Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved
Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved
Shadow Health Assessment Assignment
You will complete all assessment assignments using the Shadow Health virtual reality simulation platform.
Introduction and Pre-brief
ORDER SHADOW HEALTH ASSESSMENT HELP HERE
WE SCORE 100% AND HANDLE THE SOAP NOTE
JUST CHAT US AT THE BELOW RIGHT CORNER
Mrs. Esther Park is a 78-year-old woman who comes to the clinic complaining of abdominal pain. She reports that the pain isn’t severe, but that her daughter was concerned and brought her in. It is very important to determine whether or not the situation is an emergency and the underlying cause of Esther’s discomfort. Be sure to inquire about a variety of psychosocial factors related to the GI system, including her diet, toilet habits, immunizations, recent travel, etc. This case study will offer you the opportunity to take a complete surgical, reproductive, and current sexual history. During her physical examination, take particular note as to where Mrs. Park verbalizes pain during palpation so that you may synthesize verbal and non-verbal cues. Be sure to apply the supportive information learned in this week’s concept lab to your critical thinking process in this case study. Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved.
Transcript
Started: Apr 02, 2020 | Total Time: 198 min
All Lines (231)Interview Questions (124)Statements (15)Exam Actions (92)
Hello. My name is Jones, and i will be interviewing you today, and later do a physical examination. Welcome to the clinic
Greet
04/02/xx 11:25 AM PDT
Hello.
What is your name?
Question
04/02/xx 11:25 AM PDT
Esther Park.
What brings to the clinic today?
Question
04/02/xx 11:26 AM PDT
I have some pain in my belly. . . and I’m having difficulty going to the bathroom. My daughter was worried about me.
i am sorry you are having pain in your belly.
Empathize
04/02/xx 11:27 AM PDT
Thank you.
Whxxx?
Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved
Question
04/02/xx 11:27 AM PDT
It xxxx
I am sorry to hear this.
Empathize
04/02/xx 11:28 AM PDT
Thank you.
Are yoxxxx
Question
04/02/xx 11:28 AM PDT
I xxxx
How long xxxx
Question
04/02/xx 11:29 AM PDT
The xxxx
Has thexxxx
Question
04/02/xx 11:29 AM PDT
Well, the txxx
Where is thexxxx
Question
04/02/xx 11:30 AM PDT
The xxx
Have you xxxx
Question
04/02/xx 11:30 AM PDT
No, no. The xxxx
Is the pain inxxxx
Question
04/02/xx 11:31 AM PDT
Well my xxxx
How would xxx
Question
04/02/xx 11:32 AM PDT
Right now.xxx
can youxxx
Question
04/02/2x 11:32 AM PDT
I’d say it’sxxxx
is thexxx
Question
04/02/2x 11:32 AM PDT
Yes. Certain things can make it a tiny bit better or a tiny bit worse, I suppose. But it’s always there.
Does xxxx
Question
04/02/2x 11:33 AM PDT
Well, the type of pain never changes. And it’s always in the same place. But it did get worse two or three days ago.
What cccc
Question
04/02/2x 11:33 AM PDT
I’m not taking anything for it.
Sure, less movements can help relieve pain.
Educate
04/02/2x 11:34 AM PDT
Thank you for explaining that.
Have you xxxx
Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved
Question
04/02/2x 11:35 AM PDT
I’m xxxxxfor it.
.
.
.
CHAT US TO ORDER SHADOW HEALTH ASSESSMENT HELP
Subjective Data Collection: 32 of 32 (100.0%)
Hover To Reveal…
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
Found:
Indicates an item that you found.
Available:
Indicates an item that is available to be found. Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved
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 yield better patient data. The following details are facts of the patient’s case.
Chief Complaint
Finding:
Established chief complaint
Finding:
Reports abdominal pain
(Found)
Pro Tip: Abdominal pain can be caused by problems in the underlying organs, peritoneum, muscles, or blood vessels, changes in electrolytes or other blood contents, or even anxiety. Asking for details about the pain helps to determine the origin. Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved.
Example Question:
Do you have any abdominal pain?
Finding:
Reports difficulty “going to the bathroom”
(Found)
Pro Tip: Understanding all of a patient’s reason for visiting is an important foundation to establish. If there are multiple symptoms, follow up on each one during your interview.
Example Question:
Are you able to make a bowel movement?
