Focused Exam- Abdominal Pain transcript.pdf - Focused Exam Abdominal Pain | Completed | Shadow Health Focused Exam Abdominal Pain Results | Turned In

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Unformatted text preview: 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health Focused Exam: Abdominal Pain Results | Turned In Advanced Health Assessment - Chamberlain, NR509-April-2018 Return to Assignment Your Results Overview Lab Pass Transcript Transcript Subjective Data Collection Started: May 28, 2018 | Patient Exam Time: 153 min All Lines (250) Interview Questions (138) Statements (21) Exam Actions (91) Objective Data Collection Education & Empathy Hello my name is Sara an FNP student who will be interviewing you today Documentation Self-Reflection Greet 05/28/18 1:18 PM CDT Hello. Will you please state your name? (Clarified to what is your name and birthday.) Question 05/28/18 1:18 PM CDT My name is Esther Park, and I was born on January 7th . . . [Ms. Park reports correct birth year.] [AUDIO COMING SOON] Please State your age? (No matching questions found.) Question 05/28/18 1:19 PM CDT How old are you? Question 05/28/18 1:20 PM CDT Seventy-eight. What brought you into the clinic today? Question 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. Measured vitals Exam Action 05/28/18 1:27 PM CDT 1/29 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health When did your pain start? Question 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. Was your pain sudden? Question 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. I'm sorry to hear you're feeling bad Empathize 05/28/18 1:31 PM CDT Thank you. How often are you having the pain? Question 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. Where does it actually hurt? (Clarified to Which part of your abdomen hurts?.) Question 05/28/18 1:32 PM CDT The pain and discomfort is down low in my belly. Point of location of pain Question 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. What makes your pain worse? Question 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 CDT 2/29 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. What causes your pain? Question 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. What makes your pain worse? Question 05/28/18 1:41 PM CDT Moving around certainly doesn't help. Neither does eating. Is your pain sharp? Question 05/28/18 1:42 PM CDT No. I'd say it's crampy and. . . a dull, crampy feeling. Rate your pain on a scale of 0 to 10? Question 05/28/18 1:42 PM CDT Right now. . . 6 out of 10. I'm sorry to hear that you're feeling so bad Empathize 05/28/18 1:43 PM CDT Thank you. Does it affect your daily life? (Clarified to How has your illness affected your daily life?.) Question 05/28/18 1:43 PM 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. What provides relief? (No matching questions found.) Question 05/28/18 1:47 PM CDT 3/29 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health What makes it feel better? Question 05/28/18 1:48 PM CDT 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? Question 05/28/18 1:48 PM CDT 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 Empathize 05/28/18 1:49 PM CDT Thank you. Is your pain intermittent? (No matching questions found.) Question 05/28/18 1:49 PM CDT Is your pain constant? Question 05/28/18 1:50 PM CDT 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?.) Question 05/28/18 1:50 PM CDT When I rest and try not to move much, I feel better. But the pain is still there. What makes your pain worse? Question 05/28/18 1:50 PM CDT Moving around certainly doesn't help. Neither does eating. How is your energy level? Question 05/28/18 1:51 PM CDT Right now? I feel slow, sluggish. I just feel very uncomfortable. 4/29 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health Sorry you feel uncomfortable Empathize 05/28/18 1:51 PM CDT Thank you. Are you having constipation? (Clarified to Are you feeling constipated?.) Question 05/28/18 1:53 PM CDT 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? Question 05/28/18 1:53 PM CDT That was a few days ago. When I had a digestive upset. Diarrhea. Do you have a history of constipation? Question 05/28/18 1:53 PM CDT 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?.) Question 05/28/18 1:54 PM CDT Well, I haven't experienced constipation before, so I haven't done anything for it. Any recent diarrhea? Question 05/28/18 1:55 PM CDT Yes, I did have a bout of diarrhea pretty recently. Describe your diarrhea? Question 05/28/18 1:55 PM CDT It was very loose. Watery. 