Shadow Health Focused Exam, COPD- Subjective Data Collection Latest Updated

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7/14/2021 Focused Exam: Abdominal Pain | Completed | Shadow Health https://ichs.shadowhealth.com/assignment_attempts/10179355 1/5 Focused Exam: Abdominal Pain Results | Completed ICHS - Capstone ... Spring 2021 - June 2021, nur2811ug Return to Assignment (/assignments/507937/) Sales Tax Notification: Elsevier Inc. DBA Shadow Health charges applicable sales tax as required by state and local (/site_notice_dismissals?from_flash=true&site_noti regulations. Sign up for a live usability session! Click here for more information. Click here for more information (/site_notice_dismissals?from_flash=true&site_noti (https://www.surveymonkey.com/r/B9X2S3Y) Subjective Data Collection: 40 of 41 (97.6%) Chief Complaint Orientation History of Presenting Illness Your Results Turn In (/assignment_attempts/10179355/cho Reopen (/assignment_attempts/10179355/reope Lab Pass (/assignment_attempts/10179355/lab_pass. Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Care Plan Self-Reflection Indicates an item that you found. Indicates an item that is available to be found. 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 yie better patient data. The following details are facts o patient's case. Established chief complaint Reports abdominal pain Reports difficulty with bowel movements Asked about orientation Oriented to own person Oriented to place Oriented to situation Oriented to time Asked about onset of the pain Reports discomfort for the past five days Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. Support This study source was downloaded by 100000817113117 from CourseHero.com on 09-14-2021 07:10:40 GMT -05:00 https://www.coursehero.com/file/102320037/Focused-Exam-Abdominal-Pain-Completed-Shadow-Health-Esther-Park-Subjective-Data-Collection/ This study resource was shared via CourseHero.com 7/14/2021 Focused Exam: Abdominal Pain | Completed | Shadow Health https://ichs.shadowhealth.com/assignment_attempts/10179355 2/5 Reports pain worsened intensely 2-3 days ago Asked about location of the pain Reports pain in lower abdomen Reports pain is not localized Denies flank pain Asked about pain rating on a scale Reports current pain rating of 2/10 Reports pain at its lowest is 2/10 Reports pain at its worst is 8/10 Asked about characteristics of the pain Describes pain as dull Describes pain as cramping Describes pain as constant Describes pain as fluctuating in severity Asked about non-pharmacological relieving factors Reports that resting helps relieve pain Reports drinking warm water to relieve pain was ineffective Asked about pharmacological relieving factors Denies taking pain medication Denies taking laxatives Asked about aggravating factors Reports pain is aggravated by eating Reports pain is aggravated by physical activity Asked about impact of pain on daily life Reports recent difficulty participating in usual activities Reports low energy Followed up on constipation Reports current constipation Reports constipation all of last 5 days Asked about diarrhea Reports recent diarrhea Followed up on diarrhea Reports diarrhea about six months ago Reports diarrhea had a sudden onset Reports diarrhea lasted one day Asked about substances in stool Denies mucus in stool Denies blood in stool Asked about urination Reports slight decrease in frequency of urination Reports darker urine recently Denies blood in urine Asked about fluid intake Reports decreased thirst Reports decreased fluid intake for the last few days Typical fluid intake is 1-2 glasses of water a day Denies drinking caffeinated drinks such as coffee or soda This study source was downloaded by 100000817113117 from CourseHero.com on 09-14-2021 07:10:40 GMT -05:00 https://www.coursehero.com/file/102320037/Focused-Exam-Abdominal-Pain-Completed-Shadow-Health-Esther-Park-Subjective-Data-Collection/ This study resource was shared via CourseHero.com 7/14/2021 Focused Exam: Abdominal Pain | Completed | Shadow Health https://ichs.shadowhealth.com/assignment_attempts/10179355 3/5 Past Medical History Home Medications Social History Asked about history of constipation Denies history of constipation Asked about typical bowel movements Reports typically having a bowel movement almo every day Reports typical stools are brown Reports typical stools are formed Reports typical stools are soft Asked about allergies Reports latex allergy Denies medication allergies Denies food allergies Asked about health maintenance Reports annual check-ups Reports last Pap smear was over 10 years ago Reports belief that her level of health and activity is very good for her age Reports colonoscopy 10 years ago Asked about sexually transmitted infections Denies ever getting STI testing Denies