History of Present Illness
Finding:
Asked about oxxx
Finding:
Reports a feeling of xxxx
(Found)
Pro Tip: Wxxxx
Example Question:
How xxxx
Finding:
Reports pain with xxxx
(Found)
Pro Tip: Whenever you are assessing a symptom or a health condition, inquiring about xxxx. Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved.
Example Question:
Has thexxxx
Finding:
Asked about xxxxx
Finding:
Reports xxxx
(Found)
Pro Tip: Identification of the location of your patient’s discomfort can provide important clues about its cause and how it should be best treated.
Example Question:
Where is your discomfort located?
Finding:
Reports pain is not localized
(Found)
Pro Tip: xxxx Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved
Example Question:
Is the xxxxx
Finding:
Reports attempts to treat pain by drinking small sips of warm water
(Found)
Pro Tip: Flank pain often occurs with disorders of the urinary tract. When a patient complains of flank pain, assess for co-occurring symptoms such as fever, chills, hematuria, and dysuria.
Example Question:
Do you have pain on your sides?
Finding:
Confirmed pain rating on a scale
Finding:
Reports painxxxx
(Found)
Pro Tip: For many people, it is difficult to clearly dxxxx.
Example Question:
How would you rate your pain on a scale of one to ten?
Finding:
Asked aboutxxxx
Finding:
Describes xxxx
(Found)
Pro Tip: Asking your patient toxhelps identify its xxxcause and the severity. Patients may not know how to answer, so you may need to suggest words like xxxx
Example Question:
Can you xxxxx
Finding:
Reports pain is ixxx
(Found)
Pro Tip: It’s important to ask your patient if her pain is xxx in order to determine her level of discomfort and identify the cause of the pain. xxxx pain is often best managed with around-the-clock pain medications. Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved
Example Question:
Is your painxxxx
Finding:
Asked about xxxxx
Finding:
Reports that resting helps
(Available)
Pro Tip: It’s important to assess the nature of pain by asking about xxx. If you know your patient is taking xxxx, asking about the medication’s xxxx can help you xxxx.
Example Question:
What xxx?
Finding:
Reports attempts to xxxx
(Available)
Pro Tip: Asking about how your patient has been xxxx. The results of her previous treatment may be helpful in your diagnosis and the development of her new xxxx, as well as a good opportunity toxxx your patient on xxxx.
Example Question:
How have you been xxx?
Finding:
Reports xxxstomach
(Found)
Pro Tip: Asking about how your patient has been nxxxxes her current condition and her approach to xxxx. The results of her previous treatment may be helpful in your xxxand the development of her xxx, as well as a good opportunity to x. Esther park abdominal pain focused shadow healxxxxth assessment transcript, objective, subjective solved
Example Question:
Have you xxx?
Finding:
Asked about xxxx
Finding:
Reports pain is aggravated by eating
(Found)
Pro Tip: Asking you patient what aggravates her pain can point to factors that exacerbate symptoms and the ways in which your patient is approaching self-care.
Example Question:
Is the painxxx by xxx
Finding:
Reports xx by xx
(Found)
Pro Tip: Asking you patient what aggravates her pain can point to factors that exacerbate symptoms and the ways in which your patient is approaching self-care.
Example Question:
Is the pain aggravated by xxx
Finding:
Asked about activities of daily life
Finding:
Reports recent difficulty participating in usual activities
(Found)
Pro Tip: Asking about changes in activity level will help determine the level of disability caused by your patient’s condition. Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved
Example Question:
How has your xxx?
Finding:
Reports low xxx
(Found)
Pro Tip: Asking about x will help determine thxxe level of xxxxcaused by your patient’sxxxx.
Example Question:
Do you have x?xx
Finding:
Asked aboutxxxx
Finding:
Reports current xxx
(Found)
Pro Tip: In xxx patients, xxx is often caused byxx, xxxx side effects, xxx diets, and difficulty ambulating to the toilet, which can result in deliberate retention of xxx
Example Question:
Are you xxxx?
Finding:
Reports no history of xxxx
(Available)
Pro Tip: x
Example Question:
Are you xxx
Finding:
Followed up aboutxxx
Finding:
Reports constipation for 5 days
(Found)
Pro Tip: Whenever you are assessing a symptom or a health condition, inquiring about x assxxesses the xxxx and the xxx of the problem.
Example Question:
For how long have you beenxxxx
Finding:
Reports no attempt to treat xxx
(Found)
Pro Tip: Asking about how your patient has been managing her pain assesses her current condition and her approach to self-care. The results of her previous treatment may be helpful in your diagnosis and the development of her new treatment plan, as well as a good opportunity to educate your patient on effective self-care practices.
