Tina Jones – Abdominal Results Health Assessment – January 2023

Transcript

Started: Mar 03, 2023 | Total Time: 29 min

All Lines (71)Interview Questions (35)Statements (0)Exam Actions (36)

	Hello!	Question 03/03/23 4:48 AM MST
	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?	Question 03/03/23 4:48 AM MST
	It’s 8 p.m. on Tina Jones’ first day as a patient here at Shadow General Hospital. Your role in this simulation is that of a healthcare provider who will perform a full abdominal exam on Ms. Jones. She’s spent the whole day in bed, so you will want to determine whether she has full abdominal function and if bed rest has impacted her gastrointestinal health.
	What are my objectives in this assessment?	Question 03/03/23 4:49 AM MST
	In your interview with Ms. Jones, you will ask about her inputs and outputs (I’s and O’s) and the overall health of her abdominal system so that you can identify any issues and document findings accurately. 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. You will also inquire into the health history of Ms. Jones’ family with regards to the abdominal system so you can determine her genetic predisposition to any diseases. Regardless of whether you have assessed Tina previously, ask all questions that are medically relevant to her abdominal system. In addition to collecting subjective data, you will perform a physical exam on Ms. Jones’ abdominal system to gather objective data about the system’s health and physiology. 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?	Question 03/03/23 4:49 AM MST
	You will complete nursing tasks to protect the patients 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. Activities other than Subjective and Objective Data Collection, such as Documentation and Education and Empathy, provide valuable practice for their real-world counterparts. However, they are not automatically graded by the simulation.
	How will I be evaluated?	Question 03/03/23 4:49 AM MST
	In this assignment, you will be evaluated on your Subjective and Objective Data Collection. 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. This assignment takes on average between 35 and 50 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?	Question 03/03/23 4:49 AM MST
	In this assessment, you will become familiarized with the structure and content of abdominal exams so that with real-life patients, you can: º ask effective and comprehensive questions º use therapeutic language 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: What effects can bed rest have on the abdominal system?
	Constipation and gastric reflux	Statement 03/03/23 4:52 AM MST
	Time to begin.
	Checked vitals	Exam Action 03/03/23 4:53 AM MST
	How is current stomach and bowels? (Clarified to How are your stomach and bowels doing?.)	Question 03/03/23 4:57 AM MST
	They’re fine. (Clarified to how my stomach and bowels are.)
	How is your typical bowel habits?	Question 03/03/23 4:58 AM MST
	I don’t go every day. I go every two days, maybe.
	Do you have constipation?	Question 03/03/23 4:58 AM MST
	No, I’m not having any problems with that.
	do you have diarrhea?	Question 03/03/23 4:58 AM MST
	No.
	How is your stool characteristics?	Question 03/03/23 4:59 AM MST
	It’s normal, I think. Not hard, and not too, uh, soft or anything.
	Do you have bloating?	Question 03/03/23 4:59 AM MST
	No, I don’t feel bloated.
	do you have nausea?	Question 03/03/23 5:00 AM MST
	No, I haven’t felt nauseous.
	Do you vomit?	Question 03/03/23 5:00 AM MST
	No, I don’t feel sick at all.
	how is your food tolerance?	Question 03/03/23 5:00 AM MST
	I think my diet’s normal.
	How is your food intolerance?	Question 03/03/23 5:00 AM MST
	I think my diet’s normal.
	Have you had appetite change?	Question 03/03/23 5:01 AM MST
	I’ve definitely been eating a lot more lately.
	Do you have heartburn?	Question 03/03/23 5:01 AM MST
	No.
	Do you have urinary problem?	Question 03/03/23 5:01 AM MST
	No, I can pee fine.
	How is your frequency of urination?	Question 03/03/23 5:02 AM MST
	I’ve been noticing I’ve been having to pee a lot more recently, but I think that’s just because I’m drinking more water than normal.
	what is the character of urine?	Question 03/03/23 5:02 AM MST
	Um, light yellow or almost clear? The regular color.
	How is your fluid intake?	Question 03/03/23 5:02 AM MST
	I haven’t really been keeping track, but I drink a lot of water lately. I’ve been thirstier than usual. Oh, and sometimes I’ll drink Diet Coke too . . .
	How often do you urinate?	Question 03/03/23 5:02 AM MST
	I don’t know. Every hour or two when I’m awake?
