Focused Exam: Abdominal Pain | Completed | Shadow Health 1

Focused Exam: Abdominal Pain | Completed | Shadow Health 3/25/20, 8:32 PM



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Focused Exam: Abdominal Pain Results | Turned In
Advanced Health Assessment - January 2020, nur634
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Overview
Transcript
Transcript
Started: Feb 18, 2020 | Total Time: 128 min
Subjective Data Collection
All Lines (151) Interview Questions (60) Statements (9) Exam Actions (82)
Objective Data Collection

Education & Empathy Greet
Good morning Esther. My name is Rachell. I am your provider today.
02/18/20 1:28 PM MST
Documentation

Hello.


Question
Can you tell me what brought you today to the clinic? (Clarified to What brings you in today?.)
02/18/20 2:22 PM MST


I have pain in my belly. . . and I'm having some difficulty with going to the bathroom. My
daughter was concerned. (Clarified to why I came in.)


Empathize
I am so sorry about. I am here to help you.
02/18/20 2:22 PM MST


Thank you.


Question
How long have you had stomach pain?
02/18/20 2:28 PM MST


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


Empathize
I am so sorry. We are going to find out what's causing your abdominal pain.
02/18/20 2:29 PM MST



Thank you.



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, Focused Exam: Abdominal Pain | Completed | Shadow Health 3/25/20, 8:32 PM




Question
What part of your abdomen do you feel the pain?
02/18/20 2:29 PM MST


Nowhere except down there, in my belly.


Question
Has the stomach pain changed?
02/18/20 2:35 PM MST


Well, the type of pain never changes. And it's always in the same place. But it did get worse two
or three days ago.


Question
Have you any diarrhea?
02/18/20 2:35 PM MST


Yes, I did have a bout of diarrhea pretty recently. [AUDIO COMING SOON]


Question
Can you describe the type of pain you're feeling?
02/18/20 2:37 PM MST


I'd say it's crampy and. . . a dull, crampy feeling.


Question
Can you rate the pain from 1 through 10.
02/18/20 2:37 PM MST


Right now. . . 6 out of 10.


Question
Are there any aggravating factors? (Clarified to What aggravates the pain?.)
02/18/20 2:38 PM MST


Moving around certainly doesn't help. Neither does eating. (Clarified to what makes my pain
worse.)


Question
Do you do anything to relieve the pain?
02/18/20 2:38 PM MST


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


Question
Have you tried taking any medications?
02/18/20 2:39 PM MST


I'm not taking anything for it.


Question
Have you had any nausea and vomiting?
02/18/20 2:43 PM MST


No. I haven't vomited or had any nausea. It's more of a problem with pain. . . and difficulty going
to the bathroom.


Have you seen any blood or mucus in your stool? (Clarified to Has there been blood in your Question
stool?.) 02/18/20 2:43 PM MST



No. I've never experienced that. (Clarified to if there has been blood in my stool.)



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