Example Question:
How have you tried to treat thexxxx
Finding:
Asked about xxxx
Finding:
Reports recent xxxx
(Found)
Pro Tip: Whenever you are assessing a symptom or a health condition, inquiring about onset assesses the severity and the progression of the problem. Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved.
Example Question:
Have you recently had xxx
Finding:
Followed up about xxxx
Finding:
Reports xxxx
(Found)
Pro Tip: It’s important to ask about changes in stool characteristics because it may be a sign of a new onset of a gastrointestinal disease or disorder. xxxx is a common symptom of inflammatory bowel diseases, food allergies and intolerance, gastrointestinal infections, and many other conditions.
Example Question:
How long ago did you xxxx
Finding:
Reports xxxx had a sudden onset
(Found)
Pro Tip: It’s important to ask about changes in stool characteristics because it may be a sign of a new onset of a gastrointestinal disease or disorder. xxx is a common symptom of inflammatory bowel diseases, food allergies and intolerance, gastrointestinal infections, and many other conditions.
Example Question:
Did the xxxx happen suddenly?
Finding:
Reports diarrhea lasted one day
(Found)
Pro Tip: It’s important to ask about changes in stool characteristics because it may be a sign of a new onset of a gastrointestinal disease or disorder. Diarrhea is a common symptom of inflammatory bowel diseases, food allergies and intolerance, gastrointestinal infections, and many other conditions.
Example Question:
How long did your diarrhea last?
Finding:
Describes diarrhea as loose and watery
(Available)
Pro Tip: Asking a patient who has diarrhea to describe her stool helps identify its cause and the severity. Patients may not know how to answer, so you may need to suggest words like frothy, greasy, floating, or watery. It is also important to inquire about the presence of blood or mucus. Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved.
Example Question:
How would you describe the diarrhea?
Finding:
Asked about bowel movement patterns
Finding:
Reports last bowel movement 3 days ago
(Found)
Pro Tip: Whenever you are assessing a symptom or a health condition, inquiring about onset assesses the severity and the progression of the problem.
Example Question:
When did the constipation start?
Finding:
Reports some discomfort during bowel movement
(Available)
Pro Tip: It’s important to ask about changes in stool characteristics because it may be a sign of a new onset of a gastrointestinal disease or disorder.
Example Question:
Do you have pain during bowel movements?
Finding:
Last bowel movement was diarrhea
(Available)
Pro Tip: It’s important to ask about changes in stool characteristics because it may be a sign of a new onset of a gastrointestinal disease or disorder. Diarrhea is a common symptom of inflammatory bowel diseases, food allergies and intolerance, gastrointestinal infections, and many other conditions.
Example Question:
What was the character of your last bowel movement?
Finding:
Reports no mucus in stool
(Found)
Pro Tip: While small amounts of mucus may be present in normal stool, increased mucus in the stool is associated with a variety of intestinal disorders.
Example Question:
Has there been mucus in your stool?
Finding:
Reports no blood in stool
(Found)
Pro Tip: Bloody stool is an alarming symptom that indicates bleeding in the digestive tract. Bright red bloody stool suggests bleeding in the colon or rectum. Bloody stool that appears black or tarry suggests bleeding in upper digestive tract, such as the small intestine or stomach.
Example Question:
Has there been blood in your stool?
Finding:
Reports typically having a bowel movement almost every day
(Found)
Pro Tip: Asking about usual bowel movements facilitates baseline data collection. Asking specifically about bowel movement frequency aids in the identification of abnormalities.
Example Question:
How many bowel movements do you typically have per week?
Finding:
Reports stools usually brown, formed, and soft
(Found)
Pro Tip: Asking about usual bowel movements facilitates baseline data collection. Asking specifically about bowel movement frequency aids in the identification of abnormalities. Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved.
Example Question:
Can you describe a typical bowel movement?
Finding:
Asked about urination
Finding:
Reports recent, slight decrease in frequency of urination
(Found)
Pro Tip: Frequency of urination can be an important clue to many underlying conditions. It’s important to ask whether your patient has noticed changes in her typical habits.
Example Question:
Have you had any changes in the frequency of your urination?
Finding:
Reports darker urine recently
(Found)
Pro Tip: Darker urination can be an important clue to many underlying conditions like cirrhosis or hepatitis. It’s important to ask whether your patient has noticed changes in her typical urinary patterns.
Example Question:
Has your urine been darker recently?
