a general discomfort, about five days ago, when I started having the. . .
difficulties going to the bathroom.


Quest
Was your pain sudden?
10/29/20 12:15 AM C


No, it was gradual. I had some pain and discomfort about. . . five days ago. Then in the
past few days it got much worse.


Empath
I'm sorry to hear you're feeling bad.
10/29/20 12:16 AM C


Thank you.


Quest
How often are you having the pain?
10/29/20 12:16 AM C


Oh, it's with me all the time. The bloating, too. But certain things do make it worse.


Quest
What makes the pain worse?
10/29/20 12:17 AM C


Moving around certainly doesn't help. Neither does eating.


Quest
Where does it actually hurt? (Clarified to Which part of your abdomen hurts?.)
10/29/20 12:17 AM C


The pain and discomfort is down low in my belly. (Clarified to which part of my abdomen
hurts.)


Quest
Point of location of pain?
10/29/20 12:18 AM C


Well my whole belly is uncomfortable to some degree, but it's mostly in the lower part, that's
where the pain is. Down in my lower belly.


Empath
I am sorry to hear that.
10/29/20 12:18 AM C


Thank you.


Quest
How long does your pain last?
10/29/20 12:19 AM C


The pain is there all the time, but it gets much worse at certain points--when I move around
a lot or eat something, especially.




https://app.shadowhealth.com/assignment_attempts/8303446 2/17

, 12/4/2020 Focused Exam: Abdominal Pain | Completed | Shadow Health

Quest
What causes your pain?
10/29/20 12:19 AM C


I'm just not sure. I've been having trouble going to the bathroom, but I don't know what is
making all this happen.


Quest
Is your pain sharp?
10/29/20 12:19 AM C


No. I'd say it's crampy and. . . a dull, crampy feeling.


Quest
Rate your pain on a scale of 0 to 10.
10/29/20 12:20 AM C


Right now. . . 6 out of 10.


Empath
I'm sorry to hear that you're feeling so bad.
10/29/20 12:20 AM C


Thank you.


Quest
Does it affect your daily life? (Clarified to Has the pain affected your usual activities?.)
10/29/20 12:20 AM C


Well, I don't feel unnaturally tired or weak. But I have experienced low energy, like I need to
rest more often. (Clarified to if my pain has affected my activities.)


Quest
What makes it feel better?
10/29/20 12:21 AM C


When I rest and try not to move much, I feel better. But the pain is still there.


Quest
What have you done to relieve your pain?
10/29/20 12:21 AM C


I've tried taking small sips of warm water, resting. The warm water does nothing. A friend
suggested it, but it's nonsense.


Empath
I'm sorry you feel that way.
10/29/20 12:22 AM C


Thank you.


Quest
Is the pain constant?
10/29/20 12:22 AM C


Yes. Certain things can make it a tiny bit better or a tiny bit worse, I suppose. But it's always
there.


Quest
What makes it better?
10/29/20 12:22 AM C


When I rest and try not to move much, I feel better. But the pain is still there.


Quest
How is your energy level?
10/29/20 12:23 AM C




https://app.shadowhealth.com/assignment_attempts/8303446 3/17

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