Esther Park – Focused Exam: Abdominal Pain Results Health Assessment – January 2023

Transcript

Started: Mar 03, 2023 | Total Time: 105 min

All Lines (140)Interview Questions (53)Statements (1)Exam Actions (86)

	Hello!
	Hi. I’m Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript.
	What is the situation?
	Your patient is Esther Park, a 78-year-old Korean-American woman presenting with abdominal pain in Shadow General Hospital’s Emergency Department. Your role in this simulation is that of a healthcare provider who will conduct a focused history and physical examination of Ms. Park in order to assess her condition and transfer her care.
	What are my objectives in this assessment?
	In your interview with Ms. Park, you will ask about the history of her presenting illness and the functioning of relevant systems in order to obtain subjective data related to her abdominal pain. If you discover any disease states, ask about symptoms and the patient’s experiences of them. Your questioning should cover a broad array of the symptoms’ characteristics. In addition to collecting subjective data, you will perform a physical exam on Ms. Park to gather objective data about her health and physiology. Throughout the conversation, you should educate and empathize with Ms. Park when appropriate to increase her health literacy and sense of well-being. While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam activities in any order and move between them as needed.
	What else will this exam involve?
	You will complete nursing tasks to protect the patient’s safety, privacy, and health. You can document your findings, including vital signs, in the Electronic Health Record. This record provides necessary information for healthcare professionals who will continue patient care.
	How will I be evaluated?
	The activities evaluated by the simulation are Subjective and Objective Data Collection and Education and Empathy. Nursing tasks and Documentation, while they provide valuable practice for their real-world counterparts, are not automatically evaluated by the simulation. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. The evaluation of your physical exam is based on how successfully you report on your physical findings by selecting among clinical terms in the Electronic Health Record. Your success in Education and Empathy is based on whether you promptly respond after identifying a moment worthy of therapeutic communication. This assignment takes on average between 45 and 60 minutes. You can pause and resume the assignment at any time; your work is always saved automatically.
	How does this assignment prepare me for the real world?
	In this assessment, you will become familiarized with the structure and content of an abdominal focused exam so that with real-life patients, you can: º ask effective and comprehensive questions º educate and empathize with the patient º evaluate the patient’s risk of disease, infection, injury, and complications º and obtain and assess objective data
	In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: In a geriatric patient, what are some common considerations regarding abdominal pain?
	Physiologic changes associated with aging
	Time to begin.
	Hi, my name is Nukol, how can I help? (No matching questions found.)
	Hi, my name is Nukol. I will be your nurse today.
	Hi. I’m. . .I have this pain in my stomach.
	I am sorry for that
	Thank you, dear.
	Do you know where you are?
	Yes. I am at Shadowville General Hospital. [AUDIO COMING SOON]
	When did the the pain start?
	The pain started as a general discomfort, about five days ago, when I started having the. . . difficulties going to the bathroom.
	How can you rate the pain on a scale?
	It has its ups and downs. At the moment, I’d say it’s a 2.
	where is the location of the pain?
	The pain and discomfort is down low in my belly.
	Do you take pain medications? (Clarified to Are you taking a prescription pain med?.)
	No. The only time I’ve ever taken those was ages ago, after my surgeries. (Clarified to if I am taking prescription pain meds.)
	Do you take pain medications? (Clarified to Are you taking anything for pain?.)
	I’m not taking anything for it. (Clarified to if I am taking pain medication.)
	Do you use non-pharmacological relieving factors? (No matching questions found.)
	non-pharmacological relieving factors? (No matching questions found.)
	do you take laxatives?
	No. I can’t imagine they are very good for you.
	What aggravates the pain?
	Moving around certainly doesn’t help. Neither does eating.
	How does it impact on daily life? (Clarified to How does your health affect your activities of daily living?.)
	Well, I have been slowed down lately. This week I missed both of my fitness classes. I never miss a class. . . and I like to help with the cleaning at home, but I’m just too weak. It’s very discouraging. (Clarified to how my health affects my activities of daily living.)
	what relieves the pain?
	Resting seems to settle things down a little, but there doesnt seem to be any real relief.
	do you diarrhea?
	No. The last time I had anything of that nature was . . . maybe six months ago.
	is there mucus on stool? (Clarified to Have you had mucus in your stool?.)
	No, I haven’t noticed anything like that. (Clarified to if there has been mucus in my stool.)
	Do you urinate normally?
	I’ve been going slightly less often because. . . well, I’ve been little less thirsty than usual.
	have you contacted illnesses? (No matching questions found.)
	have you contacted any illness? (Clarified to Have you been around anyone sick?.)
	I haven’t heard any of my friends complain of anything… anything similar to the symptoms I have. (Clarified to if I have been around anyone who is sick.)
	have you travelled recently?
	No, I haven’t gone on any trips in several years.
	have you been exposed to food poisoning?
	No, I didn’t eat anything unusual.
	have you been close to someone sick?
	I haven’t heard any of my friends complain of anything… anything similar to the symptoms I have.
	Do you have a history of constipation?
	I don’t usually have problems going to the bathroom, but this has been going on for . . . about five days now. It’s taken quite a toll.
	how is your bowel movement?
	My bowel movements are usually. . . what I assume one would call normal. Not too soft, a normal brown color. Fairly regular.
	Do you have allergies?
	I have an allergy to latex.