Finding:
Reports no blood in urine
(Found)
Pro Tip: Blood in the urine can be an important clue to many underlying conditions like cancer or kidney problems. It’s important to ask whether your patient has noticed changes in her typical urinary patterns.
Example Question:
Have you had blood in your urine?
Medical History
Finding:
Asked about medications
Finding:
Reports blood pressure medication
(Found)
Pro Tip: The medication that a patient takes will indicate any relevant health conditions, their treatment plan, and how well they comply with it. Asking about relevant medication will help you to treat your patient.
Example Question:
Do you take medication for your blood pressure?
Finding:
Reports Accupril
(Available)
Pro Tip: The medication that a patient takes will indicate any relevant health conditions, their treatment plan, and how well they comply with it. Asking about relevant medication will help you to treat your patient.
Example Question:
What medication do you take for your blood pressure?
Finding:
Accupril is 10 mg
(Found)
Pro Tip: The medication that a patient takes will indicate any relevant health conditions, their treatment plan, and how well they comply with it. Asking about relevant medication will help you to treat your patient.
Example Question:
What dose of blood pressure medication do you take?
Finding:
Taken daily at 8 a.m.
(Found)
Pro Tip: The medication that a patient takes will indicate any relevant health conditions, their treatment plan, and how well they comply with it. Asking about relevant medication will help you to treat your patient. Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved
Example Question:
When did you last take blood pressure medication?
Finding:
Reports no OTC use
(Found)
Pro Tip: Patients should always be asked specifically about over-the-counter medications, as many patients will overlook talking about them. Over-the-counter medications can cause medical complications of their own or can indicate medical problems that your patient has been attempting to self-treat.
Example Question:
Do you take any over-the-counter medications?
Finding:
Asked about allergies
Finding:
Reports latex allergy
(Found)
Pro Tip: Latex allergies can cause severe and even life-threatening consequences. Always asking specifically about allergies can help ensure that your patient does not receive medication or treatment that will do her harm.
Example Question:
Are you allergic to latex?
Finding:
Reports no medication allergies
(Found)
Pro Tip: Medication allergies can cause severe and even life-threatening consequences. Always asking specifically about these allergies can help ensure that your patient does not receive medication that will do her harm.
Example Question:
Are you allergic to any medications?
Finding:
Reports no food allergies
(Found)
Pro Tip: Knowing your patient’s food allergies prevents your patient from receiving harmful food, and it helps to identify specific allergies–such as shellfish or eggs–which can contraindicate the administration of common medications or treatments that include derivatives of these substances.
Example Question:
Do you have any food allergies?
Finding:
Asked about general known health conditions
Finding:
Reports hypertension
(Found)
Pro Tip: It’s best to determine specifically whether or not the condition has been diagnosed by a healthcare professional.
Example Question:
Do you have high blood pressure?
Finding:
Diagnosed with hypertension at age 54
(Available)
Pro Tip: Learning the diagnosis date of your patient’s illness is an essential element of the illness’s history.
Example Question:
At what age were you diagnosed with hypertension? Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved
Finding:
Asked about relevant gastrointestinal history
Finding:
Reports no history of gastrointestinal disorders
(Found)
Pro Tip: Broad open questions are efficient and useful in eliciting a large amount of information from your patient. Asking about any gastrointestinal problems helps guide your assessment.
Example Question:
Do you have any GI conditions?
Finding:
Reports no history of GERD, heartburn, or ulcer
(Found)
Pro Tip: If a patient has a history of GERD, ulcer, heartburn, or perceived indigestion, it could contribute to her present condition.
Example Question:
Do you have a history of heartburn?
Finding:
Reports no history of appendicitis
(Found)
Pro Tip: In patients with lower quadrant abdominal pain, confirming a previous appendectomy can help rule out appendicitis as a cause for her current symptoms. It is important to note that elderly patients with appendicitis may present atypically and often lack certain classic symptoms such as rebound tenderness, right lower quadrant pain, fever, and anorexia.
Example Question:
Have you ever had appendicitis?
Finding:
Reports no history of stomach cancer
(Found)
Pro Tip: If a patient has a history of stomach cancer, abdominal pain could be a sign of recurrence.
Example Question:
Do you have a history of stomach cancer?
Finding:
Reports no history of liver disease
(Found)
Pro Tip: A history of liver disease could cause additional gastrointestinal complaints for a patient.
Example Question:
Do you have a history of liver disease?
