abdominal pain is generalized in location, and described as a dull pain, non-radiating. She notes some acid reflex, and reports she has a history of gastritis. She also notes decreased appetite recently. Denies any nausea or vomiting, denies any recent bowel changes. Denies current sexual activity, denies alcohol use or smoking. LMP was 2 week ago.
Chamberlain College of Nursing NR509 Advanced Physical Assessment EPISODIC SUBJECTIVE ASSESSMENT / GENERALIZED ABDOMINAL PAIN (Patient history is not included in the final immersion evaluation) INTRODUCTION _____1. Introduces self as NP student _____2. Acknowledges purpose of exam _____3. Asks open-ended questions to begin and narrows down to closed ended questions _____4. Asks questions in an appropriate, professional, manner CC / HPI _____1. Includes the following: Onset Location Duration/Timing Characteristics/Quality/Severity Aggravating factors/Associated Symptoms Relieving factors Treatment/Medications/Remedies PMH _____1. Major childhood illnesses _____5. Immunizations _____2. Major adult illnesses _____6. Allergies to medications, foods and environment _____3. Surgeries _____7. Medications (including RX, OTC, herbal) _____4. Hospitalizations FAMILY HISTORY _____1. Asks about both parents _____2. Siblings SOCIAL HISTORY _____1. Occupation _____2. Relationship status _____3. Children HABITS _____1. Tobacco _____2. ETOH /Illegal Drug Use ROS _____1. Constitutional ______4. GI _____2. HEENT ______5. GU _____3. Cardiovascular/Lungs Sub-total History Items Correct ______/24
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- Fall '15
- Physical examination, Heart sounds, Palpation