5/29 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health Last normal bowel movement? (Clarified to How are you bowel movements?.) Question 05/28/18 1:56 PM CDT 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 Question 05/28/18 1:57 PM CDT 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 Educate 05/28/18 1:57 PM CDT Thank you for explaining that. Any discomfort with your last bowel movement? Question 05/28/18 1:58 PM CDT 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? Question 05/28/18 1:58 PM CDT No, I haven't noticed anything like that. Any blood in your stool? Question 05/28/18 1:58 PM CDT No. I've never experienced that. Any problems with urination? Question 05/28/18 1:59 PM CDT No, no trouble. No urinary frequency? (Clarified to Have your changed the frequency of your urination recently?.) Question 05/28/18 1:59 PM CDT 6/29 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health I've been going slightly less often because. . . well, I've been little less thirsty than usual. I'm sorry to hear that Empathize 05/28/18 1:59 PM CDT Thank you. It is important you keep up with your water intake at least eight 8 oz glasses a day Educate 05/28/18 2:00 PM CDT Thank you for explaining that. Any color changes in your urine? Question 05/28/18 2:00 PM CDT Yes, it has been a little darker than usual lately. Any blood in your urine? Question 05/28/18 2:00 PM CDT No, it seems normal enough to me. Maybe a little darker than usual. Inspected general face: Slight flushing of cheeks Exam Action 05/28/18 2:12 PM CDT Inspected forehead and scalp Exam Action 05/28/18 2:38 PM CDT Inspected nose and mouth Exam Action 05/28/18 2:38 PM CDT Inspected left side of face Exam Action 05/28/18 2:38 PM CDT Inspected back of head Exam Action 05/28/18 2:38 PM CDT Inspected right side of face 7/29 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health Exam Action 05/28/18 2:38 PM CDT Inspected general face: Slight flushing of cheeks Exam Action 05/28/18 2:39 PM CDT Performed otoscopic examination of left naris Exam Action 05/28/18 2:45 PM CDT Performed otoscopic examination of right naris Exam Action 05/28/18 2:45 PM CDT Performed otoscopic examination of left naris Exam Action 05/28/18 2:45 PM CDT Performed otoscopic examination of right naris Exam Action 05/28/18 2:47 PM CDT Inspected mouth and throat Exam Action 05/28/18 2:49 PM CDT Inspected left side of abdomen Exam Action 05/28/18 2:50 PM CDT Inspected front of abdomen Exam Action 05/28/18 2:50 PM CDT Inspected right side of abdomen Exam Action 05/28/18 2:51 PM CDT Inspected front of abdomen Exam Action 05/28/18 2:51 PM CDT Inspected front of legs for edema: No edema Exam Action 05/28/18 2:53 PM CDT Inspected left leg for edema: No edema Exam Action 05/28/18 2:53 PM CDT 8/29 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health Inspected front of legs for edema: No edema Exam Action 05/28/18 2:53 PM CDT Inspected right leg for edema: No edema Exam Action 05/28/18 2:53 PM CDT Inspected front of legs for edema: No edema Exam Action 05/28/18 2:54 PM CDT Auscultated aortic area with the bell Exam Action 05/28/18 2:56 PM CDT Auscultated aortic area with the diaphragm Exam Action 05/28/18 2:56 PM CDT Auscultated pulmonic area with the diaphragm Exam Action 05/28/18 2:56 PM CDT Auscultated Erb's point with the diaphragm Exam Action 05/28/18 2:56 PM CDT Auscultated tricuspid area with the diaphragm Exam Action 05/28/18 2:56 PM CDT Auscultated tricuspid area with the bell Exam Action 05/28/18 2:56 PM CDT Auscultated mitral area with the bell Exam Action 05/28/18 2:57 PM CDT Auscultated breath sounds in anterior left upper lobe Exam Action 05/28/18 2:57 PM CDT Auscultated breath sounds in anterior right upper lobe Exam Action 05/28/18 2:58 PM CDT Auscultated breath sounds in anterior right middle lobe Exam Action 05/28/18 2:58 PM CDT 9/29 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health Auscultated breath sounds in anterior left mid-chest (upper lobe) Exam Action 05/28/18 2:58 PM CDT Auscultated breath sounds in anterior right lower lobe Exam Action 05/28/18 2:58 PM CDT Auscultated breath sounds in anterior left lower lobe Exam Action 05/28/18 2:58 PM CDT Auscultated breath sounds in posterior right upper lobe Exam Action 05/28/18 2:58 PM CDT Auscultated breath sounds in posterior left upper lobe Exam Action 05/28/18 2:58 PM CDT Auscultated breath sounds in posterior right mid-back (lower lobe) Exam Action 05/28/18 2:58 PM CDT Auscultated breath sounds in posterior left mid-back (lower lobe) Exam Action 05/28/18 2:58 PM CDT Auscultated breath