Focused Exam_ Abdominal Pain _ subjective.pdf

3/5/2020 ABDOMINAL PAIN Focused Exam: Abdominal Pain | Completed | Shadow Health


Focused Exam: Abdominal Pain Results | Turned In
Introduction to Health Assessment - Spring 2020, NURS 3293
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Your Results Lab Pass (/assignment_attempts/6225699/lab_pass.p




Overview
Subjective Data Collection: 38 of 41 (92.7%)
Transcript

Subjective Data Collection
Hover To Reveal... Indicates an item that you
Objective Data Collection found.
Hover over the Patient Data items Indicates an item that is
Education & Empathy below to reveal important available to be found.
information, including Pro Tips and
Documentation
Example Questions.
Care Plan

Self-Reflection
Category Scored Items Patient Data
Not Scored

Experts selected these topics as essential components A combination of open and closed questions will yield
of a strong, thorough interview with this patient. better patient data. The following details are facts of t
patient's case.



Chief Complaint


Established chief complaint Reports abdominal pain
Reports difficulty with bowel movements



Orientation


Asked about orientation Oriented to own person
Oriented to place
Oriented to situation
Oriented to time



History of Presenting Illness


Asked about onset of the pain Reports discomfort for the past five days
Reports pain worsened intensely 2-3 days ago



Asked about location of the pain Reports pain in lower abdomen
Reports pain is not localized
Denies flank pain



Asked about pain rating on a scale Reports current pain rating of 2/10
Reports pain at its lowest is 2/10
Reports pain at its worst is 8/10



Asked about characteristics of the pain Describes pain as dull
Describes pain as cramping
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, 3/5/2020 Focused Exam: Abdominal Pain | Completed | Shadow Health
Describes pain as constant
Describes pain as fluctuating in severity



Asked about non-pharmacological relieving Reports that resting helps relieve pain
factors Reports drinking warm water to relieve pain was
ineffective



Asked about pharmacological relieving factors Denies taking pain medication
Denies taking laxatives



Asked about aggravating factors Reports pain is aggravated by eating
Reports pain is aggravated by physical activity



Asked about impact of pain on daily life Reports recent difficulty participating in usual
activities
Reports low energy



Followed up on constipation Reports current constipation
Reports constipation all of last 5 days



Asked about diarrhea Reports recent diarrhea



Followed up on diarrhea Reports diarrhea about six months ago
Reports diarrhea had a sudden onset
Reports diarrhea lasted one day



Asked about substances in stool Denies mucus in stool
Denies blood in stool



Asked about urination Reports slight decrease in frequency of urination
Reports darker urine recently
Denies blood in urine



Asked about fluid intake Reports decreased thirst
Reports decreased fluid intake for the last few
days
Typical fluid intake is 1-2 glasses of water a day
Denies drinking caffeinated drinks such as coffee
or soda



Past Medical History


Asked about history of constipation Denies history of constipation



Asked about typical bowel movements Reports typically having a bowel movement almost
every day
Reports typical stools are brown
Reports typical stools are formed
Reports typical stools are soft



Asked about allergies Reports latex allergy
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