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Focused Exam Abdominal Pain Completed Shadow Health
Western Carolina University
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Focused Exam: Abdominal Pain Results | Turned InAdvanced Physical Assessment - Fall 2021, NURS
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Started: Oct 24, 2021 | Total Time: 86 min
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Your Results Reopen (/assignment_attempts/10954521/reopen
Lab Pass (/assignment_attempts/10954521/lab_pass Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Assessment and Plan Student Survey
Interview Questions (111) Statements (23) Exam Actions (86) Hello my name is Shawn I will be your nurse today Hello. What brings you in today I have pain in my belly... and I'm having some difficulty with going tdaughter was concerned. o the bathroom. My I'm so sorry to hear that Thank you. Can you tell me your name and date of birth My name is Esther Park, and I was born on January 7th... [Ms. Park reyear.] ports correct birth Can you tell me where you are today Thank you. Can you describe your pain I'd say it's crampy and... a dull, crampy feeling. How would you rate your pain on a scale of zero to ten Right now... 6 out of 10. I'm sorry to hear that
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Thank you. Does your pain radiates I wouldn't say that, no. It's more of a general pain that stays in one place. Can you tell me exactly where your pain is located The pain and discomfort is down low in my belly. When was your last bowel movement Five days ago or so, when all this started. [AUDIO COMING SOON] Have you taken anything I'm not taking anything for it. Have you taken anything for your I'm not taking anything for it. What medications are you taking Just the medication for my blood pressure. What medication do you take for your blood pressure It's called Accupril. What dosage do you take 10 milligrams. How many times daily do you take I take it every morning at about 8 a., after breakfast. How long have you been taking Accupril I've been taking it since I was diagnosed. I was... 54. Do you take any other medications SupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupport
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My only known health issue is hypertension, but it's very well managed. At very healthy. my age, I feel that's
Do you smoke I've never smoked a cigarette in my life. What a sad habit. Do you drink alcohol Yes, but very little. How much alcohol do you drink Very little. How much alcohol in one week do you drink (Clarified to How much do you drink per week?.) On Sundays, I have my only drink for the week. (Clarified to how much alcohol I have a week.) What type of drink is it I mostly just drink water. Sometimes chamomile tea. Are you eating I can eat, but not much. My daughter makes sure I get a little something here and there. What type of diet do you follow I usually eat low fat foods, healthy proteins... on holidays our traditional dishes then. Korean dishes. But usually I eat very light gets together, so I make
Do use recreational drugs (Clarified to Do you use recreational drugs?.) I have never used drugs of any kind. (Clarified to if I use recreational drugs.) Do you have any family history Let's see... high cholesterol and diabetes. My father was an overwebrothers, they live in California. One of them has high cholesterol andight man. My two older now prostate cancer, but he's not having the surgery. His doctor says his cancer is very slow growinhave high blood pressure. Both my parents had high blood pressure, and so do I, so you mightg. Both... Yes, both say that runs in my family. Does your pain level fluctuate (Clarified to Does the pain fluctuate?.) Well, the type of pain never changes. And it's always in the same place or three days ago. (Clarified to if the pain fluctuates.) But it did get worse SupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupport
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Does anything relieve your pain When I rest and try not to move much, I feel better. But the pain is still there. Does anything make the pain worse Yes. When I move around the house or try to garden, I feel more exercise classes. I was sure that would be too much. I prefer to bepain. And I did not go to my active, but my daughter wants me to rest. Are you active Yes, I garden, take walks. I take exercise classes at the community centeand I started enjoying Pilates as well. r -- water aerobics,
That sounds great. Thank you. Exercise is very good for getting the bowels moving Thank you for explaining that. Have you had any surgeries I've had two operations, both many years ago. Have you ever had children I've had three pregnancies... I have two wonderful grown children. What happened with the third pregnancy It was an unexpected pregnancy, when I was forty--a joyful surprise., delivered by C-section. It was what they called an umbilical cord. But the baby wasaccident--where the cord wraps around the baby's neck. I'm so sorry to hear that Thank you. Have you ever been hospitalized Yes. I had a couple surgeries years ago. And of course I stayed in thJennifer and Timothy were born. e hospital briefly when
Have you ever taken any laxatives SupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupport
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Did you notice any mucus No, I don't think so. Was there any blood in your stool No, I haven't seen blood in my stools. [AUDIO COMING SOON] What color was your urine Yellow and... maybe a bit darker than usual. How dark (No matching questions found.)