sounds in posterior left lower lobe Exam Action 05/28/18 2:58 PM CDT Auscultated breath sounds in posterior left lower lobe on side Exam Action 05/28/18 2:58 PM CDT Auscultated breath sounds in posterior left lower lobe near spine Exam Action 05/28/18 2:58 PM CDT Auscultated breath sounds in posterior right lower lobe near spine Exam Action 05/28/18 2:58 PM CDT Auscultated breath sounds in posterior right lower lobe on side Exam Action 05/28/18 2:58 PM CDT Auscultated breath sounds in posterior right lower lobe Exam Action 05/28/18 2:59 PM CDT 10/29 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health Auscultated aorta in abdomen Exam Action 05/28/18 2:59 PM CDT Auscultated left upper quadrant Exam Action 05/28/18 3:00 PM CDT Auscultated right upper quadrant Exam Action 05/28/18 3:00 PM CDT Auscultated right lower quadrant Exam Action 05/28/18 3:00 PM CDT Auscultated left lower quadrant Exam Action 05/28/18 3:00 PM CDT Auscultated left renal artery Exam Action 05/28/18 3:01 PM CDT Auscultated right renal artery Exam Action 05/28/18 3:01 PM CDT Auscultated left iliac artery Exam Action 05/28/18 3:01 PM CDT Auscultated right iliac artery Exam Action 05/28/18 3:01 PM CDT Auscultated left femoral artery Exam Action 05/28/18 3:01 PM CDT Auscultated right femoral artery Exam Action 05/28/18 3:01 PM CDT Auscultated over spleen Exam Action 05/28/18 3:02 PM CDT Auscultated over liver Exam Action 05/28/18 3:02 PM CDT 11/29 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health Percussed left upper quadrant Exam Action 05/28/18 3:05 PM CDT Percussed right upper quadrant Exam Action 05/28/18 3:05 PM CDT Percussed right lower quadrant Exam Action 05/28/18 3:05 PM CDT Percussed left lower quadrant Exam Action 05/28/18 3:05 PM CDT Percussed left upper quadrant Exam Action 05/28/18 3:05 PM CDT Percussed right upper quadrant Exam Action 05/28/18 3:05 PM CDT Percussed right lower quadrant Exam Action 05/28/18 3:05 PM CDT Percussed left lower quadrant Exam Action 05/28/18 3:05 PM CDT Percussed for spleen Exam Action 05/28/18 3:06 PM CDT Percussed for spleen Exam Action 05/28/18 3:06 PM CDT Percussed for spleen Exam Action 05/28/18 3:06 PM CDT Percussed for spleen Exam Action 05/28/18 3:06 PM CDT Percussed for liver span: 7 cm in the mid-clavicular line Exam Action 05/28/18 3:07 PM CDT 12/29 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health Percussed right flank for CVA tenderness Percussed left flank for CVA tenderness Palpated right lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension Exam Action 05/28/18 3:08 PM CDT Exam Action 05/28/18 3:08 PM CDT Exam Action 05/28/18 3:10 PM CDT That feels alright. Palpated left lower quadrant with light pressure: Tenderness reported; palpable guarding and distension, no masses Exam Action 05/28/18 3:10 PM CDT Mmm, it feels sore there. Palpated left upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension Exam Action 05/28/18 3:11 PM CDT That feels alright. Palpated right upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension Exam Action 05/28/18 3:11 PM CDT That feels alright. Palpated right upper quadrant with deep pressure: No masses Exam Action 05/28/18 3:14 PM CDT That feels alright. Palpated left upper quadrant with deep pressure: No masses Exam Action 05/28/18 3:14 PM CDT That feels alright. Palpated right lower quadrant: with deep pressure: No masses 13/29 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health Exam Action 05/28/18 3:14 PM CDT That feels alright. Palpated left lower quadrant with deep pressure: Firm, oblong mass (2x4 cm) Exam Action 05/28/18 3:15 PM CDT Ooo, that--that's sore right there. Aortic width is 2 cm: No lateral pulsation Exam Action 05/28/18 3:17 PM CDT Palpated for liver: Palpable 1 cm below right costal margin Exam Action 05/28/18 3:17 PM CDT Palpated for spleen: Not palpable Exam Action 05/28/18 3:18 PM CDT Palpated bladder: Not palpable; no distention or tenderness Exam Action 05/28/18 3:18 PM CDT Palpated for left kidney: Not palpable Exam Action 05/28/18 3:19 PM CDT Palpated for right kidney: Not palpable Exam Action 05/28/18 3:19 PM CDT Tested skin turgor Exam Action 05/28/18 3:19 PM CDT Performed pelvic exam Exam Action 05/28/18 3:20 PM CDT Performed digital rectal exam Exam Action 05/28/18 3:21 PM CDT Checked urinalysis Exam Action 05/28/18 3:23 PM CDT 14/29 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health What medications do you take? Question 05/28/18 3:25 PM CDT Just the medication for my blood pressure. What is the name of the medication? Question 05/28/18 3:25 PM CDT It's