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Focused Exam-Abdominal Pain Esther Parks Shadowhealth Subjective
Family Nurse Practitioner Ii (NUR 535)
Southern Connecticut State University
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Focused Exam: Abdominal Pain Results | Turned In
Subjective Data Collection: 33 of 34 (97%)
Chief Complaint
Orientation
History of Presenting Illness
Your Results
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Program Competency Progress
Student Survey
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 y better patient data. The following details are facts the 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, frequency, and duration of pain
Reports discomfort for the past ûve days Reports pain with gradual onset that worsened 2-3 days ago
Asked about location of pain Reports pain in lower abdomen Reports pain is not localized
Hover To Reveal...
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
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Past Medical History
Asked about pain rating on a scale Reports pain rating of 6/
Asked about characteristics of the pain Describes pain as dull and cramping Describes pain as üuctuating in severity
Asked about non-pharmacological relieving factors
Reports that resting helps relieve pain Reports drinking warm water to relieve pain wa 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 constipation most of last 5 days Denies any attempt to treat constipation
Asked about diarrhea Reports recent diarrhea
Followed up about diarrhea Reports diarrhea about six months ago Reports diarrhea had a sudden onset Reports diarrhea lasted one day Describes diarrhea as loose and watery
Asked about substances in stool Denies mucus in stool Denies blood in stool
Asked about urination Reports recent, slight decrease in frequency of urination Reports darker urine recently Denies blood in urine
Asked about üuid intake Reports decreased thirst Reports decreased üuid intake for the last few days Reports typical üuid intake is 1-2 glasses of water a day Denies drinking caffeinated liquids
Asked about contact with illnesses Denies recent travel Denies exposure to food poisoning
Asked about history of constipation Denies history of constipation
Review of Systems
Denies efforts to incorporate ûber in her diet Reports eating a vegetable every 1 or 2 days Reports eating fruit every 3 or 4 days
Asked about typical activity level Reports typically high level of mobility and independence Reports typically having a moderate activity lev
Asked about substance use Denies illicit drug use Denies cigarette smoking Reports low alcohol consumption
Followed up about alcohol consumption Reports drinking 1 night a week Reports 1 drink per sitting Reports typical drink is white wine
Asked about constitutional health Denies recent weight changes Denies fever Denies chills Denies night sweats Reports short-term feeling of exhaustion
Asked review of systems for gastrointestinal Reports bloating Reports slight increase in gassiness Reports loss of appetite Denies nausea Denies vomiting
Asked review of systems for genitourinary Reports onset of menopause was age 54 Denies history of bladder problems Denies painful urination Denies burning with urination Denies urinary incontinence Denies history of UTIs Denies gynecological problems Denies vaginal bleeding or discharge
Asked about review of systems for cardiovascular
Denies palpitations Denies chest discomfort Denies racing heartbeat
Focused Exam-Abdominal Pain Esther Parks Shadowhealth Subjective
Course: Family Nurse Practitioner Ii (NUR 535)
University: Southern Connecticut State University
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Students also viewed
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