STI symptoms Asked about current sexual activity Reports currently sexually active Asked about pre-existing health conditions Reports high blood pressure Asked about history of surgery Reports C-section Reports C-section at age 40 Reports cholecystectomy Reports cholecystectomy at age 42 Denies post-operative complications Asked about typical medications Reports high blood pressure medication Followed up on high blood pressure medication Reports medication for high blood pressure is quinapril (Accupril) Reports high blood pressure medication is 10 mg Reports taking high blood pressure medication daily at 8 a.m. Denies typically taking any OTC medications Asked about activities of daily living Denies difficulty toileting alone Denies difficulty dressing Denies difficulty feeding self Denies difficulty walking Denies difficulty bathing Denies difficulty transferring in and out of chairs This study source was downloaded by 100000817113117 from CourseHero.com on 09-14-2021 07:10:40 GMT -05:00 https://www.coursehero.com/file/102320037/Focused-Exam-Abdominal-Pain-Completed-Shadow-Health-Esther-Park-Subjective-Data-Collection/ This study resource was shared via CourseHero.com 7/14/2021 Focused Exam: Abdominal Pain | Completed | Shadow Health https://ichs.shadowhealth.com/assignment_attempts/10179355 4/5 Review of Systems Asked about diet Reports last meal was toast at breakfast Reports typically eating 3 meals Denies eating snacks regularly Reports typical breakfast is toast Reports typical lunch is soup Reports sometimes skipping lunch due to low appetite Reports typical dinner is chicken or fish with rice Asked about fiber intake Denies taking fiber supplements Denies efforts to incorporate fiber in her diet Reports eating a vegetable every 1 or 2 days Reports eating fruit every 3 or 4 days Asked about typical activity level Reports typically high level of mobility and independence Reports typically having a moderate activity level Asked about substance use Denies illicit drug use Denies cigarette smoking Reports low alcohol consumption Followed-up on alcohol consumption Reports drinking 1 night a week Reports 1 drink per sitting Reports typical drink is white wine Asked about psychosocial history Reports living with her daughter Reports strong familial support system Denies recent travel Asked about experience of abuse Denies being physically abused Denies being sexually abused Denies being emotionally abused Denies being financially abused Denies being verbally abused Asked about constitutional health Denies recent weight changes Denies recent fever Denies chills Denies night sweats Denies swelling Reports short-term feeling of exhaustion Denies sleep issues Asked about history of gastrointestinal disorders Denies history of GERD or ulcer Denies history of appendicitis Denies history of stomach cancer Denies history of liver disease Asked about cardiovascular health Denies palpitations Denies chest discomfort Denies racing heartbeat This study source was downloaded by 100000817113117 from CourseHero.com on 09-14-2021 07:10:40 GMT -05:00 https://www.coursehero.com/file/102320037/Focused-Exam-Abdominal-Pain-Completed-Shadow-Health-Esther-Park-Subjective-Data-Collection/ This study resource was shared via CourseHero.com 7/14/2021 Focused Exam: Abdominal Pain | Completed | Shadow Health https://ichs.shadowhealth.com/assignment_attempts/10179355 5/5 Asked about throat irritation Denies sore throat Asked about respiratory health Denies coughing Denies difficulty swallowing Denies difficulty breathing Asked additional review of systems for gastrointestinal Reports bloating Reports slight increase in gas Reports loss of appetite in the past few days Denies nausea Denies vomiting Denies food poisoning Asked review of systems for genitourinary Denies history of bladder problems Denies painful urination Denies burning with urination Denies urinary incontinence Denies history of UTIs Denies holding in urine unnecessarily Denies gynecological problems Denies vaginal bleeding Denies vaginal discharge Reports onset of menopause was age 54 Denies history of kidney problems Comments If your instructor provides individual feedback on this assignment, it will appear here. © Shadow Health 2012 - 2021 (800) 860-3241 | Help Desk (https://support.shadowhealth.com/) | Terms of Service (/static/terms_of_service) | Privacy Policy ↗ (/static/privacy_policy) | Patents (https://www.shadowhealth.com/patents) ® This study source was downloaded by 100000817113117 from CourseHero.com on 09-14-2021 07:10:40 GMT -05:00 https://www.coursehero.com/file/102320037/Focused-Exam-Abdominal-Pain-Completed-Shadow-Health-Esther-Park-Subjective-Data-Collection/ This study resource was shared via CourseHero.com [Show More]

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