called Accupril. How much accupril do you take? Question 05/28/18 3:26 PM CDT 10 milligrams. How many times a day do you take accupril? (No matching questions found.) Question 05/28/18 3:26 PM CDT How many times a day do you take your medication? (No matching questions found.) Question 05/28/18 3:26 PM CDT How often do you take your medication? Question 05/28/18 3:26 PM CDT Yes, that's very important. I never skip a dose. How often do you take your medication? Question 05/28/18 3:27 PM CDT Yes, that's very important. I never skip a dose. How many times a day? (No matching questions found.) Question 05/28/18 3:27 PM CDT When do you take your medication? (Clarified to When do you take your blood pressure medication?.) Question 05/28/18 3:27 PM CDT I take it every morning at about 8 a.m., after breakfast. 15/29 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health When was the last time you took your medication? Question 05/28/18 3:27 PM CDT I took my Accupril this morning, at around 8. It is important to take your medication everyday as prescribed Educate 05/28/18 3:28 PM CDT Thank you for explaining that. I'm glad you take your medication as prescribed Empathize 05/28/18 3:28 PM CDT Thank you. Do you take any over-the-counter medications? Question 05/28/18 3:28 PM CDT No. Those over-the-counter medicines. . . Tylenol--they say it's very bad for the stomach. I understand Empathize 05/28/18 3:29 PM CDT Thank you. Do you have any allergies to medication? Question 05/28/18 3:29 PM CDT No, not that I'm aware of. Any allergies to anything? (Clarified to are you allergic to anything else.) Question 05/28/18 3:29 PM CDT Just latex, that's it. 16/29 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health What happens when you come in contact with latex? (Clarified to What are the symptoms of your latex allergy?.) Question 05/28/18 3:30 PM CDT I get an itchy skin rash. Do you have high blood pressure? Question 05/28/18 3:30 PM CDT Yes, I have been diagnosed with high blood pressure. But I take very good care of that. That is good to know Empathize 05/28/18 3:30 PM CDT Thank you. When were you diagnosed with high blood pressure? Question 05/28/18 3:30 PM CDT I believe I was diagnosed when... I must have been 54. Do you have any history of gastrointestinal disorders? Question 05/28/18 3:31 PM CDT No, I have a good stomach. I've never had this kind of trouble before. And I'm usually fairly regular. Do you have a history of reflux? (No matching questions found.) Question 05/28/18 3:32 PM CDT History of reflux? (No matching questions found.) Question 05/28/18 3:32 PM CDT History of GERD? Question 05/28/18 3:32 PM CDT No. I don't get indigestion, heartburn, nothing like that. history of ulcers? 17/29 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health Question 05/28/18 3:32 PM CDT No, I've never had one. History of appendicitis? Question 05/28/18 3:33 PM CDT No. History of stomach cancer? (Clarified to Have you had stomach cancer.) Question 05/28/18 3:33 PM CDT No. History of liver disease? (Clarified to do you have liver disease.) Question 05/28/18 3:33 PM CDT I've never had any problems with my liver. Any history of surgeries? Question 05/28/18 3:34 PM CDT I've had two operations, both many years ago. What operations did you have? Question 05/28/18 3:34 PM CDT I've had two. I had my gallbladder out, and I had a C-section. Both in my early 40s. Any complications with your surgery? (Clarified to Have you had problems after surgery?.) Question 05/28/18 3:35 PM CDT No, no complications. Any family history of gastrointestinal disorders? Question 05/28/18 3:36 PM CDT 18/29 5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health Well, I do remember my father having heartburn on occasion. But I can't think of anyone having anything, other than that. Any family history of GERD? (Clarified to do your family members have health problems.) Question 05/28/18 3:36 PM CDT Let's see. . . high cholesterol and diabetes. My father was an overweight man. My two older brothers, they live in California. One of them has high cholesterol and now prostate cancer, but he's not having the surgery. His doctor says his cancer is very slow growing. Both. . . Yes, both have high blood pressure. Both my parents had high blood pressure, and so do I, so you might say that runs in my family. Is your father still alive? Question 05/28/18 3:37 PM CDT No. I'm sorry to hear that Empathize 05/28/18 3:37 PM CDT Thank you. Any family history of stomach cancer? Question 05/28/18...
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