Focused Exam Abdominal Pain transcript.

5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health


Focused Exam: Abdominal Pain Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-April-2018
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Overview
Transcript
Transcript
Started: May 28, 2018 | Patient Exam Time: 153 min
Subjective Data Collection
All Lines (250) Interview Questions (138) Statements (21) Exam Actions (91)
Objective Data Collection
Greet
Education & Empathy Hello my name is Sara an FNP student who will be interviewing you
05/28/18 1:18 PM
today
CDT
Documentation

Self-Reflection
Hello.


Question
Will you please state your name? (Clarified to what is your name and
05/28/18 1:18 PM
birthday.)
CDT


My name is Esther Park, and I was born on January 7th . . . [Ms. Park
reports correct birth year.] [AUDIO COMING SOON]


Question
Please State your age? (No matching questions found.) 05/28/18 1:19 PM
CDT


Question
How old are you? 05/28/18 1:20 PM
CDT



Seventy-eight.


Question
What brought you into the clinic today? 05/28/18 1:21 PM
CDT


I have some pain in my belly. . . and I'm having difficulty going to the
bathroom. My daughter was worried about me.


Exam Action
Measured vitals 05/28/18 1:27 PM
CDT




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,5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health

Question
When did your pain start? 05/28/18 1:29 PM
CDT


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


Question
Was your pain sudden? 05/28/18 1:31 PM
CDT


No, it was gradual. I had some pain and discomfort about. . . five
days ago. Then in the past few days it got much worse.


Empathize
I'm sorry to hear you're feeling bad 05/28/18 1:31 PM
CDT



Thank you.


Question
How often are you having the pain? 05/28/18 1:31 PM
CDT


Oh, it's with me all the time. The bloating, too. But certain things do
make it worse.


Question
Where does it actually hurt? (Clarified to Which part of your abdomen
05/28/18 1:32 PM
hurts?.)
CDT



The pain and discomfort is down low in my belly.


Question
Point of location of pain 05/28/18 1:33 PM
CDT


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.


Question
What makes your pain worse? 05/28/18 1:33 PM
CDT



Moving around certainly doesn't help. Neither does eating.


How long is your pain last? Question
05/28/18 1:34 PM
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, 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health


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.


Question
What causes your pain? 05/28/18 1:41 PM
CDT


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.


Question
What makes your pain worse? 05/28/18 1:41 PM
CDT



Moving around certainly doesn't help. Neither does eating.


Question
Is your pain sharp? 05/28/18 1:42 PM
CDT



No. I'd say it's crampy and. . . a dull, crampy feeling.


Question
Rate your pain on a scale of 0 to 10? 05/28/18 1:42 PM
CDT



Right now. . . 6 out of 10.


Empathize
I'm sorry to hear that you're feeling so bad 05/28/18 1:43 PM
CDT



Thank you.


Question
Does it affect your daily life? (Clarified to How has your illness
05/28/18 1:43 PM
affected your daily life?.)
CDT


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.


Question
What provides relief? (No matching questions found.) 05/28/18 1:47 PM
CDT




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