Focused Exam: Abdominal Pain Results | Turned In Advanced Physical Assessment - March 2020, advanced_physical_assessment__td8__031720_

Focused Exam: Abdominal Pain Results | Turned In Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1

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Transcript

Started: Apr 22, 2020 | Total Time: 115 min

Question 04/22/20 3:02 PM MD

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Your Results Lab Pass (/assignment_attempts/6709886/lab_pass.pd

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Education & Empathy

Documentation

Student Survey

All Lines (271) Interview Questions (135) Statements (42) Exam Actions (94)

Hello.

Thank you for explaining that.

What brings you into the office today

I have some pain in my belly. . . and I’m having difficulty going to the bathroom. My daughter was worried about me.

Thank you.

What do you mean by difficult going to the bathroom (Clarified to What do you mean by difficulty going to the bathroom?.)

Well, for several days I’ve had to strain to even have a bowel movement, and I can’t make it happen. And the pain is there in my stomach. [AUDIO COMING SOON] (Clarified to what I mean by difficulty going to the bathroom.)

Thank you for explaining that.

What is your name and date of birth

My name is Esther Park, and I was born on January 7th . . . [Ms. Park reports correct birth year.]

Do you know where you’re at today

Yes. I am at Shadowville General Clinic.

Do you know what time it is (Clarified to What is todays date?.)

https://aspen.shadowhealth.com/assignments/313482/

https://aspen.shadowhealth.com/assignment_attempts/6709886/lab_pass.pdf

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Today must be . . . [Ms. Park reports the correct date]. (Clarified to what today’s date is.)

What time is it (No matching questions found.)

When did the pain start

The pain started as a general discomfort, about five days ago, when I started having the. . . difficulties going to the bathroom.

Where is the pain at

The pain and discomfort is down low in my belly.

How long is this been happening

I have not felt as energetic as usual for — I believe for the past week.

Describe your pain

I’d say it’s crampy and. . . a dull, crampy feeling.

Thank you.

Is there anything that makes it worse

Yes. When I move around the house or try to garden, I feel more pain. And I did not go to my exercise classes. I was sure that would be too much. I prefer to be active, but my daughter wants me to rest.

Does the pain radiate anywhere in your body

I wouldn’t say that, no. It’s more of a general pain that stays in one place.

Does anything make the pain better

When I rest and try not to move much, I feel better. But the pain is still there.

can you Point to your pain (Clarified to Can you point to the location of your abdominal pain?.)

Well my whole belly is uncomfortable to some degree, but it’s mostly in the lower part, that’s where the pain is. Down in my lower belly. (Clarified to if I can point to where my abdominal pain is.)

Does your back hurt

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No. I think my exercising helps me avoid that.

What is your pain scale from 1 to 10

Right now. . . 6 out of 10.

What is the pain at its worst (Clarified to What would you rate your pain at its worst?.)

I’d say it’s as bad as it gets right now. . . about a 6 out of 10. (Clarified to how I would rate my pain at its worst.)

Is this all the time (No matching questions found.)

Is this constant pain (Clarified to Is your pain constant?.)

Yes. Certain things can make it a tiny bit better or a tiny bit worse, I suppose. But it’s always there. (Clarified to if the pain is constant.)

What makes it better

When I rest and try not to move much, I feel better. But the pain is still there.

Have you tried anything to help it

I’ve tried taking small sips of warm water, resting. The warm water does nothing. A friend suggested it, but it’s nonsense.

Are you taking any pain medication

I’m not taking anything for it.

Are you taking any laxatives (Clarified to Have you tried taking laxatives?.)

I haven’t tried laxatives. I don’t think they’re very good for you. [AUDIO COMING SOON] (Clarified to if I have tried taking laxatives.)

Thank you for explaining that.

Does eating make it worse (Clarified to Does eating anything make your pain worse?.)

Yes. The pain is there all the time, but eating can make it worse. (Clarified to if eating makes the pain worse.)

