Focused Exam: Abdominal Pain Results | Turned In

5/ Focused Exam: Abdominal Pain |


Focused Exam: Abdominal Pain Results | Turned In
Advanced Health Assessment - Chamberlain,
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Your Results Lab Pass




Transcript
Overview

Transcript

Subjective Data Collection
All Lines Interview Questions Statements Exam Actions
(250) (138) (21) (91)
Objective Data Collection

Education & Empathy Greet
Hello my name is Sara an FNP student who will be interviewing you
05/28/18 1:18 PM
today
Documentation CDT


Self-Reflection
Hello.


Question
Will you please state your name? (Clarified to what is your name
05/28/18 1:18 PM
and birthday.)
CDT


My name is Esther Park, and I was born on January 7th . . . [Ms.
Park reports correct birth year.] [AUDIO COMING SOON]


Question
Please State your age? (No matching questions found.) 05/28/18 1:19 PM
CDT


Question
How old are you? 05/28/18 1:20 PM
CDT



Seventy-eight.


Question
What brought you into the clinic 05/28/18 1:21 PM
today? CDT


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


Exam Action
Measured vitals 05/28/18 1:27 PM
CDT




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,5/ Focused Exam: Abdominal Pain |

Question
When did your pain start?
05/28/18 1:29 PM
CDT

The pain started as a general discomfort, about five days ago, when I started having the. . . difficult




Question
Was your pain sudden?
05/28/18 1:31 PM
CDT

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




Empathize
I'm sorry to hear you're feeling bad
05/28/18 1:31 PM
CDT


Thank you.



Question
How often are you having the pain?
05/28/18 1:31 PM
CDT

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




Where does it actually hurt? (Clarified to Which part of your abdomen hurts?.) Question
05/28/18 1:32 PM
CDT


The pain and discomfort is down low in my belly.



Question
Point of location of pain
05/28/18 1:33 PM
CDT

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




Question
What makes your pain worse?
05/28/18 1:33 PM
CDT


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


How long is your pain last?
Question
05/28/18 1:34 PM
CDT




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, 5/ Focused Exam: Abdominal Pain |

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




Question
What causes your pain?
05/28/18 1:41 PM
CDT

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




Question
What makes your pain worse?
05/28/18 1:41 PM
CDT


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



Question
Is your pain sharp?
05/28/18 1:42 PM
CDT


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



Question
Rate your pain on a scale of 0 to 10?
05/28/18 1:42 PM
CDT


Right now. . . 6 out of 10.



Empathize
I'm sorry to hear that you're feeling so bad
05/28/18 1:43 PM
CDT


Thank you.



Does it affect your daily life? (Clarified to How has your illness affected your daily life?.)
Question
05/28/18 1:43 PM
CDT

Well, I have been slowed down lately. This week I missed both of my fitness classes. I never miss a cl




Question
What provides relief? (No matching questions found.)
05/28/18 1:47 PM
CDT




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