	What do you each for breakfast? (Clarified to What’s your usual breakfast?.)	Question 03/03/23 5:03 AM MST
	I usually have either cereal or toast, or if I pick something up on my way to work, I’ll get a muffin or some pumpkin bread. (Clarified to what I usually eat for breakfast.)
	Are you okay with all foods?	Question 03/03/23 5:03 AM MST
	I’m doing better than yesterday around this time, that’s for sure.
	what kind of foods cause bloating? (Clarified to What kinds of foods do you eat?.)	Question 03/03/23 5:04 AM MST
	Let’s see. . . a muffin or pumpkin bread for breakfast, a sandwich for lunch, and some kind of meat with a veggie for dinner. (Clarified to what kinds of foods I eat.)
	Do you use tobacco?	Question 03/03/23 5:05 AM MST
	No. I think it’s gross.
	Do you consume alcohol?	Question 03/03/23 5:05 AM MST
	Very rarely.
	Do you use illicit drugs?	Question 03/03/23 5:05 AM MST
	Yeah, in high school and a little after that I smoked pot sometimes. But I haven’t done anything like that in a long time.
	Have you had recent weight loss?	Question 03/03/23 5:05 AM MST
	Well, I think I’ve lost some weight this month. [AUDIO COMING SOON]
	Have much weight have you lost?	Question 03/03/23 5:06 AM MST
	I think I lost about ten pounds. [AUDIO COMING SOON]
	Hos your gall bladder? (Clarified to Do you have problems with your gallbladder?.)	Question 03/03/23 5:06 AM MST
	No, as far as I know my gallbladder’s never had any problems. (Clarified to if I have gallbladder problems.)
	Do you have a family history of bowel disease?	Question 03/03/23 5:07 AM MST
	No.
	Do you have a family history of colon cancer?	Question 03/03/23 5:07 AM MST
	Um, Grandpa Jones died of colon cancer.
	Do you have food allergies?	Question 03/03/23 5:08 AM MST
	Nope, no food allergies that I know of.
	Inspected left side of abdomen	Exam Action 03/03/23 5:13 AM MST
	Inspected front of abdomen	Exam Action 03/03/23 5:13 AM MST
	Inspected right side of abdomen	Exam Action 03/03/23 5:13 AM MST
	Inspected front of abdomen	Exam Action 03/03/23 5:14 AM MST
	Inspected left side of abdomen	Exam Action 03/03/23 5:14 AM MST
	Auscultated right upper quadrant	Exam Action 03/03/23 5:14 AM MST
	Auscultated left upper quadrant	Exam Action 03/03/23 5:14 AM MST
	Auscultated left lower quadrant	Exam Action 03/03/23 5:14 AM MST
	Auscultated right lower quadrant	Exam Action 03/03/23 5:14 AM MST
	Auscultated aorta in abdomen	Exam Action 03/03/23 5:14 AM MST
	Auscultated right renal artery	Exam Action 03/03/23 5:15 AM MST
	Auscultated left renal artery	Exam Action 03/03/23 5:15 AM MST
	Auscultated right Iliac artery	Exam Action 03/03/23 5:15 AM MST
	Auscultated left Iliac artery	Exam Action 03/03/23 5:15 AM MST
	Auscultated left femoral artery	Exam Action 03/03/23 5:15 AM MST
	Auscultated right femoral artery	Exam Action 03/03/23 5:15 AM MST
	Percussed right upper quadrant	Exam Action 03/03/23 5:15 AM MST
	Percussed left upper quadrant	Exam Action 03/03/23 5:15 AM MST
	Percussed right lower quadrant	Exam Action 03/03/23 5:15 AM MST
	Percussed left lower quadrant	Exam Action 03/03/23 5:15 AM MST
	Percussed left flank for CVA tenderness	Exam Action 03/03/23 5:15 AM MST
	Percussed right flank for CVA tenderness	Exam Action 03/03/23 5:15 AM MST
	Percussed for liver span: 7 cm in the mid-clavicular line	Exam Action 03/03/23 5:15 AM MST
	Palpated right upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension	Exam Action 03/03/23 5:16 AM MST
	Palpated left upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension	Exam Action 03/03/23 5:16 AM MST
	Palpated right lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension	Exam Action 03/03/23 5:16 AM MST
	Palpated left lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension	Exam Action 03/03/23 5:16 AM MST
	Palpated right upper quadrant with deep pressure: No masses	Exam Action 03/03/23 5:16 AM MST
	Palpated left upper quadrant with deep pressure: No masses	Exam Action 03/03/23 5:16 AM MST
	Palpated right lower quadrant: with deep pressure: No masses	Exam Action 03/03/23 5:16 AM MST
	Palpated left lower quadrant with deep pressure: No masses	Exam Action 03/03/23 5:16 AM MST
	Palpated liver: Palpable 1 cm below right costal margin	Exam Action 03/03/23 5:16 AM MST
	Palpated for spleen: Not palpable	Exam Action 03/03/23 5:17 AM MST
	Palpated for right kidney: Not palpable	Exam Action 03/03/23 5:17 AM MST
	Palpated for left kidney: Not palpable	Exam Action 03/03/23 5:17 AM MST

 

Subjective Data Collection: 24 of 24 (100.0%)

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.