	do you have pre-existing health conditions? (Clarified to Do you have other health conditions?.)
	My only known health issue is hypertension, but it’s very well managed. At my age, I feel that’s very healthy. (Clarified to if I have other medical problems.)
	which medications do you take? (Clarified to What medications do you take?.)
	Just the medication for my blood pressure. (Clarified to what medications I am taking.)
	Have you had surgery?
	I’ve had two operations, both many years ago.
	How is your access to healthcare? (Clarified to Do you have difficulty accessing healthcare because of transportation?.)
	No. I dont drive anymore, but my daughter drives me around if I need it. [AUDIO COMING SOON] (Clarified to if I have difficulty accessing healthcare because of transportation.)
	How is your access to healthcare? (Clarified to Do you have access to healthcare?.)
	I have health insurance. Shadow Mutual. (Clarified to if I have access to healthcare.)
	How is your diet?
	I would say my diet is fine . . . I don’t do anything special.
	Do you have a cardiovascular system?
	I don’t have heart problems. Just a little high blood pressure.
	Do you have a urinary system?
	No, it seems normal enough to me. Maybe a little darker than usual.
	Do you have GYN problems?
	I haven’t had any.
	Do you drink alcohol?
	Yes, but very little.
	Do you use illicit drugs?
	I have never used drugs of any kind.
	Do you consume alcohol?
	Yes, but very little.
	Measured vitals
	Inspected general face: Slight flushing of cheeks
	Inspected forehead and scalp
	Inspected nose and mouth
	Inspected left side of face
	Inspected back of head
	Inspected left side of face
	Inspected general face: Slight flushing of cheeks
	Inspected right side of face
	Inspected back of head
	Inspected right side of face
	Inspected general face: Slight flushing of cheeks
	Performed otoscopic examination of right naris
	Performed otoscopic examination of left naris
	Inspected mouth and throat
	Inspected right side of abdomen
	Inspected front of abdomen
	Inspected right side of abdomen
	Inspected front of abdomen
	Inspected left side of abdomen
	Inspected front of abdomen
	Inspected right leg for edema: No edema
	Inspected front of legs for edema: No edema
	Inspected left leg for edema: No edema
	Inspected front of legs for edema: No edema
	Inspected right leg for edema: No edema
	Auscultated aortic area with the bell
	Auscultated aortic area with the diaphragm
	Auscultated pulmonic area with the diaphragm
	Auscultated pulmonic area with the bell
	Auscultated Erb’s point with the bell
	Auscultated Erb’s point with the diaphragm
	Auscultated tricuspid area with the diaphragm
	Auscultated tricuspid area with the bell
	Auscultated mitral area with the bell
	Auscultated mitral area with the diaphragm
	Auscultated mitral area with the bell
	Auscultated breath sounds in anterior right upper lobe
	Auscultated breath sounds in anterior left upper lobe
	Auscultated breath sounds in anterior right middle lobe
	Auscultated breath sounds in anterior left mid-chest (upper lobe)
	Auscultated breath sounds in anterior right lower lobe
	Auscultated breath sounds in anterior left lower lobe
	Auscultated breath sounds in posterior left upper lobe
	Auscultated breath sounds in posterior right upper lobe
	Auscultated breath sounds in posterior left mid-back (lower lobe)
	Auscultated breath sounds in posterior right mid-back (lower lobe)
	Auscultated breath sounds in posterior left lower lobe
	Auscultated breath sounds in posterior right lower lobe
	Auscultated breath sounds in posterior left lower lobe on side
	Auscultated breath sounds in posterior left lower lobe near spine
	Auscultated breath sounds in posterior right lower lobe near spine
	Auscultated breath sounds in posterior right lower lobe on side
	Auscultated aorta in abdomen
	Auscultated right upper quadrant
	Auscultated left upper quadrant
	Auscultated right lower quadrant
	Auscultated left lower quadrant
	Auscultated right renal artery
	Auscultated left renal artery
	Auscultated right iliac artery
	Auscultated left iliac artery
	Auscultated left femoral artery
	Auscultated right femoral artery
	Percussed right upper quadrant
	Percussed left upper quadrant
	Percussed right lower quadrant
	Percussed left lower quadrant
	Percussed right flank for CVA tenderness
	Percussed left flank for CVA tenderness
	Percussed for spleen
	Percussed for liver span: 7 cm in the mid-clavicular line
	Palpated right upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension
	Palpated left upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension
	Palpated right lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension
	Palpated left lower quadrant with light pressure: Tenderness reported; palpable guarding and distension, no masses
	Palpated right upper quadrant with deep pressure: No masses
	Palpated left upper quadrant with deep pressure: No masses
	Palpated left lower quadrant with deep pressure: Firm, oblong mass (2x4cm)
	Palpated right lower quadrant: with deep pressure: No masses
	Palpated for liver: Palpable 1 cm below right costal margin
	Palpated for spleen: Not palpable
	Palpated bladder: Not palpable; no distention or tenderness
	Palpated for right kidney: Not palpable
	Palpated for left kidney: Not palpable
	Tested skin turgor
	Hello, I am back
	Hello, dear.
	Do you take fiber supplements?
	No, I don’t take any extra fiber. I hadn’t quite considered it . . .
	How much alcohol do you take?
	Perhaps a glass of white wine a week.
	how is your gastrointestinal system?
	I suppose I have felt bloated. . .and less hungry.
	Do you have nausea?
	No. I haven’t vomited or had any nausea. It’s more of a problem with pain. . . and difficulty going to the bathroom.
	Do you have a problem with your genitourinary system?
	No. I have managed to avoid diabetes.
	Do you have a headache?
	No.
	Do you take any antibiotics?
	The only medication I take is for my blood pressure. It doesn’t seem to affect these belly troubles, one way or the other.
	Do you eat a lot of fiber?
	I don’t know how much fiber is in what . . . I don’t think about it, even. I have a vegetable every day or two, which I’d guess has fiber.
	Do you exercise?
	Yes, I usually love exercise–water aerobics, Pilates. . . I take classes at the community center. But with this pain and feeling so uncomfortable this week, I’ve skipped my classes. I don’t like that . . . I feel out of sorts.
	Do you have problem swallowing?
	No. I am able to swallow without any problems.

