Exam (elaborations) NR 509 FOCUSED EXAM SHADOW HEALTH Pain Results Transcript

Exam (elaborations) NR 509 FOCUSED EXAM SHADOW HEALTH Pain Results Transcript LLiinneess (()) 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health Question 05/28/18 1:29 PM CDT Question 05/28/18 1:31 PM CDT Empathize 05/28/18 1:31 PM CDT Question 05/28/18 1:31 PM CDT Question 05/28/18 1:32 PM CDT Question 05/28/18 1:33 PM CDT Question 05/28/18 1:33 PM CDT Question 05/28/18 1:34 PM CDT When did your pain start? The pain started as a general discomfort, about five days ago, when I started having the. . . difficulties going to the bathroom. Was your pain sudden? No, it was gradual. I had some pain and discomfort about. . . five days ago. Then in the past few days it got much worse. I'm sorry to hear you're feeling bad Thank you. How often are you having the pain? 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?.) The pain and discomfort is down low in my belly. Point of location of pain 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. What makes your pain worse? Moving around certainly doesn't help. Neither does eating. How long is your pain last? 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health Question 05/28/18 1:41 PM CDT Question 05/28/18 1:41 PM CDT Question 05/28/18 1:42 PM CDT Question 05/28/18 1:42 PM CDT Empathize 05/28/18 1:43 PM CDT Question 05/28/18 1:43 PM CDT Question 05/28/18 1:47 PM CDT 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. What causes your pain? 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. What makes your pain worse? Moving around certainly doesn't help. Neither does eating. Is your pain sharp? No. I'd say it's crampy and. . . a dull, crampy feeling. Rate your pain on a scale of 0 to 10? Right now. . . 6 out of 10. I'm sorry to hear that you're feeling so bad Thank you. Does it affect your daily life? (Clarified to How has your illness affected your daily life?.) Well, I have been slowed down lately. This week I missed both of my fitness classes. I never miss a class. . . and I like to help with the cleaning at home, but my daughter--she worries too much--she wants me to rest. What provides relief? (No matching questions found.) 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health Question 05/28/18 1:48 PM CDT Question 05/28/18 1:48 PM CDT Empathize 05/28/18 1:49 PM CDT Question 05/28/18 1:49 PM CDT Question 05/28/18 1:50 PM CDT Question 05/28/18 1:50 PM CDT Question 05/28/18 1:50 PM CDT Question 05/28/18 1:51 PM CDT What makes it feel better? When I rest and try not to move much, I feel better. But the pain is still there. What have you done to relieve your pain? I've tried taking small sips of warm water, resting. The warm water does nothing. A friend suggested it, but it's nonsense. I'm sorry you feel that way Thank you. Is your pain intermittent? (No matching questions found.) Is your pain constant? Yes. Certain things can make it a tiny bit better or a tiny bit worse, I suppose. But it's always there. What makes it better? (Clarified to What makes your pain feel better?.) When I rest and try not to move much, I feel better. But the pain is still there. What makes your pain worse? Moving around certainly doesn't help. Neither does eating. How is your energy level? Right now? I feel slow, sluggish. I just feel very uncomfortable. 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health Empathize 05/28/18 1:51 PM CDT Question 05/28/18 1:53 PM CDT Question 05/28/18 1:53 PM CDT Question 05/28/18 1:53 PM CDT Question 05/28/18 1:54 PM CDT Question 05/28/18 1:55 PM CDT Question 05/28/18 1:55 PM CDT Sorry you feel uncomfortable Thank you. Are you having constipation? (Clarified to Are you feeling constipated?.) Well, yes. . . other than my. . . digestive upset. . . I haven't moved my bowels for several days. When was the last time you had a bowel movement? That was a few days ago. When I had a digestive upset. Diarrhea. Do you have a history of constipation? I don't usually have problems going to the bathroom. . . but this has been going on for. . . about five days now. Other than the digestive upset I had a few days ago. Any treatment for constipation? (Clarified to How have you treated the constipation?.) Well, I haven't experienced constipation before, so I haven't done anything for it. Any recent diarrhea? Yes, I did have a bout of diarrhea pretty recently. Describe your diarrhea? It was very loose. Watery. 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health Question 05/28/18 1:56 PM CDT Question 05/28/18 1:57 PM CDT Educate 05/28/18 1:57 PM CDT Question 05/28/18 1:58 PM CDT Question 05/28/18 1:58 PM CDT Question 05/28/18 1:58 PM CDT Question 05/28/18 1:59 PM CDT Question 05/28/18 1:59 PM CDT Last normal bowel movement? (Clarified to How are you bowel movements?.) My bowel movements are usually. . . what I assume one would call normal. Not too soft, a normal brown color. Fairly regular. How often are your bowel movements Before this? Every day. Well, I miss a day now and then, but usually every day. It is important to have a bowel movement everyday Thank you for explaining that. Any discomfort with your last bowel movement? Yes, I have been very uncomfortable in my belly--my lower belly. It's been going on for almost a week. Any mucus in your stool? No, I haven't noticed anything like that. Any blood in your stool? No. I've never experienced that. Any problems with urination? No, no trouble. No urinary frequency? (Clarified to Have your changed the frequency of your urination recently?.) 