Relevant Medical History

Finding:

Asked about current stomach and bowels

Finding:

Denies current abdominal issues

(Found)

Pro Tip: Asking Tina whether she is currently experiencing any stomach or bowel difficulties helps you determine her ability to receive an interview and her need for immediate care.

Example Question:

Do you have any current abdominal issues?

Finding:

Asked about typical bowel habits

Finding:

Reports a bowel movement every two days

(Found)

Pro Tip: Asking Tina how often she has bowel movements is significant in understanding her gastrointestinal symptoms, as the bowels can cause or be caused by numerous conditions.

Example Question:

How often do you have a bowel movement?

Finding:

Reports last bowel movement was yesterday morning

(Available)

Pro Tip: Asking Tina when her last bowel movement was is significant in understanding her gastrointestinal symptoms, as a long period of time between bowel movements can indicate an underlying condition and potential discomfort.

Example Question:

When was your last bowel movement?

Finding:

Asked about constipation

Finding:

Denies constipation

(Found)

Pro Tip: Asking Tina about any constipation she experiences is significant in understanding her gastrointestinal symptoms, as constipation can be uncomfortable and point to an underlying condition.

Example Question:

Have you been constipated?

Finding:

Denies hard stools

(Found)

Pro Tip: Asking Tina about any hard stools she experiences is significant in understanding her gastrointestinal symptoms, as hard stools can be uncomfortable and point to an underlying condition.

Example Question:

Have you had hard stools?

Finding:

Denies straining during bowel movement

(Available)

Pro Tip: Asking Tina about any straining she experiences during bowel movements is significant in understanding her gastrointestinal symptoms, as straining can be uncomfortable and point to an underlying condition.

Example Question:

Do you strain during a bowel movement?

Finding:

Asked about diarrhea

Finding:

Denies diarrhea

(Found)

Pro Tip: Asking Tina whether she is currently experiencing any diarrhea helps you determine her ability to receive an interview and her need for immediate care.

Example Question:

Do you have diarrhea?

Finding:

Followed up on stool characteristics

Finding:

Reports stool is formed

(Found)

Pro Tip: Asking Tina if her stools are formed is significant in understanding her gastrointestinal symptoms and any potential conditions.

Example Question:

Are your stools formed?

Finding:

Reports color is medium-brown

(Available)

Pro Tip: Asking Tina what colors her stools are is significant in understanding her gastrointestinal symptoms and any potential conditions.

Example Question:

What color are your stools?

Finding:

Denies blood in stool

(Available)

Pro Tip: Asking Tina if her stools contain blood is significant in understanding her gastrointestinal symptoms and any potential conditions.

Example Question:

Do you notice blood in your stool?

Finding:

Denies mucus in stool

(Available)

Pro Tip: Asking Tina if her stools contain mucus is significant in understanding her gastrointestinal symptoms and any potential conditions.

Example Question:

Do you notice mucus in your stool?

Finding:

Asked about gassiness

Finding:

Denies excessive gassiness

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing, like gas, details the way her individual symptoms and pain manifest.

Example Question:

Have you been feeling gassy?

Finding:

Denies bloating

(Found)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing, like bloating, details the way her individual symptoms and pain manifest.

Example Question:

Have you been experiencing bloating?

Finding:

Asked about nausea

Finding:

Denies nausea

(Found)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing, like nausea, details the way her individual symptoms and pain manifest.

Example Question:

Have you been having nausea?

Finding:

Asked about vomiting

Finding:

Denies vomiting

(Found)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing, like vomiting, details the way her individual symptoms and pain manifest.

Example Question:

Have you been vomiting recently?

Finding:

Asked about food intolerance

Finding:

Denies food intolerance

(Found)

Pro Tip: Certain foods can cause people to become ill depending on their personal physiology. Asking Tina whether there are foods she can’t tolerate allows you to determine her need for follow-up tests or diet recommendations.