Subjective Data Collection: 36 of 41 (87.8%)

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.

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.

Example Question:

Do you have any abdominal pain?

Finding:

Reports difficulty with bowel movements

(Found)

Pro Tip: Understanding all of a patient’s reason for visiting is an important foundation to establish. If there are multiple symptoms, especially related symptoms like constipation and bowel pain, follow up on each one during your interview.

Example Question:

Are you able to have a bowel movement?

Orientation

Finding:

Asked about orientation

Finding:

Oriented to own person

(Available)

Pro Tip: You should ask geriatric patients to state their name so you can determine their cognitive functioning.

Example Question:

Can you tell me who you are?

Finding:

Oriented to place

(Found)

Pro Tip: You should ask geriatric patients to identify where they are so you can determine their cognitive functioning.

Example Question:

Do you know where you are right now?

Finding:

Oriented to situation

(Available)

Pro Tip: You should ask geriatric patients to identify their reason for being here so you can determine their cognitive functioning.

Example Question:

Do you know why you are here today?

Finding:

Oriented to time

(Available)

Pro Tip: You should ask geriatric patients to identify the date and year so you can determine their cognitive functioning.

Example Question:

What is the date and year?

History of Presenting Illness

Finding:

Asked about onset of the pain

Finding:

Reports discomfort for the past five days

(Found)

Pro Tip: Whenever you are assessing a symptom or a health condition, in this case stomach pain, inquiring about onset allows you to assess the severity and the progression of the problem.

Example Question:

How long have you had stomach pain?

Finding:

Reports pain worsened intensely 2-3 days ago

(Available)

Pro Tip: Whenever you are assessing a symptom or a health condition, in this case stomach pain, inquiring about changes in the pain allows you to assess the severity and the progression of the problem.

Example Question:

Has the stomach pain changed?

Finding:

Asked about location of the pain

Finding:

Reports pain in lower abdomen

(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

(Available)

Pro Tip: Identifying the location of your patient’s pain provides important clues about its cause and how to treat it best.

Example Question:

Is the pain in a specific spot?

Finding:

Denies flank pain

(Available)

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:

Asked about pain rating on a scale

Finding:

Reports current pain rating of 2/10

(Found)

Pro Tip: For many people, it is difficult to clearly describe pain. Asking your patient to rate her pain on a scale from zero to 10 develops a consistent measure of pain severity.

Example Question:

How would you rate your pain on a scale of one to ten?

Finding:

Reports pain at its lowest is 2/10

(Available)

Pro Tip: For many people, it is difficult to clearly describe pain. Asking your patient to rate her pain at its lowest on a scale from zero to 10 develops a consistent measure of pain severity.

Example Question:

How would you rate your pain at its lowest?

Finding:

Reports pain at its worst is 8/10

(Available)

Pro Tip: For many people, it is difficult to clearly describe pain. Asking your patient to rate her pain at its highest on a scale from zero to 10 develops a consistent measure of pain severity.

Example Question:

How would you rate your pain at its worst?

Finding:

Asked about characteristics of the pain

Finding:

Describes pain as dull

(Available)

Pro Tip: Asking your patient to describe her pain helps identify its cause and the severity. Patients may not know how to answer, so you may need to suggest words like sharp, dull, burning, throbbing, or shooting.

Example Question:

Can you describe the pain?

Finding:

Describes pain as cramping

(Available)

Pro Tip: Asking your patient to describe her pain helps identify its cause and the severity. Patients may not know how to answer, so you may need to suggest words like sharp, dull, burning, throbbing, or shooting.

Example Question:

Can you describe the pain?

Finding:

Describes pain as constant

(Found)

Pro Tip: It’s important to ask your patient if her pain is constant or intermittent in order to determine her level of discomfort and identify the cause of the pain. Constant pain is often best managed with around-the-clock pain medications.

Example Question:

Is your pain constant?

Finding:

Describes pain as fluctuating in severity

(Found)

Pro Tip: Whenever you are assessing a symptom or a health condition, in this case stomach pain, inquiring about changes in the pain allows you to assess the severity and the nature of the problem.

Example Question:

Does your pain fluctuate?

Finding:

Asked about non-pharmacological relieving factors

Finding:

Reports that resting helps relieve pain

(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:

What relieves your pain besides medication?

Finding:

Reports drinking warm water to relieve pain was ineffective

(Available)

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:

What relieves your pain besides medication?

Finding:

Asked about pharmacological relieving factors

Finding:

Denies taking pain medication

(Found)

Pro Tip: It’s important to assess the nature of pain by asking about relief. If you know your patient is taking pain medication, asking about the medication’s effectiveness can help you adjust treatment as needed.

Example Question:

Have you taken medication for the stomach pain?

Finding:

Denies taking laxatives

(Found)

Pro Tip: It’s important to assess the nature of pain by asking about relief. If you know your patient is taking laxatives for constipation, asking about the medication’s effectiveness can help you adjust treatment as needed.

Example Question:

Have you taken laxatives?

Finding:

Asked about aggravating factors

Finding:

Reports pain is aggravated by eating

(Found)

Pro Tip: Asking your patient what aggravates her pain can point to factors that exacerbate symptoms and the ways in which your patient is approaching self-care. In patients with stomach pain, whether or not eating exacerbates pain may help you identify the nature of the condition.

Example Question:

Does eating aggravate the pain?

Finding:

Reports pain is aggravated by physical activity

(Found)

Pro Tip: Asking your patient what aggravates her pain can point to factors that exacerbate symptoms and the ways in which your patient is approaching self-care. In patients with stomach pain, whether or not physical activity exacerbates pain may help you identify the nature of the condition.

Example Question:

Does physical activity aggravate the pain?

Finding:

Asked about impact of pain on 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.

Example Question:

How has your illness affected your daily life?

Finding:

Reports low energy

(Found)

Pro Tip: Asking about changes in energy level will help determine the level of disability caused by your patient’s condition.

Example Question:

Have you had low energy?

Finding:

Followed up on constipation

Finding:

Reports current constipation

(Found)

Pro Tip: Asking a patient with recent constipation if they are currently experiencing symptoms can help you to determine the patient’s discomfort level, ability to conduct an interview, and need for immediate care.

Example Question:

Are you constipated right now?

Finding:

Reports constipation all of last 5 days

(Found)

Pro Tip: Whenever you are assessing a symptom such as constipation, inquiring about onset allows you to assess the severity and the progression of the problem.