How dark was your urine (No matching questions found.)
You had any blood in your No, it seems normal enough to me. Maybe a little darker than usual. You been thirsty lately (Clarified to Do you get excessive thirst?.) I'm not usually especially thirsty, but since my... discomfort, I hawater as usual. (Clarified to if I have been really thirsty lately.) ven't been drinking as much
How many glasses of water do you drink daily Usually I drink, oh, two glasses of water a day. But it's been difficfew days. [AUDIO COMING SOON] ult to drink much in the last
You drink any other fluids No. I avoid caffeinated drinks altogether. That's good Thank you. Caffeine can make your heart race Thank you for explaining that. How many bowel movements do you typically have per week Before this? Every day. Well, I miss a day now and then, but usually every day. SupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupport
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Are your stools usually firm No, it was not normal for me at all. It was diarrhea. Are your stools usually formed Usually, yes. But not when I had the diarrhea. You have any food allergies No. Initialize pelvic exam (No matching questions found.)
When was your last pap smear A pap smear? I haven't had one in years. Ten years, at least. Have you had a colonoscopy I've had two colonoscopies. The last one was ten years ago. When was your last call now I remember having a flu shot... maybe a year ago. Two years ago. Something like that. Are you married I was married for nearly 50 years. My husband, Shin, passed away 6 years ago. I'm so sorry to hear that Thank you. Are you dating (Clarified to Do you date?.) I have a relationship with one man. We are intimately involved. (Clarified to if I date.) Have you had sexual relations I'm only attracted to men. Have you had sex SupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupport
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Usually I love to walk. I go for a walk every day. But since I've been sick, I've needed to rest. Do you have any problems preparing your own meals (Clarified to Have you trouble preparing meals?.) ever had any
Any kind of movement makes my abdominal discomfort worse, but I don't usuallyproblems with that. (Clarified to if I have had trouble preparing meals.) have
What do you typically eat Hm. Toast for breakfast. For lunch... usually soup. But I don'tdinner I eat fish, or sometimes chicken, and rice. [AUDIO COMING SO always have lunch. And forON]
Take any supplements No, I don't take anything like that. Do you take any extra fiber No, I don't take any extra fiber. My diet is very healthy. Supplementing your diet with fiber helps get the bowels and check Thank you for explaining that. You eat fruit I try to eat a fruit every three or four days... mostly I have toand chicken or fish with rice for dinner. And I have vegetables oneast for breakfast, soup for lunch, every one or two days. [AUDIO COMING SOON] Do you live alone No. I live with my daughter, Jennifer. It must be nice Thank you. Have you traveled anywhere recently No, I haven't gone on any trips in several years. Do you feel safe in your home Yes, I do. SupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupport
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Do you have somebody that loves and cares for you (No matching questions found.)
Do you have someone that cares for you (No matching questions found.)
Have you ever been abused No. Have you had any recent weight changes No, not that I've noticed. Have you had any swelling (Clarified to Can you tell me if you have ever hyour joints?.) ad swelling around
Well, I don't know anyone my age who isn't a little stiff first tnoticed anything unusual. (Clarified to if I have had swelling in my joints in the morning. But I haven't)
Do you sleep okay I sleep alright. Usually, I feel rested. How many hours do you sleep per night Hm... Around 7 hours per night. Have any other problems with your skin My skin is fine... I guess it's a little dry sometimes. You have any shortness of breath (Clarified to Do you currently have shortness of breath?.) No. My breathing is fine. (Clarified to if I have shortness of breath right now.) Have any difficulty swallowing (Clarified to Do you have difficulty swallowing?.) No. I am able to swallow without any problems. (Clarified to if I have trouble swallowing.) Have any problems with memory (Clarified to Do you have memory problems?.) No. Of course I'm a little bit more forgetful than when I was 30, keeps my mind sharp. I read 2 or 3 books per week. (Clarified to if I havebut not much. Reading--I think it memory problems.)