Is it worse when you’re walking around (Clarified to How are you getting around?.)

When I have to go somewhere that’s too far for me to walk, my daughter drives me. But usually, I get most places by walking. I usually like to do that whenever I can. (Clarified to how I am getting around.)

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Question 04/22/20 3:26 PM MD

Thank you for explaining that.

Does this interfere with your daily activities (Clarified to Has the pain affected your usual activities?.)

Well, I don’t feel unnaturally tired or weak. But I have experienced low energy, like I need to rest more often. (Clarified to if my pain has affected my activities.)

Thank you.

Do you take naps (Clarified to Do you take vitamins or supplements?.)

No, I don’t take anything like that. (Clarified to if I take vitamins or supplements.)

Have you had any diarrhea

Yes, I did have a bout of diarrhea pretty recently. [AUDIO COMING SOON]

How often do you get diarrhea

I don’t have diarrhea often at all. . . the bout six months ago was the first time in a long while. [AUDIO COMING SOON]

When was your last diarrhea episode

That must have been six months ago. It lasted for a day. [AUDIO COMING SOON]

Do you have anything on your stool like mucus (No matching questions found.)

Do you have anything on your stool like blood or mucus (No matching questions found.)

Do you have bloody stools

No. I’ve never experienced that.

do you have mucus in your stool

No, I haven’t noticed anything like that.

Are you avoiding okay

No.

Do you have trouble peeing

No, no trouble.

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What color is your urine

Yellow and. . . maybe a bit darker than usual.

Do you have blood in your urine

No, it seems normal enough to me. Maybe a little darker than usual.

How much fluids are you taking Daily

Usually I drink, oh, two glasses of water a day. But it’s been difficult to drink much in the last few days. [AUDIO COMING SOON]

Thank you for explaining that.

Do you drink caffeinated drinks

No. I avoid caffeinated drinks altogether.

Do you drink soda

No, I never do.

What is your typical bowel movement routine

What has been happening with my. . . digestion. . . is new. I’m usually fairly regular, but I haven’t moved my bowels in about five days. [AUDIO COMING SOON]

What color is your stool

Brown. A normal shade of brown. Like. . . oh, I don’t know. Cardboard.

Is it soft or hard (No matching questions found.)

is your stool soft or hard

My stool? Usually it’s brown, not too hard. Solid. Not watery.

Are you allergic to any medication

No, not that I’m aware of.

Do you have any food allergies

No.

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Are you allergic to anything

I have an allergy to latex.

What happens with latex

I get an itchy skin rash.

Do you see the doctor regularly

Yes. I usually see Dr. Keller, here–at Shadowville Primary Care. But I was told she’s out today.

When was your last pap smear

A pap smear? I haven’t had one in years. Ten years, at least.

define your health today

I haven’t been feeling well lately.

Have you ever had a colonoscopy

I’ve had two colonoscopies. The last one was ten years ago.

What was your results (Clarified to What was the result of your colonoscopy?.)

They had nothing to report. [AUDIO COMING SOON] (Clarified to what the result of my colonoscopy was.)

What was your result for your last pap smear

A pap smear? I haven’t had one in years. Ten years, at least.

what is your result for your pap smear (Clarified to What was the result of your last smear test?.)

It was years ago, so I don’t remember anything about it. I’m sure it was fine. (Clarified to what the result of my last pap smear was.)

Have you ever had any sexual transmitted infections (Clarified to Do you have a history of STD?.)

No, I’ve never had anything… like that. (Clarified to if I have had an STD.)

Are you still sexually active

I have a gentleman friend and, yes… We are intimate.

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Does it burn or hurt with urination (Clarified to Do you feel burning when you urinate?.)

No, my urination has felt normal. (Clarified to if it burns when I urinate.)

Thank you for explaining that.

do you take any blood pressure medications

Yes.

Have you had trouble with your blood pressure lately

Yes, I have been diagnosed with high blood pressure. But I take very good care of that.