Example Question:

For how long have you been constipated?

Finding:

Asked about diarrhea

Finding:

Reports recent diarrhea

(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:

Have you had diarrhea recently?

Finding:

Followed up on diarrhea

Finding:

Reports diarrhea about six months ago

(Found)

Pro Tip: It’s important to ask about the onset of stool changes 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 ago did you get diarrhea?

Finding:

Reports diarrhea had a sudden onset

(Available)

Pro Tip: It’s important to ask about the suddenness of diarrhea 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:

Did the diarrhea happen suddenly?

Finding:

Reports diarrhea lasted one day

(Available)

Pro Tip: It’s important to ask about the duration of diarrhea 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:

Asked about substances in stool

Finding:

Denies 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:

Denies blood in stool

(Available)

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:

Asked about urination

Finding:

Reports 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:

Denies 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?

Finding:

Asked about fluid intake

Finding:

Reports decreased thirst

(Found)

Pro Tip: An increase in thirst can mean a variety of underlying conditions. Asking your patient if she has been thirstier than usual can indicate a possible underlying symptom.

Example Question:

Have you been thirstier lately?

Finding:

Reports decreased fluid intake for the last few days

(Found)

Pro Tip: Asking about fluid intake is a key component of a thorough health assessment, especially for patients experiencing symptoms often affected by hydration, like stomach pain and constipation.

Example Question:

Have you had changes in your fluid intake?

Finding:

Typical fluid intake is 1-2 glasses of water a day

(Available)

Pro Tip: Asking about how many glasses of water a patient drinks daily is a key component of a thorough health assessment, especially for patients experiencing symptoms often affected by hydration, like stomach pain and constipation.

Example Question:

How many glasses of water do you drink daily?

Finding:

Denies drinking caffeinated drinks such as coffee or soda

(Available)

Pro Tip: Asking about fluid intake is a key component of a thorough health assessment. Inadequate fluid intake or dehydration can be a common problem among aging adults.

Example Question:

Do you drink caffeinated beverages?

Past Medical History

Finding:

Asked about history of constipation

Finding:

Denies history of constipation

(Found)

Pro Tip: In geriatric patients, constipation is often caused by inadequate fluid intake, medication side effects, low-fiber diets, and difficulty ambulating to the toilet, which can result in retention of stool. Ask patients experiencing constipation whether it is a recurring issue so you can explore for potential causes.

Example Question:

Are you typically constipated?

Finding:

Asked about typical bowel movements

Finding:

Reports typically having a bowel movement almost every day

(Available)

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 typical stools are brown

(Found)

Pro Tip: Although it may be uncomfortable, it is important to ask about the color of usual bowel movements because the stool relays valuable information about gastrointestinal health.

Example Question:

Are your stools typically brown?

Finding:

Reports typical stools are formed

(Found)

Pro Tip: Although it may be uncomfortable, it is important to ask about formedness of usual bowel movements because the stool relays valuable information about gastrointestinal health.

Example Question:

Are your stools typically formed?

Finding:

Reports typical stools are soft

(Found)

Pro Tip: Although it may be uncomfortable, it is important to ask the softness or hardness of usual bowel movements because the stool relays valuable information about gastrointestinal health.

Example Question:

Are your stools typically soft?

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:

Do you have a latex allergy?

Finding:

Denies medication allergies

(Available)

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:

Denies food allergies

(Available)

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 health maintenance

Finding:

Reports annual check-ups

(Available)

Pro Tip: Access to healthcare and resources heavily influences one’s health condition. This information can be helpful when educating your patient and developing a discharge plan.

Example Question:

Do you have a primary care doctor?

Finding:

Reports last Pap smear was over 10 years ago

(Available)

Pro Tip: A regular Pap smear is indicated for female patients between 21 and 65. Checking your patient’s screening status can give important information about overall health care compliance as well as gynecological health.

Example Question:

When was your last pap smear?

Finding:

Reports belief that her level of health and activity is very good for her age

(Found)

Pro Tip: Your patient’s perception of health provides insight into her self-awareness, her health goals, and her approach to self-care. This information should be considered when developing her plan of care.

Example Question:

Do you feel you are healthy?

Finding:

Reports colonoscopy 10 years ago

(Available)

Pro Tip: Colonoscopies are an important part of geriatric health maintenance. Establishing Esther’s last colonoscopy will help you assess any possible complications with her colon.

Example Question:

Have you had a colonoscopy?

Finding:

Asked about sexually transmitted infections

Finding:

Denies ever getting STI testing

(Available)

Pro Tip: When assessing your patient’s sexual health, it is critical to ask whether she has been tested for sexually transmitted infections, especially patients with gastrointestinal conditions, as these are sometimes caused by STIs.

Example Question:

Have you ever been tested for STIs?

Finding:

Denies STI symptoms

(Available)

Pro Tip: When assessing your patient’s sexual health, it is critical to ask whether she has experienced symptoms of sexually transmitted infection. As many sexually transmitted infections are asymptomatic in women, your patient may not recognize if she has been infected.

Example Question:

Have you had STI symptoms?

Finding:

Asked about current sexual activity

Finding:

Reports currently sexually active

(Available)

Pro Tip: Sexual activity can increase your patient’s risk factor for sexually transmitted infections, so it’s important to ask specifically about current sexual activity.

Example Question:

Are you sexually active?

Finding:

Asked about pre-existing health conditions

Finding:

Reports high blood pressure

(Found)

Pro Tip: Asking generally about a patient’s pre-existing health conditions allows you to ascertain how well they are controlled and whether they may be affecting the patient’s present illness.

Example Question:

Do you have high blood pressure?

Finding:

Asked about history of surgery

Finding:

Reports C-section

(Available)

Pro Tip: Information about your patient’s pregnancy complications can provide you with insight into past medical conditions.

Example Question:

Did you have any complications during pregnancy?

