nr 509 focused exam abdominal pain transcript focused exam abdominal pain results | turned in advanced health assessment chamberlain
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Focused Exam: Abdominal Pain Results | Turned In
Advanced Health Assessment - Chamberlain, NR509
1/29
,Focused Exam: Abdominal Pain Results | Turned In
Advanced Health Assessment - Chamberlain, NR509
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Transcript
Overview
Transcript
Started: May 28, 2018 | Patient Exam Time: 153 min
Subjective Data Collection
All Lines Interview Questions Statements Exam Actions
(250) (138) (21) (91)
Objective Data Collection
Education & Empathy Greet
Hello my name is Sara an FNP student who will be interviewing you
05/28/18 1:18 PM
today
Documentation CDT
Self-Reflection
Hello.
Question
Will you please state your name? (Clarified to what is your name
05/28/18 1:18 PM
and birthday.)
CDT
My name is Esther Park, and I was born on January 7th . . . [Ms.
Park reports correct birth year.] [AUDIO COMING SOON]
Question
Please State your age? (No matching questions found.) 05/28/18 1:19 PM
CDT
Question
How old are you? 05/28/18 1:20 PM
CDT
Seventy-eight.
Question
What brought you into the clinic 05/28/18 1:21 PM
today? CDT
I have some pain in my belly. . . and I'm having difficulty going to
the bathroom. My daughter was worried about me.
Exam Action
Measured vitals 05/28/18 1:27 PM
CDT
2/29
, Question
When did your pain start?
05/28/18 1:29 PM
CDT
The pain started as a general discomfort, about five days ago, when I started having the. . . difficult
Question
Was your pain sudden?
05/28/18 1:31 PM
CDT
No, it was gradual. I had some pain and discomfort about. . . five days ago. Then in the past few day
Empathize
I'm sorry to hear you're feeling bad
05/28/18 1:31 PM
CDT
Thank you.
Question
How often are you having the pain?
05/28/18 1:31 PM
CDT
Oh, it's with me all the time. The bloating, too. But certain things do make it worse.
Where does it actually hurt? (Clarified to Which part of your abdomen hurts?.) Question
05/28/18 1:32 PM
CDT
The pain and discomfort is down low in my belly.
Question
Point of location of pain
05/28/18 1:33 PM
CDT
Well my whole belly is uncomfortable to some degree, but it's mostly in the lower part, that's where
Question
What makes your pain worse?
05/28/18 1:33 PM
CDT
Moving around certainly doesn't help. Neither does eating.
How long is your pain last?
Question
05/28/18 1:34 PM
CDT
3/29
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