Thank you for explaining that.

Have you had any surgeries

I’ve had two operations, both many years ago.

What was the reason for your surgery (Clarified to What type of surgery did you have?.)

I’ve had two. I had my gallbladder out, and I had a C-section. Both in my early 40s. (Clarified to what surgery I had.)

Have you been hospitalized before

Yes. I had a couple surgeries years ago. And of course I stayed in the hospital briefly when Jennifer and Timothy were born.

Are you taking any over-the-counter medication

No. Those over-the-counter medicines. . . Tylenol–they say it’s very bad for the stomach.

Difficult with daily activities (Clarified to Have you required assistance in performing daily activities?.)

Usually I don’t need much help. But since I’ve been sick, my daughter has been helping me, doing things around the house–gardening, cleaning, making sure I eat a little something. She’s very busy with her job, and it’s very sweet of her to help me. (Clarified to if I have needed help with daily activities.)

Are you able to dress yourself

No — I had to miss my exercise classes this week — I didn’t have the energy for them. That’s unusual for me.

Do you need help eating

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I don’t need any help right now. Thank you.

Do you have difficult walking (Clarified to Is it hard for me to walk?.)

I can walk just fine. (Clarified to if it is hard for me to walk.)

Do you need help bathing

No, I can do that myself.

Are you able to get in and out of a chair

Any kind of movement makes my abdominal discomfort worse, but I don’t usually have problems with that.

Tell me about your diet (Clarified to What is your diet like?.)

I usually eat low fat foods, healthy proteins. . . on holidays our family gets together, so I make traditional dishes then. Korean dishes. But usually I eat very light. (Clarified to what my diet is like.)

Do you eat three meals a day

Usually three, but sometimes I skip breakfast. I don’t eat snacks.

What are you eating habits (Clarified to What are your eating habits?.)

Hm. Toast for breakfast. For lunch. . . usually soup. But I don’t always have lunch. And for dinner I eat fish, or sometimes chicken, and rice. [AUDIO COMING SOON] (Clarified to what my eating habits are.)

Thank you for explaining that.

Have you had any change in weight

No, not that I’ve noticed.

Have you had any fever or chills

No, I haven’t been feverish or chilly. [AUDIO COMING SOON]

Have you had night sweats

No. That is not a problem for me.

so you see swelling in your extremities or face

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Nothing is swelling that I know of.

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 often and what type of alcohol

Very little.

How often do you drink alcohol

Very little.

Do you take illicit drugs

I have never used drugs of any kind.

Thank you for explaining that.

How much alcohol do you drink

Very little.

How often do you drink in a week

On Sundays, I have my only drink for the week.

What kind of alcohol do you drink

I always have one glass of wine. A dry white wine.

Do you live alone

No. I live with my daughter, Jennifer.

Do you have family around besides Jennifer

Two wonderful grown-up children. Jennifer and Timothy.

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Do you have grandchildren

Oh, I would have loved to have had grandchildren. Both of my children… Everything is about their careers. But I supposed–some of my friends, their children are grown–in their 40s, 50s– and they never found their way. So I’m very lucky.

Thank you.

Do you travel

My late husband Shin and I went on a few vacations with the kids–Florida, once to St. Thomas in the Caribbean. And once I went to Munich, Germany where Shin was doing a lecture. But since he died, I’ve only gone on one trip–to Houston, to see my son.

Thank you.

Have you had been physically abused

No, never.

Have you ever been sexually abused (No matching questions found.)

have you been abused sexually

No.

Have you been emotionally abused

No, the people in my life–they treat me very well.

Are you okay with your finances

No. My daughter handles the bills.

Is that going well for you (No matching questions found.)

Thank you.

Do you have trouble sleeping

No, usually I sleep right through the night.

Have you ever had a history of appendicitis (No matching questions found.)

Question 04/22/20 3:46 PM MD

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Have you ever had appendicitis

No.