Finding:

Reports C-section at age 40

(Available)

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

(Available)

Pro Tip: Information about your patient’s gallbladder and whether it has been removed can provide you with potential insight into her current gastrointestinal pain.

Example Question:

Have you had your gallbladder removed?

Finding:

Reports cholecystectomy at age 42

(Available)

Pro Tip: Information about your patient’s gallbladder and when it was removed can provide you with potential insight into her current gastrointestinal pain.

Example Question:

At what age did you have your gallbladder removed?

Finding:

Denies 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?

Home Medications

Finding:

Asked about typical medications

Finding:

Reports high 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, in this case for the patient’s high blood pressure, medication will help you to treat your patient.

Example Question:

Do you take high blood pressure medication?

Finding:

Followed up on high blood pressure medication

Finding:

Reports medication for high blood pressure is quinapril (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 the name of the medication, in this case for blood pressure, will help you to treat your patient.

Example Question:

What medication do you take for your high blood pressure?

Finding:

Reports high blood pressure medication is 10 mg

(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 the dose of the medication, in this case for blood pressure, will help you to treat your patient.

Example Question:

What dose is your high blood pressure medication?

Finding:

Reports taking high blood pressure medication daily at 8 a.m.

(Available)

Pro Tip: Asking about the last dose of the patient’s high blood pressure medication will help you to treat your patient, especially in considering whether there are contraindications for any new medications the patient may receive in care.

Example Question:

When do you take your high blood pressure medication?

Finding:

Denies typically taking any OTC medications

(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?

Social History

Finding:

Asked about activities of daily living

Finding:

Denies difficulty toileting alone

(Available)

Pro Tip: Due to their potentially impaired physical and cognitive functioning, geriatric people may have greater difficulty with activities of daily living. Asking older patients about their ability to get on and off the toilet allows you to determine if greater caretaking is necessary.

Example Question:

Do you have difficulty getting on and off the toilet?

Finding:

Denies difficulty dressing

(Available)

Pro Tip: Due to their potentially impaired physical and cognitive functioning, geriatric people may have greater difficulty with activities of daily living. Asking older patients about their ability to dress on their own allows you to determine if greater caretaking is necessary.

Example Question:

Do you have difficulty dressing yourself?

Finding:

Denies difficulty feeding self

(Available)

Pro Tip: Due to their potentially impaired physical and cognitive functioning, geriatric people may have greater difficulty with activities of daily living. Asking older patients about their ability to feed themselves allows you to determine if greater caretaking is necessary.

Example Question:

Do you have difficulty feeding yourself?

Finding:

Denies difficulty walking

(Available)

Pro Tip: Due to their potentially impaired physical and cognitive functioning, geriatric people may have greater difficulty with activities of daily living. Asking older patients about their ability to walk allows you to determine if greater caretaking is necessary.

Example Question:

Do you have difficulty walking?

Finding:

Denies difficulty bathing

(Available)

Pro Tip: Due to their potentially impaired physical and cognitive functioning, geriatric people may have greater difficulty with activities of daily living. Asking older patients about their ability to bathe on their own allows you to determine if greater caretaking is necessary.

Example Question:

Do you have difficulty bathing yourself?

Finding:

Denies difficulty transferring in and out of chairs

(Available)

Pro Tip: Due to their potentially impaired physical and cognitive functioning, geriatric people may have greater difficulty with activities of daily living. Asking older patients about their ability to get in and out of chairs allows you to determine if greater caretaking is necessary.

Example Question:

Do you have difficulty getting in and out of chairs?

Finding:

Asked about diet

Finding:

Reports last meal was toast at breakfast

(Available)

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:

Reports typically eating 3 meals

(Available)

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 per day?

Finding:

Denies eating snacks regularly

(Available)

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 do you typically eat for a snack?

Finding:

Reports typical breakfast is toast

(Available)

Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Asking Esther about what she typically has 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:

Reports typical lunch is soup

(Available)

Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Asking Esther about what she typically has for lunch 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 lunch?

Finding:

Reports sometimes skipping lunch due to low appetite

(Available)

Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Asking Esther about what she typically has for lunch 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 lunch?

Finding:

Reports typical dinner is chicken or fish with rice

(Available)

Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Asking Esther about what she typically has 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:

Denies taking 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:

Denies efforts to incorporate fiber in her diet

(Found)

Pro Tip: A high fiber diet helps to reduce constipation. Asking Esther about how she perceives her fiber consumption will help you to assess whether her intake and any gaps in health literacy.

Example Question:

Do you think you get enough fiber?

Finding:

Reports eating a vegetable every 1 or 2 days

(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.

Example Question:

What sources of fiber do you eat?

Finding:

Reports eating fruit every 3 or 4 days

(Available)

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.

Example Question:

Do you eat fruit?

Finding:

Asked about typical activity level

Finding:

Reports typically high level of mobility and independence

(Found)

Pro Tip: Assessing your patient’s typical level of activity and mobility will help you determine the level of disability associated with their current medical condition.

Example Question:

Do you stay active?

Finding:

Reports typically having a moderate activity level

(Found)

Pro Tip: Assessing your patient’s typical level of activity and mobility will help you determine the level of disability associated with their current medical condition.

Example Question:

What is your typical activity level?

Finding:

Asked about substance use

Finding:

Denies illicit drug use

(Found)

Pro Tip: Many drugs affect the central nervous system or can cause cardiovascular complications. Asking Esther if she uses illicit drugs will indicate whether drug use puts her at risk for health complications.

Example Question:

Do you use illicit drugs?

Finding:

Denies cigarette smoking

(Available)

Pro Tip: Tobacco affects the heart by reducing the amount of oxygen the blood is able to carry. Asking Esther if she uses tobacco will allow you to assess whether the condition is caused, in part, by tobacco use.

Example Question:

Do you smoke cigarettes?

Finding:

Reports low alcohol consumption

(Found)

Pro Tip: Chronic alcohol use can result in a range of health problems. Asking Esther whether she drinks alcohol will allow you to assess whether she has any indicators of alcoholism or other health conditions.

