Esther Parks abdominal pain - subjective data collection.docx

Subjective Data Collection: 28 of 32 (87.5%) Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.  Found: Indicates an item that you found.  Available: 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. Chief Complaint  Finding: Established chief complaint  Finding: Reports abdominal pain (Found) Esther Parks abdominal pain - subjective data collection Pro Tip: Abdominal pain can be caused by problems in the underlying organs, peritoneum, muscles, or blood vessels, changes in electrolytes or other blood contents, or even anxiety. Asking for details about the pain helps to determine the origin. Example Question: Do you have any abdominal pain?  Finding: Reports difficulty "going to the bathroom" (Found) Pro Tip: Understanding all of a patient's reason for visiting is an important foundation to establish. If there are multiple symptoms, follow up on each one during your interview. Example Question: Are you able to make a bowel movement? History of Present Illness  Finding: Asked about onset, frequency, and duration of pain  Finding: Reports a feeling of discomfort for the past five days (Found) Pro Tip: Whenever you are assessing a symptom or a health condition, inquiring about onset assesses the severity and the progression of the problem. Example Question: How long have you had stomach pain?  Finding: Reports pain with gradual onset that worsened 2-3 days ago (Found) Pro Tip: Whenever you are assessing a symptom or a health condition, inquiring about onset assesses the severity and the progression of the problem. Example Question: Has the stomach pain changed?  Finding: Asked about location of pain  Finding: Reports pain in lower abdomen (Found) Pro Tip: Identification of the location of your patient's discomfort can provide important clues about its cause and how it should be best treated. Example Question: Where is your discomfort located?  Finding: Reports pain is not localized (Found) Pro Tip: Identifying the location of your patient's pain provides important clues about its cause and how to treat it best. Example Question: Is the pain in a specific spot?  Finding: Reports attempts to treat pain by drinking small sips of warm water (Available) Pro Tip: Flank pain often occurs with disorders of the urinary tract. When a patient complains of flank pain, assess for co-occurring symptoms such as fever, chills, hematuria, and dysuria. Example Question: Do you have pain on your sides?  Finding: Confirmed pain rating on a scale  Finding: Reports pain rating of 6/10 (Found) Pro Tip: For many people, it is difficult to clearly describe pain. Asking your patient to rate her pain on a scale from 0 to 10 develops a consistent measure of pain severity. Example Question: How would you rate your pain on a scale of one to ten?  Finding: Asked about character of pain  Finding: Describes pain as dull and crampy (Found) Pro Tip: Asking your patient to describe her pain helps identify its cause and the severity. Patients may not know how to answer, so you may need to suggest words like sharp, dull, burning, throbbing, or shooting. Example Question: Can you describe the pain?  Finding: Reports pain is intermittent with aggravating factors (Found) Pro Tip: It's important to ask your patient if her pain is constant or intermittent in order to determine her level of discomfort and identify the cause of the pain. Constant pain is often best managed with around-the-clock pain medications. Example Question: Is your pain constant?  Finding: Asked about treatment and relieving factors  Finding: Reports that resting helps (Found) Pro Tip: It's important to assess the nature of pain by asking about relief. If you know your patient is taking pain medication, asking about the medication's effectiveness can help you adjust treatment as needed. Example Question: What relieves your pain?  Finding: Reports attempts to treat pain by drinking small sips of warm water (Found) Pro Tip: Asking about how your patient has been managing her pain assesses her current condition and her approach to self-care. The results of her previous treatment may be helpful in your diagnosis and the development of her new treatment plan, as well as a good opportunity to educate your patient on effective self-care practices. Example Question: How have you been treating the pain?  Finding: Reports no pain medication for stomach (Found) Pro Tip: Asking about how your patient has been managing her pain assesses her current condition and her approach to self-care. The results of her previous treatment may be helpful in your diagnosis and the development of her new treatment plan, as well as a good opportunity to educate your patient on effective self-care practices. Example Question: Have you taken medication for the stomach pain?  Finding: Asked about aggravating factors  Finding: Reports pain is aggravated by eating (Found) Pro Tip: Asking you patient what aggravates her pain can point to factors that exacerbate symptoms and the ways in which your patient is approaching self-care. Example Question: Is the pain aggravated by eating?  Finding: Reports pain is aggravated by physical activity (Found) Pro Tip: Asking you patient what aggravates her pain can point to factors that exacerbate symptoms and the ways in which your patient is approaching self-care. Example Question: Is the pain aggravated by physical activity?  Finding: Asked about activities of daily life  Finding: Reports recent difficulty participating in usual activities (Available) Pro Tip: Asking about changes in activity level will help determine the level of disability caused by your patient's condition. Example Question: How has your illness affected your daily life?  Finding: Reports low energy level (Available) Pro Tip: Asking about changes in energy level will help determine the level of disability caused by your patient's condition. Example Question: Do you have low energy?  Finding: Asked about constipation  Finding: Reports current constipation (Found) Pro Tip: In geriatric patients, constipation is often caused by inadequate fluid intake, medication side effects, low-fiber diets, and difficulty ambulating to the toilet, which can result in deliberate retention of stool. Example Question: Are you constipated?  Finding: Reports no history of constipation (Found) Pro Tip: In geriatric patients, constipation is often caused by inadequate fluid intake, medication side effects, low-fiber diets, and difficulty ambulating to the toilet, which can result in retention of stool. Example Question: Are you typically constipated?  Finding: Followed up about constipation  Finding: Reports constipation for 5 days (Found) Pro Tip: Whenever you are assessing a symptom or a health condition, inquiring about onset assesses the severity and the progression of the problem. Example Question: For how long have you been constipated?  Finding: Reports no attempt to treat constipation (Found) Pro Tip: Asking about how your patient has been managing her pain assesses her current condition and her approach to self-care. The results of her previous treatment may be helpful in your diagnosis and the development of her new treatment plan, as well as a good opportunity to educate your patient on effective self-care practices. Example Question: How have you tried to treat the constipation?  Finding: Asked about diarrhea  Finding: Reports recent diarrhea (Found) Pro Tip: Whenever you are assessing a symptom or a health condition, inquiring about onset assesses the severity and the progression of the problem. Example Question: Have you recently had diarrhea?  Finding: Followed up about diarrhea  Finding: Reports diarrhea 3 days ago (Found) Pro Tip: It's important to ask about changes in stool characteristics because it may be a sign of a new onset of a gastrointestinal disease or disorder. Diarrhea is a common symptom of inflammatory bowel diseases, food allergies and intolerance, gastrointestinal infections, and many other conditions. Example Question: How long ago did you get diarrhea?  Finding: Reports diarrhea had a sudden onset (Available) Pro Tip: It's important to ask about changes in stool characteristics because it may be a sign of a new onset of a gastrointestinal disease or disorder. Diarrhea is a common symptom of inflammatory bowel diseases, food allergies and intolerance, gastrointestinal infections, and many other conditions