Have you had any stomach cancer (Clarified to Have you had stomach cancer?.)

No. (Clarified to if I have had stomach cancer.)

Is there a family history of stomach cancer

No.

Do you or your family have liver disease

No, not that I know of.

Have you ever had GERD

No. I don’t get indigestion, heartburn, nothing like that.

Do you have a family history of ulcer (Clarified to Do your family members have health problems?.)

Let’s see. . . high cholesterol and diabetes. My father was an overweight man. My two older brothers, they live in California. One of them has high cholesterol and now prostate cancer, but he’s not having the surgery. His doctor says his cancer is very slow growing. Both. . . Yes, both have high blood pressure. Both my parents had high blood pressure, and so do I, so you might say that runs in my family. (Clarified to if my family members have health problems.)

Thank you for explaining that.

Have you ever had any palpitation

No. My heart rate has always been normal.

Have you ever had chest discomfort (Clarified to Have you ever had chest pain?.)

No, I don’t ever experience chest pain. (Clarified to if I have ever had chest pain.)

Have you ever felt your heart rate was going fast

No. My heart rate has always been normal.

Do you have any sore throat

No. My throat is fine.

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Do you have any cough

No, I haven’t been coughing at all.

Do you have difficulty swallowing

No. I am able to swallow without any problems.

Do you have difficulty breathing (Clarified to Do you have breathing problems?.)

No. I can breathe well. My lungs feel very healthy. (Clarified to if I have breathing problems.)

Do you have any bloating

Yes. Quite a bit.

Are you gassy

Hm. I have been experiencing some of that.

Do you feel nauseous

No. I haven’t vomited or had any nausea. It’s more of a problem with pain. . . and difficulty going to the bathroom.

Have you had food poisoning

Years ago I eat some bad shellfish. . . this doesn’t feel like that.

Do you have vomiting

Very rarely. The last time I vomited. . . I had a stomach virus a few years ago. One of those nasty, 24-hour bugs.

Do you have bladder problems

No.

You have any history of bladder cancer (Clarified to Have you had a bladder infection?.)

No, never. (Clarified to if I have had a bladder infection.)

Have you ever had problem gynecological

I haven’t had any.

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Do you have vaginal bleeding

No.

Do you have menopause (Clarified to How long ago did you have menopause?.)

Oh my. . . it was twenty years or more ago. . . I think I was 54. (Clarified to how long ago I underwent menopause.)

Do you have any kidney problems

No, I’ve never had any kidney trouble.

Thank you.

Thank you for explaining that.

the stethoscope may be cold (No matching questions found.)

Thank you for explaining that.

Is that tender (No matching questions found.)

Is that tender to touch (No matching questions found.)

did that hurt (No matching questions found.)

Thank you for explaining that.

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Thank you for explaining that.

That feels alright.

Mmm, it feels sore there.

Thank you.

Thank you for explaining that.

That feels alright.

Ooo, that–that’s sore right there.

Thank you for explaining that.

Bart would you like a flu injection (No matching questions found.)

Miss Park would you like to have a flu injection

Not today. Maybe I’ll get one at my next check-up, if my doctor recommends it.

Thank you for explaining that.

How many pregnancies have you had

I’ve had three pregnancies… I have two wonderful grown children.

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Did you have a miscarriage

No, not a miscarriage. When I was forty I had a baby, delivered by C-section. It was what they called an umbilical cord accident–where the cord wraps around the baby’s neck. It was a stillbirth.

Thank you.

Do you have any depression

I don’t struggle with depression, thankfully. I feel positive about my life.

Did you have resources for the loss of your child (No matching questions found.)

Did you need therapy for the loss of your child (No matching questions found.)

Are you coping with the loss of your child

I like to think so. I think I’m good at letting things go–not holding onto resentments, things that make me sad. Between my friends, my daughter, and. . . and also my gentleman friend, I have good people around me.

Thank you for explaining that.

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