Example Question:

Do you consume alcohol?

Finding:

Followed-up on alcohol consumption

Finding:

Reports drinking 1 night a week

(Found)

Pro Tip: Finding out the number of nights a patient drinks each week is a good baseline for asking additional questions about alcohol consumption.

Example Question:

How many nights a week do you drink alcohol?

Finding:

Reports 1 drink per sitting

(Found)

Pro Tip: Asking the patient how many drinks she has per month is a way to gauge her understanding of her own level of drinking.

Example Question:

How many alcoholic drinks do you have in a month?

Finding:

Reports typical drink is white wine

(Found)

Pro Tip: The type of drink the patient consumes gives you a basic indicator of what proof of alcohol the patient is ingesting.

Example Question:

When you have alcohol, what do you typically drink?

Finding:

Asked about psychosocial history

Finding:

Reports living with her daughter

(Found)

Pro Tip: Asking your patient whom she lives with will help to identify any caregivers in the home who are available to assist her. Living situation can also relay information about your patient’s relationships, socioeconomic status, functional ability, and sense of self.

Example Question:

Do you live with anyone?

Finding:

Reports strong familial support system

(Found)

Pro Tip: Social support is important for coping with daily stressors and for maintaining quality of life. Your patient’s relationships with others can be assessed by your asking about social support.

Example Question:

Who can you go to for support?

Finding:

Denies recent travel

(Found)

Pro Tip: Recent travel or new experiences can result in gastrointestinal or other stressors. Asking Esther if she’s traveled recently might reveal a new experience that’s affected her health.

Example Question:

Have you traveled anywhere recently?

Finding:

Asked about experience of abuse

Finding:

Denies being physically abused

(Available)

Pro Tip: Due to their potentially impaired physical and cognitive functioning, geriatric people are particularly susceptible to an array of abuses. It is important to ask older patients if they are being physically abused so you can follow up appropriately.

Example Question:

Have you experienced any physical abuse?

Finding:

Denies being sexually abused

(Available)

Pro Tip: Due to their potentially impaired physical and cognitive functioning, geriatric people are particularly susceptible to an array of abuses. It is important to ask older patients if they are being sexually abused so you can follow up appropriately.

Example Question:

Have you experienced any sexual abuse?

Finding:

Denies being emotionally abused

(Available)

Pro Tip: Due to their potentially impaired physical and cognitive functioning, geriatric people are particularly susceptible to an array of abuses. It is important to ask older patients if they are being emotionally abused so you can follow up appropriately.

Example Question:

Have you experienced any emotional abuse?

Finding:

Denies being financially abused

(Available)

Pro Tip: Due to their potentially impaired physical and cognitive functioning, geriatric people are particularly susceptible to an array of abuses. It is important to ask older patients if they are being financially abused so you can follow up appropriately.

Example Question:

Have you experienced any financial abuse?

Finding:

Denies being verbally abused

(Available)

Pro Tip: Due to their potentially impaired physical and cognitive functioning, geriatric people are particularly susceptible to an array of abuses. It is important to ask older patients if they are being verbally abused so you can follow up appropriately.

Example Question:

Have you experienced any verbal abuse?

Review of Systems

Finding:

Asked about constitutional health

Finding:

Denies recent weight changes

(Available)

Pro Tip: Changes in weight can be a symptom of many medical conditions or may simply be a result of a change in lifestyle. It’s important to ask about changes in weight during your assessment.

Example Question:

Have you had any recent weight changes?

Finding:

Denies recent fever

(Available)

Pro Tip: When a patient presents with abdominal pain, the presence or absence of fever may help identify the patient’s condition.

Example Question:

Have you had a fever recently?

Finding:

Denies chills

(Available)

Pro Tip: If a patient has chills, it could indicate the onset of a fever.

Example Question:

Have you had chills?

Finding:

Denies night sweats

(Available)

Pro Tip: Night sweats can be a symptom of conditions such as perimenopause, or diseases or serious physical ailments.

Example Question:

Do you have night sweats?

Finding:

Denies swelling

(Available)

Pro Tip: Swelling can indicate allergic reaction or edema, both of which could be caused by medication.

Example Question:

Have you had any swelling?

Finding:

Reports short-term feeling of exhaustion

(Found)

Pro Tip: Asking about fatigue as a symptom is an important gauge for the seriousness of a patient’s condition, and as an indicator of the impact on the patient’s daily life.

Example Question:

Do you have fatigue?

Finding:

Denies sleep issues

(Available)

Pro Tip: Sleep issues can be an indicator of health problems, and it is important to ask the patient about it in order to narrow your treatment plan.

Example Question:

Have you had difficulty sleeping?

Finding:

Asked about history of gastrointestinal disorders

Finding:

Denies history of GERD or ulcer

(Available)

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:

Denies history of appendicitis

(Available)

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:

Denies history of stomach cancer

(Available)

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:

Denies history of liver disease

(Available)

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 cardiovascular health

Finding:

Denies palpitations

(Available)

Pro Tip: Palpitations might be an indicator of an underlying cardiovascular or mental health condition, such as anxiety.

Example Question:

Do you have palpitations?

Finding:

Denies chest discomfort

(Available)

Pro Tip: Chest discomfort could be a symptom of gastrointestinal conditions such as GERD.

Example Question:

Do you have chest pain?

Finding:

Denies racing heartbeat

(Available)

Pro Tip: Racing heart might be an indicator of an underlying cardiovascular or mental health condition, such as anxiety.

Example Question:

Does your heart race?

Finding:

Asked about throat irritation

Finding:

Denies sore throat

(Available)

Pro Tip: A sore throat could be a symptom of gastrointestinal conditions such as GERD.

Example Question:

Do you have a sore throat?

Finding:

Asked about respiratory health

Finding:

Denies coughing

(Available)

Pro Tip: Coughing could be a symptom of gastrointestinal conditions such as GERD.

Example Question:

Have you been coughing?

