Exam (elaborations) NR 509 FOCUSED EXAM Abdominal Pain Results Shadow Health

Exam (elaborations) NR 509 FOCUSED EXAM Abdominal Pain Results Shadow Health view Transcript Subjective Data Collection Objective Data Collection Documentation SBAR Indicates an item that you found. Indicates an item that is available to be found. Category Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Patient Data Not Scored A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. History of Presenting Illness Established chief complaint Reports abdominal pain Reports difficulty "going to the bathroom" Asked about onset of the pain Reports a feeling of discomfort for the past five days Reports pain with gradual onset that worsened 2-3 days ago Asked about location of the pain Reports pain in lower abdomen Reports pain is not localized Reports no flank pain Subjective Data Collection: 29 of 30 (96.7%) © Shadow Health 2018 ® Focused Exam: Abdominal Pain | Completed | Shadow Health 1 of 5 4/22/2018, 11:47 PM This study resource was shared via CourseH This study source was downloaded by from CourseH on :24:18 GMT -05:00 This study resource was shared via CourseH Confirmed pain rating on a scale Reports pain rating of 6/10 Asked about character of the pain Describes pain as dull and crampy Reports pain is intermittent with aggravating factors Asked about treatment and relieving factors Reports that resting helps Reports attempts to treat pain by drinking small sips of warm water Reports no pain medication for stomach Asked about aggravating factors Reports pain is aggravated by eating Reports pain is aggravated by physical activity Asked about activities of daily life Reports recent difficulty participating in usual activities Reports low energy Asked about constipation Reports current constipation Reports no history of constipation Asked follow-up about constipation Reports constipation for 5 days Reports no attempt to treat constipation Asked about diarrhea Reports recent diarrhea Asked follow-up about diarrhea Reports diarrhea 3 days ago Reports diarrhea had a sudden onset Reports diarrhea lasted one day Describes diarrhea as loose and watery Asked about bowel movement patterns Reports last bowel movement 3 days ago Reports some discomfort during bowel movement Last bowel movement was diarrhea Denies mucus in stool Denies blood in stool Reports typically having a bowel movement almost every day Reports stools usually brown, formed, and soft Asked about urination Reports recent, slight decrease in frequency of urination Reports darker urine recently Denies blood in urine Asked about fluid intake Reports no increase in thirst Focused Exam: Abdominal Pain | Completed | Shadow Health 2 of 5 4/22/2018, 11:47 PM This study resource was shared via CourseH This study source was downloaded by from CourseH on :24:18 GMT -05:00 This study resource was shared via CourseH Reports decreased fluid intake for the last few days Typical fluid intake is six glasses of water a day Reports sometimes drinking chamomile tea Denies drinking caffeinated drinks such as coffee or soda Asked about health maintenance Reports annual check-ups Reports most recent Pap smear 10 years ago Reports belief that her level of health and activity is very good for her age Reports no STI testing Reports colonoscopy 10 years ago Asked about fiber intake Reports no fiber supplements Reports belief that she gets enough fiber Reports getting fiber from a daily vegetable Reports getting fiber from a daily piece of fruit Asked about activity level Reports high level of mobility and independence Reports moderate activity level Regularly attends fitness class Reports gardening as a hobby Asked about diet Reports last meal was toast at breakfast Typically eats 3 meals Typically does not eat snacks Typical breakfast is a piece of fruit Typical lunch is soup, but sometimes skips lunch Typical dinner is chicken or fish with vegetables and rice Asked about history of surgery Reports c-section C-section at age 40 Reports cholecystectomy Cholecystectomy at age 42 Reports no post-operative complications Asked about current sexual activity Reports currently sexually active Reports no vaginal intercourse Reports oral sex Asked about allergies Reports latex allergy Reports no medication allergies Reports no food allergies Asked about medications Reports blood pressure medication Reports Accupril Accupril is 10 mg Focused Exam: Abdominal Pain | Completed | Shadow Health 3 of 5 4/22/2018, 11:47 PM This study resource was shared via CourseH This study source was downloaded by from CourseH on :24:18 GMT -05:00 This study resource was shared via CourseH Taken daily at 8 a.m. Reports no OTC use Asked about substance use Denies illicit drug use Denies cigarette smoking Reports low alcohol consumption Asked follow-up about alcohol consumption Reports drinking 1 night a week Reports 1 drink per sitting Reports 4 drinks per month Reports typical drink is white wine Asked about psychosocial history Reports living with her daughter Reports strong familial support system Reports no recent travel Review of Systems Asked about gastrointestinal history Denies history of gastrointestinal disorders Denies history of GERD or ulcer Denies history of appendicitis Denies history of stomach cancer Denies history of liver disease Asked associated symptoms Reports no recent fever Reports no chills Reports no night sweats Reports short-term feeling of exhaustion Reports no sore throat Reports no coughing Reports no dysphagia Reports no difficulty breathing Reports no chest discomfort Reports no palpitations Asked review of systems for gastrointestinal Reports bloating Reports slight increase in flatus Reports loss of appetite Reports no nausea Reports no vomiting Reports no recent weight changes Reports no exposure to food poisoning Asked review of systems for genitourinary Reports no painful urination Reports no burning with urination Reports no urinary incontinence Reports no history of UTIs Focused Exam: Abdominal Pain | Completed | Shadow Health 4 of 5 4/22/2018, 11:47 PM This study resource was shared via CourseH This study source was downloaded by from CourseH on :24:18 GMT -05:00 This study resource was shared via CourseH Reports no gynecological problems Reports no vaginal bleeding Reports no vaginal discharge Onset of menopause was age 54 Reports no history of kidney problems Reports no history of bladder problems Comments If your 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