Finding:
Asked about relevant history of surgery
Finding:
Reports c-section
(Found)
Pro Tip: Information about your patient’s pregnancy complications can provide you with insight into past medical conditions. Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved
Example Question:
Did you have any complications during pregnancy?
Finding:
C-section at age 40
(Found)
Pro Tip: Information about your patient’s pregnancy can provide you with insight into past medical conditions.
Example Question:
At what age did you have a C-section?
Finding:
Reports cholecystectomy
(Found)
Pro Tip: Information about your patient’s past surgeries can provide you with insight into past medical conditions.
Example Question:
Have you had your gallbladder removed?
Finding:
Cholecystectomy at age 42
(Found)
Pro Tip: Establishing a timeline about your patient’s past surgeries can provide you with insight into past medical conditions.
Example Question:
At what age did you have your gallbladder removed?
Finding:
Reports no post-operative complications
(Available)
Pro Tip: Asking about any postoperative complications in your patient’s history may provide information relevant to identifying her present condition.
Example Question:
Did you have any complications after your surgery?
Social History
Finding:
Asked about diet
Finding:
Reports last meal was toast at breakfast
(Found)
Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Asking Esther about her last meal will indicate her typical eating habits and allow you to assess whether her eating habits put her at risk of cardiovascular disease or other health complications.
Example Question:
What was your last meal?
Finding:
Typically eats 3 meals
(Found)
Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Asking Esther about what she typically eats will allow you to assess whether her eating habits put her at risk of cardiovascular disease or other health complications.
Example Question:
How many meals do you typically eat in a day?
Finding:
Typically does not eat snacks
(Found)
Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Asking Esther about what she typically has for a snack will allow you to assess whether her eating habits put her at risk of cardiovascular disease or other health complications.
Example Question:
What is a typical snack for you?
Finding:
Typical breakfast is a piece of fruit
(Found)
Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Asking Esther about what she typically eats for breakfast will allow you to assess whether her eating habits put her at risk of cardiovascular disease or other health complications.
Example Question:
What do you usually eat for breakfast?
Finding:
Typical lunch is soup, sometimes skips lunch
(Found)
Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Asking Esther about what she typically eats for lunch will allow you to assess whether her eating habits put her at risk of cardiovascular disease or other health complications. Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved
Example Question:
What do you usually eat for lunch?
Finding:
Typical dinner is chicken or fish with vegetables and rice
(Found)
Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Asking Esther about what she typically eats for dinner will allow you to assess whether her eating habits put her at risk of cardiovascular disease or other health complications.
Example Question:
What do you usually eat for dinner?
Finding:
Asked about fiber intake
Finding:
Reports no fiber supplements
(Found)
Pro Tip: A high fiber diet helps to reduce constipation. Asking Esther if she takes fiber supplements will help you to assess whether she gets enough fiber in her diet.
Example Question:
Do you take fiber supplements?
Finding:
Reports belief that she gets enough fiber
(Found)
Pro Tip: A high fiber diet helps to reduce constipation. Asking Esther about her fiber consumption will help you to assess whether she gets enough fiber in her diet.
Example Question:
Do you think you get enough fiber?
Finding:
Reports getting fiber from a daily vegetable
(Found)
Pro Tip: A high fiber diet helps to reduce constipation. Asking Esther what sources of fiber she eats will help you to assess whether she gets enough fiber in her diet. Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved
Example Question:
What sources of fiber do you eat?
Finding:
Reports getting fiber from a daily piece of fruit
.
.
.
