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Focused Exam: Abdominal Pain Results | Turned In
Physical Diagnosis - Fall 2020, CLSC 6103
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Overview
Transcript
Transcript
Started: Oct 29, 2020 | Total Time: 92 min
Subjective Data Collection
All Lines (212) Interview Questions (94) Statements (28) Exam Actions (90)
Objective Data Collection
Education & Empathy Gre
Hello. My name is Kevin and I will be doing your exam today.
10/29/20 12:11 AM C
Documentation
Program Competency Progress Hello.
Quest
Will you please state your name? (Clarified to what is your name and birthday.)
10/29/20 12:12 AM C
Esther Park.
Quest
When is your birthday?
10/29/20 12:12 AM C
My birthday is January 7th.
Quest
Please state your age.
10/29/20 12:13 AM C
Esther Park.
Quest
How old are you?
10/29/20 12:13 AM C
Seventy-eight.
Quest
What brought you into today?
10/29/20 12:13 AM C
I have some pain in my belly. . . and I'm having difficulty going to the bathroom. My
daughter was worried about me.
Support
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,12/4/2020 Focused Exam: Abdominal Pain | Completed | Shadow Health
Empath
I am sorry to hear that Esther.
10/29/20 12:14 AM C
Thank you.
Exam Act
Measured vitals
10/29/20 12:14 AM C
Quest
When did your pain start?
10/29/20 12:15 AM C
The pain started as a general discomfort, about five days ago, when I started having the. . .
difficulties going to the bathroom.
Quest
Was your pain sudden?
10/29/20 12:15 AM C
No, it was gradual. I had some pain and discomfort about. . . five days ago. Then in the
past few days it got much worse.
Empath
I'm sorry to hear you're feeling bad.
10/29/20 12:16 AM C
Thank you.
Quest
How often are you having the pain?
10/29/20 12:16 AM C
Oh, it's with me all the time. The bloating, too. But certain things do make it worse.
Quest
What makes the pain worse?
10/29/20 12:17 AM C
Moving around certainly doesn't help. Neither does eating.
Quest
Where does it actually hurt? (Clarified to Which part of your abdomen hurts?.)
10/29/20 12:17 AM C
The pain and discomfort is down low in my belly. (Clarified to which part of my abdomen
hurts.)
Quest
Point of location of pain?
10/29/20 12:18 AM C
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.
Empath
I am sorry to hear that.
10/29/20 12:18 AM C
Thank you.
Quest
How long does your pain last?
10/29/20 12:19 AM C
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.
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, 12/4/2020 Focused Exam: Abdominal Pain | Completed | Shadow Health
Quest
What causes your pain?
10/29/20 12:19 AM C
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.
Quest
Is your pain sharp?
10/29/20 12:19 AM C
No. I'd say it's crampy and. . . a dull, crampy feeling.
Quest
Rate your pain on a scale of 0 to 10.
10/29/20 12:20 AM C
Right now. . . 6 out of 10.
Empath
I'm sorry to hear that you're feeling so bad.
10/29/20 12:20 AM C
Thank you.
Quest
Does it affect your daily life? (Clarified to Has the pain affected your usual activities?.)
10/29/20 12:20 AM C
Well, I don't feel unnaturally tired or weak. But I have experienced low energy, like I need to
rest more often. (Clarified to if my pain has affected my activities.)
Quest
What makes it feel better?
10/29/20 12:21 AM C
When I rest and try not to move much, I feel better. But the pain is still there.
Quest
What have you done to relieve your pain?
10/29/20 12:21 AM C
I've tried taking small sips of warm water, resting. The warm water does nothing. A friend
suggested it, but it's nonsense.
Empath
I'm sorry you feel that way.
10/29/20 12:22 AM C
Thank you.
Quest
Is the pain constant?
10/29/20 12:22 AM C
Yes. Certain things can make it a tiny bit better or a tiny bit worse, I suppose. But it's always
there.
Quest
What makes it better?
10/29/20 12:22 AM C
When I rest and try not to move much, I feel better. But the pain is still there.
Quest
How is your energy level?
10/29/20 12:23 AM C
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