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health Empathize 05/28/18 1:59 PM CDT Educate 05/28/18 2:00 PM CDT Question 05/28/18 2:00 PM CDT Question 05/28/18 2:00 PM CDT Exam Action 05/28/18 2:12 PM CDT Exam Action 05/28/18 2:38 PM CDT Exam Action 05/28/18 2:38 PM CDT Exam Action 05/28/18 2:38 PM CDT Exam Action 05/28/18 2:38 PM CDT I've been going slightly less often because. . . well, I've been little less thirsty than usual. I'm sorry to hear that Thank you. It is important you keep up with your water intake at least eight 8 oz glasses a day Thank you for explaining that. Any color changes in your urine? Yes, it has been a little darker than usual lately. Any blood in your urine? No, it seems normal enough to me. Maybe a little darker than usual. Inspected general face: Slight flushing of cheeks Inspected forehead and scalp Inspected nose and mouth Inspected left side of face Inspected back of head Inspected right side of face 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health Exam Action 05/28/18 2:38 PM CDT Exam Action 05/28/18 2:39 PM CDT Exam Action 05/28/18 2:45 PM CDT Exam Action 05/28/18 2:45 PM CDT Exam Action 05/28/18 2:45 PM CDT Exam Action 05/28/18 2:47 PM CDT Exam Action 05/28/18 2:49 PM CDT Exam Action 05/28/18 2:50 PM CDT Exam Action 05/28/18 2:50 PM CDT Exam Action 05/28/18 2:51 PM CDT Exam Action 05/28/18 2:51 PM CDT Exam Action 05/28/18 2:53 PM CDT Exam Action 05/28/18 2:53 PM CDT Inspected general face: Slight flushing of cheeks Performed otoscopic examination of left naris Performed otoscopic examination of right naris Performed otoscopic examination of left naris Performed otoscopic examination of right naris Inspected mouth and throat Inspected left side of abdomen Inspected front of abdomen Inspected right side of abdomen Inspected front of abdomen Inspected front of legs for edema: No edema Inspected left leg for edema: No edema 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health Exam Action 05/28/18 2:53 PM CDT Exam Action 05/28/18 2:53 PM CDT Exam Action 05/28/18 2:54 PM CDT Exam Action 05/28/18 2:56 PM CDT Exam Action 05/28/18 2:56 PM CDT Exam Action 05/28/18 2:56 PM CDT Exam Action 05/28/18 2:56 PM CDT Exam Action 05/28/18 2:56 PM CDT Exam Action 05/28/18 2:56 PM CDT Exam Action 05/28/18 2:57 PM CDT Exam Action 05/28/18 2:57 PM CDT Exam Action 05/28/18 2:58 PM CDT Exam Action 05/28/18 2:58 PM CDT Inspected front of legs for edema: No edema Inspected right leg for edema: No edema Inspected front of legs for edema: No edema Auscultated aortic area with the bell Auscultated aortic area with the diaphragm Auscultated pulmonic area with the diaphragm Auscultated Erb's point with the diaphragm Auscultated tricuspid area with the diaphragm Auscultated tricuspid area with the bell Auscultated mitral area with the bell Auscultated breath sounds in anterior left upper lobe Auscultated breath sounds in anterior right upper lobe Auscultated breath sounds in anterior right middle lobe 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health Exam Action 05/28/18 2:58 PM CDT Exam Action 05/28/18 2:58 PM CDT Exam Action 05/28/18 2:58 PM CDT Exam Action 05/28/18 2:58 PM CDT Exam Action 05/28/18 2:58 PM CDT Exam Action 05/28/18 2:58 PM CDT Exam Action 05/28/18 2:58 PM CDT Exam Action 05/28/18 2:58 PM CDT Exam Action 05/28/18 2:58 PM CDT Exam Action 05/28/18 2:58 PM CDT Exam Action 05/28/18 2:58 PM CDT Exam Action 05/28/18 2:58 PM CDT Exam Action 05/28/18 2:59 PM CDT Auscultated breath sounds in anterior left mid-chest (upper lobe) Auscultated breath sounds in anterior right lower lobe Auscultated breath sounds in anterior left lower lobe Auscultated breath sounds in posterior right upper lobe Auscultated breath sounds in posterior left upper lobe Auscultated breath sounds in posterior right mid-back (lower lobe) Auscultated breath sounds in posterior left mid-back (lower lobe) Auscultated breath sounds in posterior left lower lobe Auscultated breath sounds in posterior left lower lobe on side Auscultated breath sounds in posterior left lower lobe near spine Auscultated breath sounds in posterior right lower lobe near spine Auscultated breath sounds in posterior right lower lobe on side Auscultated breath sounds in posterior right lower lobe 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health Exam Action 05/28/18 2:59 PM CDT Exam Action 05/28/18 3:00 PM CDT Exam Action 05/28/18 3:00 PM CDT Exam Action 05/28/18 3:00 PM CDT Exam Action 05/28/18 3:00 PM CDT Exam Action 05/28/18 3:01 PM CDT Exam Action 05/28/18 3:01 PM CDT Exam Action 05/28/18 3:01 PM CDT Exam Action 05/28/18 3:01 PM CDT Exam Action