Objective Data Collection: 26 of 26 (100%)
Correct
Partially correct
Incorrect
Missed
Inspected head and face
1 of 1 point
Skull Symmetry (1/3 point)
Symmetric
Asymmetric
Facial Feature Symmetry (1/3 point)
Symmetric
Asymmetric
Appearance (1/3 point)
No visible abnormal findings
Flushed appearance
Rash or lesion
Skin growths (freckles, moles, or birth mark)
Excessive hair growth
Evidence of skin trauma (scar, laceration, or bruising)
Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved
Inspected nasal mucosa
1 of 1 point
Appearance (1/1 point)
Moist and pink
Dry appearance
Redness
Inspected mouth
1 of 1 point
Oral Mucosa (1/1 point)
Moist and pink
Dry appearance
Redness
Inspected abdomen
1 of 1 point
Inspected for edema in lower extremities
1 of 1 point
Auscultated heart sounds
1 of 1 point
Auscultated breath sounds
1 of 1 point
Auscultated abdominal aorta
1 of 1 point
Auscultated bowel sounds
1 of 1 point
Bowel Sounds (1/2 point)
Absent
Hypoactive
Normoactive
Hyperactive
Location Of Non Normoactive Bowel Sounds (1/2 point)
All quadrants normoactive
Right upper quadrant
Right lower quadrant
Left upper quadrant
Left lower quadrant
Auscultated abdominal arteries
1 of 1 point
Auscultated organs
1 of 1 point
Percussed abdomen
1 of 1 point
Percussed spleen
1 of 1 point
Percussed liver
1 of 1 point
Percussed CVA tenderness
1 of 1 point
Palpated abdomen – light
1 of 1 point
Tenderness (1/3 point)
None reported
Tenderness reported
Location Of Tenderness (1/3 point)
No quadrants tender
Right upper quadrant
Right lower quadrant
Left upper quadrant
Left lower quadrant
Observations (1/3 point)
No additional observations
Masses
Guarding
Distension
Palpated abdomen – deep
1 of 1 point
Palpated aortic width
1 of 1 point
Palpated liver
1 of 1 point
Palpated spleen
1 of 1 point
Palpated bladder
1 of 1 point
Palpated kidneys
1 of 1 point
Right (1/2 point)
Not palpable
Palpable
Left (1/2 point)
Not palpable
Palpable
Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved
Tested skin turgor
1 of 1 point
Performed pelvic exam
1 of 1 point
Performed digital rectal exam
1 of 1 point
Observations (1/1 point)
No abnormal findings
Hemorrhoids
Fissures
SHADOW HEALTH ASSESSMENT HELP EXPERTS
Ulceration
Weak sphincter tone
Fecal mass in rectal vault
Checked urinalysis
1 of 1 point
.
.
.
Education & Empathy : 5 of 7 (71.4%)
During the patient interview, there are a number of opportunities to provide patient education and empathy. The opportunities listed below are those identified by nursing experts to be of particular importance to this patient. A Model Statement is provided as an example of an appropriate response to each opportunity.
Opportunities marked as Not Encountered are opportunities that were not elicited in the interview
Opportunities marked as Not Followed Up are missed opportunities that were present in the interview, but where no statements were made
Opportunities marked as Followed Up were followed up by students, and include the dialogue between student and patient Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved.
1 Symptoms
Followed Up
Description: Ms. Park describes the symptoms that have been bothering her.
What brings to the clinic today?
Question
11:26 AM PDT
I have some pain in my belly. . . and I’m having difficulty going to the bathroom. My daughter was worried about me.
i am sorry you are having pain in your belly.
Empathize
11:27 AM PDT
Thank you.
When did the abdominal discomfort begin?
Question
11:27 AM PDT
It all started. . . about five days ago. When I started having trouble going to the bathroom. Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved
I am sorry to hear this.
Empathize
11:28 AM PDT
Thank you.
Does eating aggravate the pain?
Question
11:37 AM PDT
Yes. The pain is there all the time, but eating can make it worse.
does physical activity aggravate pain?
Question
11:38 AM PDT
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.
i am sorry for th discomfort.
Empathize
11:38 AM PDT
Thank you.
do you get constipation often?
Question
11:51 AM PDT
I don’t usually have problems going to the bathroom. . . but this has been going on for. . . about five days now. [AUDIO COMING SOON]
How many bowel movements do you typically have per week?
Question
11:52 AM PDT
Before this? Every day. Well, I miss a day now and then, but usually every day.
Are your stools usually formed?
Question
11:53 AM PDT
Usually, yes. But not when I had the diarrhea.
are your stools typically soft ?
Question
11:54 AM PDT
I haven’t even been able to move my bowels! I had diarrhea a while back, though . . . six months ago, maybe.
You said you have latex allergy? (Clarified to: What are the symptoms of your latex allergy?)
Question
11:54 AM PDT
I get an itchy skin rash. (Clarified to: what the symptoms of my latex allergy are)
sorry about this skin rash.
Empathize
11:55 AM PDT
Thank you.
Do you have problems with eating?
Question
12:28 PM PDT
Yes. I haven’t eaten much these last few days.
Sorry about that.
Empathize
12:29 PM PDT
Thank you.
Do you have problems getting in and out of chairs?
Question
12:30 PM PDT
Any kind of movement makes my abdominal discomfort worse, but I don’t usually have problems with that.
Am sorry for that discomfort.
Empathize
12:31 PM PDT
Thank you.
Model Statement: “I’m sorry you’re having these symptoms. It’s good that you came in today so we can see what is causing your discomfort.” Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved
2 Medications
Followe
