Exam (elaborations)
Shadow Health-Focused Exam: Abdominal Pain Exam
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Shadow Health-Focused Exam: Abdominal Pain Exam
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Shadow Health-Focused Exam:Abdominal Pain Exam
Asked review of systems for genitourinary - -Denies....
-hx of bladder problems
-painful urination
-burning with urination
-urinary incontinence
-hx of UTIs
-holding urine unneccessarily
-gynecological problems
-vaginal bleeding
-vaginal discharge
-hx of kidney problems
Reports....
-onset of menopause, was age 54
-Establish cheif complaint - --Reports abdominal pain
-Reports difficulty with bowel movements
-Asked about orientation - -Oriented to...
-own person
-place
-situation
-time
-Asked about the onset of pain - -Reports...
-discomfort for the past five days
- pain worsened intensely 2-3 days ago
-Asked about location of the pain - -Reports...
- pain in lower abdomen
-pain is not localized
Denies...
-flank pain
-Asked about pain rating on a scale - -Reports...
-current pain rating of 2/10
-lowest pain is 2/10
-worst pain is 8/10
-Asked about characteristics of the pain - -Describes pain as...
-dull
-cramping
, -constant
-fluctuating in severity
-Asked about non-pharmacological relieving factors - -Reports...
-resting helps relieve pain
-drinking warm water to relieve pain was ineffective
-Asked about pharmacological relieving factors - -Denies...
-taking pain medication
-taking laxatives
-Asked about aggravating factors - -Reports pain is aggravated by...
- eating
- physical activity
-Asked about impact of pain on daily life - -Reports...
- recent difficulty participating in usual activities
- low energy
-Followed up on constipation - -Reports...
- current constipation
- constipation all of last 5 days
-Asked about diarrhea - -- Reports recent diarrhea
-Followed up on diarrhea - -Reports diarrhea...
- about 6 months ago
- had a sudden onset
- lasted one day
-Asked about substance of stool - -Denies...
- mucus in stool
- blood in stool
-Asked about urination - -Reports...
- slight decrease in frequency of urination
- darker urine recently
- blood in urine
-Asked about fluid intake - -Reports decreased...
- thirst
- fluid intake
- typical fluid intake, 1-2 glasses of water a day
- Denies drinking caffeinated drinks such as coffee or soda
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