3/1/2020 Focused Exam: Abdominal Pain | Completed | Shadow Health
1/5
Focused Exam: Abdominal Pain Results | Completed
Subjective Data Collection: 41
... [Show More] 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
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Category Scored Items
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Patient Data
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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
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This study source was downloaded by 100000852290574 from CourseHero.com on 11-09-2022 01:43:41 GMT -06:00
https://www.coursehero.com/file/56393123/Focused-Exam-Abdominal-Pain-subjectivepdf/
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 100000852290574 from CourseHero.com on 11-09-2022 01:43:41 GMT -06:00
https://www.coursehero.com/file/56393123/Focused-Exam-Abdominal-Pain-subjectivepdf/
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 100000852290574 from CourseHero.com on 11-09-2022 01:43:41 GMT -06:00 Denies efforts to incorporate fiber in her diet [Show Less]