Focused Exam_ Abdominal Pain _ subjective

3/1/2020 Focused Exam: Abdominal Pain | Completed | Shadow Health 1/5 Focused Exam: Abdominal Pain Results | Completed Subjective Data Collection: 41 of 41 (100.0%) Chief Complaint Orientation History of Presenting Illness Your Results Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Care Plan Indicates an item that you found. Indicates an item that is available to be found. Category Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Patient Data Not Scored A combination of open and closed questions will yield better patient data. The following details are facts of t patient's case. Established chief complaint Reports abdominal pain Reports difficulty with bowel movements Asked about orientation Oriented to own person Oriented to place Oriented to situation Oriented to time 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 Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. This study source was downloaded by from CourseH on :43:41 GMT -06:00 3/1/2020 Focused Exam: Abdominal Pain | Completed | Shadow Health 2/5 Past Medical History Asked about characteristics of the pain Describes pain as dull Describes pain as cramping Describes pain as constant Describes pain as fluctuating in severity Asked about non-pharmacological relieving factors Reports that resting helps relieve pain 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 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 This study source was downloaded by from CourseH on :43:41 GMT -06:00 3/1/2020 Focused Exam: Abdominal Pain | Completed | Shadow Health 3/5 Home Medications Social History Asked about allergies Reports latex allergy Denies medication allergies Denies food allergies Asked about health maintenance Reports annual check-ups Reports last Pap smear was over 10 years ago Reports belief that her level of health and activity is very good for her age Reports colonoscopy 10 years ago Asked about sexually transmitted infections Denies ever getting STI testing Denies STI symptoms Asked about current sexual activity Reports currently sexually active Asked about pre-existing health conditions Reports high blood pressure Asked about history of surgery Reports C-section Reports C-section at age 40 Reports cholecystectomy Reports cholecystectomy at age 42 Denies post-operative complications Asked about typical medications Reports high blood pressure medication Followed up on high blood pressure medication Reports medication for high blood pressure is quinapril (Accupril) Reports high blood pressure medication is 10 mg Reports taking high blood pressure medication daily at 8 a.m. Denies typically taking any OTC medications Asked about activities of daily living Denies difficulty toileting alone Denies difficulty dressing Denies difficulty feeding self Denies difficulty walking Denies difficulty bathing Denies difficulty transferring in and out of chairs Asked about diet Reports last meal was toast at breakfast Reports typically eating 3 meals Denies eating snacks regularly Reports typical breakfast is toast Reports typical lunch is soup Reports sometimes skipping lunch due to low appetite Reports typical dinner is chicken or fish with rice Asked about fiber intake Denies taking fiber supplements This study source was downloaded by from CourseH on :43:41 GMT -06:00 Denies efforts to incorporate fiber in her diet