When did you start menopause Oh my... it was twenty years or more ago... I think I was 54. SupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupport
10/24/21 9:15 PM ED Exam Action 10/24/21 9:15 PM ED Exam Action 10/24/21 9:15 PM ED Exam Action 10/24/21 9:15 PM ED Exam Action 10/24/21 9:15 PM ED Exam Action 10/24/21 9:15 PM ED Exam Action 10/24/21 9:15 PM ED Exam Action 10/24/21 9:16 PM ED Exam Action 10/24/21 9:16 PM ED Exam Action 10/24/21 9:16 PM ED Exam Action 10/24/21 9:16 PM ED Exam Action 10/24/21 9:18 PM ED Exam Action 10/24/21 9:18 PM ED Exam Action 10/24/21 9:19 PM ED Educate
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Inspected right side of face Inspected general face: Slight flushing of cheeks Performed otoscopic examination of right naris Performed otoscopic examination of left naris Inspected mouth and throat Inspected left side of abdomen Inspected front of abdomen Inspected right side of abdomen Inspected front of abdomen Inspected left side of abdomen Inspected front of abdomen Inspected left side of abdomen Inspected front of abdomen
Go to take a look at your lower extremities Thank you for explaining that. Inspected front of legs for edema: No edema Inspected left leg for edema: No edema Inspected front of legs for edema: No edema Inspected right leg for edema: No edema Inspected front of legs for edema: No edema
Going to listen to your heart lungs and bowels now SupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupport
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Thank you for explaining that. Auscultated aortic area with the bell Auscultated aortic area with the diaphragm Auscultated pulmonic area with the diaphragm Auscultated Erb's point with the diaphragm Auscultated tricuspid area with the diaphragm Auscultated mitral area with the diaphragm Auscultated breath sounds in anterior right upper lobe Auscultated breath sounds in anterior left upper lobe Auscultated breath sounds in anterior right middle lobe Auscultated breath sounds in anterior left mid-chest (upper lobe) Auscultated breath sounds in anterior left lower lobe Auscultated breath sounds in anterior right lower lobe Auscultated breath sounds in posterior left upper lobe Auscultated breath sounds in posterior right upper lobe Auscultated breath sounds in posterior left mid-back (lower lobe) Auscultated breath sounds in posterior right mid-back (lower lobe) Auscultated breath sounds in posterior left lower lobe Auscultated breath sounds in posterior right lower lobe Auscultated breath sounds in posterior left lower lobe on side Auscultated breath sounds in posterior right lower lobe on side SupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupport
10/24/21 9:26 PM ED Empathize
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Yes. It hurts all over, that whole lower area. I'm sorry to hear that Thank you. Percussed for spleen Percussed for liver span: 7 cm in the mid-clavicular line Percussed left flank for CVA tenderness Percussed right flank for CVA tenderness I'm going to feel your abdomen Thank you for explaining that. Please let me know if you feel any pain (No matching questions found.) Will you let me know if you feel any pain I don't like to complain, but my daughter says I'm not myself. I guess can't do the things I normally do. I've been lying on the couch during the daytime. That's not theI show pain by, well--I usual Esther.
guarding, or distension Palpated right upper quadrant with light pressure: No tenderness reported; no masses, That feels alright.
guarding, or distension Palpated left upper quadrant with light pressure: No tenderness reported; no masses, That feels alright.
distension, no masses Palpated left lower quadrant with light pressure: Tenderness reported; palpable guarding and Mmm, it feels sore there.
guarding, or distension Palpated right lower quadrant with light pressure: No tenderness reported; no masses, That feels alright. Palpated right upper quadrant with deep pressure: No masses SupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupportSupport
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That feels alright. Palpated left upper quadrant with deep pressure: No masses That feels alright. Palpated left lower quadrant with deep pressure: Firm, oblong mass (2x4 cm) Ooo, that--that's sore right there. Palpated right lower quadrant: with deep pressure: No masses That feels alright. Aortic width is 2 cm: No lateral pulsation Palpated for liver: Palpable 1 cm below right costal margin Palpated for spleen: Not palpable Palpated bladder: Not palpable; no distention or tenderness Palpated for right kidney: Not palpable Palpated for left kidney: Not palpable Tested skin turgor May I perform a pelvic exam (No matching questions found.) I'm going to perform a pelvic exam Thank you for explaining that. Performed pelvic exam Performed digital rectal exam Checked urinalysis
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Focused Exam Abdominal Pain Completed Shadow Health
University: Western Carolina University