Finding:

Denies difficulty swallowing

(Found)

Pro Tip: Difficulty swallowing could be a symptom of gastrointestinal conditions such as GERD.

Example Question:

Do you have difficulty swallowing?

Finding:

Denies difficulty breathing

(Available)

Pro Tip: Difficulty breathing could be an indicator that the patient’s condition is serious. It’s important to confirm that a patient is able to breathe without problems.

Example Question:

Have you had difficulty breathing?

Finding:

Asked additional review of systems for gastrointestinal

Finding:

Reports bloating

(Found)

Pro Tip: Bloating can occur alone or as a symptom of an underlying disorder. It is important to assess other symptoms in order to determine the cause of bloating.

Example Question:

Do you feel bloated?

Finding:

Reports slight increase in gas

(Available)

Pro Tip: While the normal frequency of burping and flatus varies widely, a sudden or marked increase in gas can be a symptom of a gastrointestinal disorder. When a patient complains of increased gas, it is important to identify any co-occurring symptoms.

Example Question:

Do you have more gas than usual?

Finding:

Reports loss of appetite in the past few days

(Found)

Pro Tip: Assessing appetite guides understanding of patient health. Lack of appetite may indicate an abnormality.

Example Question:

How is your appetite?

Finding:

Denies nausea

(Found)

Pro Tip: Nausea is an important subjective symptom to understand in any gastrointestinal complaint.

Example Question:

Do you have nausea?

Finding:

Denies vomiting

(Found)

Pro Tip: Presence of vomiting would indicate a complaint such as food poisoning or infection.

Example Question:

Have you been vomiting?

Finding:

Denies food poisoning

(Found)

Pro Tip: If a patient has a past experience with food poisoning, she may be able to compare and contrast her present symptoms with previous illnesses.

Example Question:

Do you have food poisoning?

Finding:

Asked review of systems for genitourinary

Finding:

Denies history of bladder problems

(Found)

Pro Tip: If a patient has a history of bladder disease, it could contribute or relate to her present condition.

Example Question:

Do you have a history of bladder disease?

Finding:

Denies painful urination

(Available)

Pro Tip: It is important to ask about pain during urination to assess for infection or inflammation of the urinary tract.

Example Question:

Do you have any pain when you urinate?

Finding:

Denies burning with urination

(Available)

Pro Tip: It is important to ask about burning during urination to assess for infection or inflammation of the urinary tract.

Example Question:

Do you have burning with urination?

Finding:

Denies urinary incontinence

(Available)

Pro Tip: Stress incontinence is common in geriatric women, particularly those who have had multiple vaginal deliveries. It’s important to ask about incontinence, especially during physical strain, laughing, coughing, or sneezing.

Example Question:

Do you have problems holding your urine?

Finding:

Denies history of UTIs

(Available)

Pro Tip: A history of frequent or severe UTIs could lead to scar tissue in the urinary tract, bladder, or kidneys.

Example Question:

Have you had past urinary tract infections?

Finding:

Denies holding in urine unnecessarily

(Available)

Pro Tip: Holding in urine unnecessarily can increase a patient’s risk of urinary tract infections.

Example Question:

Do you hold your urine in unnecessarily?

Finding:

Denies gynecological problems

(Found)

Pro Tip: Broad open questions are efficient and useful in eliciting a large amount of information from your patient. Asking about any gynecological problems should guide your assessment.

Example Question:

Do you have any gynecological problems?

Finding:

Denies vaginal bleeding

(Available)

Pro Tip: Postmenopausal vaginal bleeding is an abnormal finding that can often be attributed to the thinning of uterine and vaginal linings. However, it may also occur due to trauma, certain cancers, and infections, including STDs.

Example Question:

Do you have vaginal bleeding?

Finding:

Denies vaginal discharge

(Available)

Pro Tip: A patient whose vaginal discharge is foul-smelling, yellow or green, or curd-like, or irritating should be assessed for disorders of the reproductive system, including STDs.

Example Question:

Do you have vaginal discharge?

Finding:

Reports onset of menopause was age 54

(Available)

Pro Tip: Establishing a timeline for when Esther began menopause is important in assessing her gynecological history and understanding any concerns she might have.

Example Question:

When did you start menopause?

Finding:

Denies history of kidney problems

Objective Data Collection: 19.67 of 21 (93.67%)

•  Correct
•  Partially correct

•  Incorrect
•  Missed

 Inspected head and face

0.67 of 1 point

 

Skull Symmetry (1/3 point)

•  Symmetric
•  Asymmetric

Facial Feature Symmetry (1/3 point)

•  Symmetric
•  Asymmetric

Appearance (No 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)

 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

 

Symmetry (1/3 point)

•  Symmetric
•  Asymmetric

Contour (1/3 point)

•  Flat
•  Rounded
•  Protuberant
•  Hollowed

Appearance (1/3 point)

•  No visible abnormal findings
•  Rash
•  Striae
•  Bulging around umbilicus
•  Distension
•  Visible masses (warts, cysts, or tumors)
•  Freckles, birthmark, or discoloration
•  Excessive hair growth
•  Scarring
•  Laceration, lesion, or wound
•  Bruising
•  Redness
•  Jaundice
•  Prominent veins

 Inspected for edema in lower extremities

1 of 1 point

 

Right: Edema (1/4 point)

•  No edema
•  Pitting
•  Non-pitting

Right: Severity Of Edema (1/4 point)

•  No edema
•  1+ Slight pitting
•  2+ Deeper pit, disappears in 10 to 15 seconds
•  3+ Noticeably deep pit that lasts more than a minute
•  4+ Very deep pit that lasts 2 to 5 minutes

Left: Edema (1/4 point)

•  No edema
•  Pitting
•  Non-pitting

Left: Severity Of Edema (1/4 point)

•  No edema
•  1+ Slight pitting
•  2+ Deeper pit, disappears in 10 to 15 seconds
•  3+ Noticeably deep pit that lasts more than a minute
•  4+ Very deep pit that lasts 2 to 5 minutes

 Auscultated heart sounds

1 of 1 point

 

Heart Sounds (1/2 point)

•  S1 and S2 audible
•  S1, S2, and S3 audible
•  S1, S2, and S4 audible
•  S1, S2, S3, and S4 audible

Extra Heart Sounds (1/2 point)

•  No extra sounds
•  Gallops
•  Murmur
•  Friction rub
•  Valve clicks

 Auscultated breath sounds

1 of 1 point

 

Breath Sounds (1/3 point)

•  Present in all areas
•  Diminished in some areas
•  Absent in some areas

Adventitious Sounds (1/3 point)

•  No adventitious sounds
•  Wheezing
•  Fine crackles
•  Stridor
•  Rhonchi
•  Rales

Location (1/3 point)

•  All areas clear
•  Adventitious sounds in anterior right upper lobe
•  Adventitious sounds in anterior right middle lobe
•  Adventitious sounds in anterior right lower lobe
•  Adventitious sounds in anterior left upper lobe
•  Adventitious sounds in anterior left lower lobe
•  Adventitious sounds in posterior right upper lobe
•  Adventitious sounds in posterior right lower lobe
•  Adventitious sounds in posterior left upper lobe
•  Adventitious sounds in posterior left lower lobe

 Auscultated abdominal aorta

1 of 1 point

 

Sound (1/1 point)

•  No bruit
•  Bruit

 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

 

Right: Renal (1/6 point)

•  No bruit
•  Bruit

Right: Iliac (1/6 point)

•  No bruit
•  Bruit

Right: Femoral (1/6 point)

•  No bruit
•  Bruit

Left: Renal (1/6 point)

•  No bruit
•  Bruit

Left: Iliac (1/6 point)

•  No bruit
•  Bruit

Left: Femoral (1/6 point)

•  No bruit
•  Bruit

 Percussed abdomen

0 of 1 point

 

Observations (No point)

•  All areas generally tympanic
•  Some areas dull, some tympanic
•  Some areas resonant

 Percussed CVA tenderness

1 of 1 point

 

Patient Reaction (1/1 point)

•  Did not react
•  Pain reaction

 Percussed spleen

1 of 1 point

 

Spleen (1/1 point)

•  Tympany
•  Dullness

 Percussed liver

1 of 1 point

 

Liver Span (1/1 point)

•  Smaller than 6 cm
•  Between 6 and 12 cm
•  Greater than 12 cm

 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

 

Presence Of Unexpected Mass (1/2 point)

•  No palpable mass
•  Palpable mass

Location Of Mass (1/2 point)

•  No palpable mass
•  Right upper quadrant
•  Right lower quadrant
•  Left upper quadrant
•  Left lower quadrant
•  Around umbilicus

 Palpated liver

1 of 1 point

 

Detection (1/1 point)

•  Not palpable
•  Palpable

 Palpated spleen

1 of 1 point

 

Detection (1/1 point)

•  Not palpable
•  Palpable

 Palpated bladder

1 of 1 point

 

Detection (1/1 point)

•  Not palpable
•  Palpable

 Palpated kidneys

1 of 1 point

 

Right (1/2 point)

•  Palpable
•  Not palpable

Left (1/2 point)

•  Palpable
•  Not palpable

 Tested skin turgor

1 of 1 point

 

Observations (1/1 point)

•  No tenting
•  Tenting

Education & Empathy : 1 of 4 (25.0%)

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

 1 Pain and Constipation

Followed Up

 

	Description: Ms. Park describes the symptoms that have been bothering her.
	Hi, my name is Nukol. I will be your nurse today.
	Hi. I’m. . .I have this pain in my stomach.
	I am sorry for that
	Thank you, dear.
	Model Statement: “I’m sorry you’re having these symptoms; it sounds like you’re under great discomfort. It’s good that you came in today so we can discuss how to alleviate your discomfort and improve your gastrointestinal health.”

 2 Fatigue and Activity Level

Not Followed Up

 

	Description: Ms. Park describes being more fatigued and having less energy for her daily activities.
	Do you exercise?
	Yes, I usually love exercise–water aerobics, Pilates. . . I take classes at the community center. But with this pain and feeling so uncomfortable this week, I’ve skipped my classes. I don’t like that . . . I feel out of sorts.
	Do you have problem swallowing?
	No. I am able to swallow without any problems.
	Model Statement: “I’m sorry you’ve been more tired and haven’t been able to live your daily life with your normal vigor. It’s always unpleasant when an illness makes you feel unlike yourself. Rest assured that we will work to improve your energy levels and get you able to participate in your regular activities.”

 3 Diet and Fiber

Not Followed Up

 

	Description: Ms. Park describes her dietary habits and reveals a lack of consistent fiber intake.
	Do you eat a lot of fiber?
	I don’t know how much fiber is in what . . . I don’t think about it, even. I have a vegetable every day or two, which I’d guess has fiber.
	Do you exercise?
	Model Statement: “Thanks for telling me about your diet. The USDA recommends that adults eat around 28 grams of fiber per day, which is several servings of fruits, vegetables, and whole grains. Enough fiber can help regulate your digestive system and prevent gastrointestinal upsets, so let’s talk about ways you might increase your fiber intake.”

 4 Fluid Intake

Not Followed Up

 

	Description: Ms. Park describes drinking 1-2 glasses of water a day.
	Do you urinate normally?
	I’ve been going slightly less often because. . . well, I’ve been little less thirsty than usual.
	have you contacted any illness? (Clarified to: Have you been around anyone sick?)
	I haven’t heard any of my friends complain of anything… anything similar to the symptoms I have. (Clarified to: if I have been around anyone who is sick)
	have you travelled recently?
	No, I haven’t gone on any trips in several years.
	Model Statement: “It’s a really healthy practice to be drinking water every day, and it’s great that you are! You have room to drink even a few more glasses per day, or as much as is comfortable. This would help prevent dehydration and increase your overall health, especially in your gastrointestinal system.”

 

 

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