Example Question:

Are there any foods that make you sick?

Finding:

Asked about appetite changes

Finding:

Reports recent increase in appetite

(Found)

Pro Tip: Pain can have a substantial effect on diet and appetite. Asking Tina if her appetite has increased will illustrate the ways in which her symptoms are manifesting.

Example Question:

Has your appetite increased?

Finding:

Reports appetite increase started about a month ago

(Available)

Pro Tip: Pain can have a substantial effect on diet and appetite. Asking Tina when her appetite increased will illustrate the ways in which her symptoms are manifesting.

Example Question:

When did your appetite increase?

Finding:

Asked about GERD and heartburn

Finding:

Denies heartburn

(Found)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing, like heartburn, details the way her individual symptoms and pain manifest.

Example Question:

Do you have heartburn?

Finding:

Denies chest pain

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing, like chest pain, details the way her individual symptoms and pain manifest.

Example Question:

Do you ever get chest pain?

Finding:

Denies history of GERD

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing, like GERD, details the way her individual symptoms and pain manifest.

Example Question:

Have you ever had GERD?

Finding:

Asked about urinary problems

Finding:

Reports increased urination

(Found)

Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if she has been urinating more than usual can help you to determine the cause of Tina’s symptoms.

Example Question:

Have you been urinating more frequently?

Finding:

Reports waking up to urinate during the night

(Available)

Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if she has to wake up to urinate can help you to determine the cause of Tina’s symptoms.

Example Question:

Are you waking up in the middle of the night to urinate?

Finding:

Denies incontinence

(Available)

Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if she is having bladder control problems can help you to determine the cause of Tina’s symptoms.

Example Question:

Are you having bladder control problems?

Finding:

Denies painful or difficult urination

(Found)

Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if urination has been difficult for her can help you to determine the cause of Tina’s symptoms.

Example Question:

Has urinating been difficult for you?

Finding:

Asked frequency and duration of increased urination

Finding:

Reports urinating every hour or two during the day

(Found)

Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina how many times she urinates during the day can help you to determine the cause of Tina’s symptoms.

Example Question:

How many times do you urinate during the day?

Finding:

Reports waking up to pee more than once per night

(Available)

Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina how frequently she has to wake up to urinate can help you to determine the cause of Tina’s symptoms.

Example Question:

How often do you wake up to urinate in the night?

Finding:

Reports frequent urination started a few months ago

(Available)

Pro Tip: Bladder dysfunction can indicate a GI problem. Establishing a timeline of Tina’s increase in urinary frequency can help you to determine the cause of Tina’s symptoms.

Example Question:

When did you start urinating more frequently?

Finding:

Asked about character of urine

Finding:

Reports urine is light yellow or clear

(Found)

Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina what color her urine is can help you to determine the cause of Tina’s symptoms.

Example Question:

What color is your urine usually?

Finding:

Denies blood in urine

(Available)

Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if her urine ever contains blood can help you to determine the cause of Tina’s symptoms.

Example Question:

Have you had blood in your urine?

Finding:

Denies abnormal odor to urine

(Available)

Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if her urine has a strong odor can help you to determine the cause of Tina’s symptoms.

Example Question:

Does your urine have an abnormal odor?

Finding:

Asked about fluid intake

Finding:

Reports increased water intake

(Found)

Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if she is drinking more water lately can help you to determine the cause of Tina’s symptoms.

Example Question:

Are you drinking more water lately?

Finding:

Reports increased thirst

(Found)

Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if she has been thirstier lately can help you to determine the cause of Tina’s symptoms.

Example Question:

Have you been thirstier lately?

Finding:

Asked about typical meals

Finding:

Reports typical breakfast is cereal, bread, or a muffin

(Found)

Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she typically has for breakfast will illustrate her recent dietary patterns.

Example Question:

What is your typical breakfast?

Finding:

Reports typical lunch is a sandwich and chips

(Available)

Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she typically has for lunch will illustrate her recent dietary patterns.

Example Question:

What is your typical lunch?

Finding:

Reports typical dinner is chicken, a vegetable or potatoes, and bread

(Available)

Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she typically has for dinner will illustrate her recent dietary patterns.

Example Question:

What is your typical dinner?

Finding:

Reports typical snack is pretzels, French fries, crackers or chips

(Available)

Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she typically has for a snack will illustrate her recent dietary patterns.

Example Question:

What is a typical snack for you?

Risk Factors

Finding:

Asked about tobacco use

Finding:

Denies tobacco use

(Found)

Pro Tip: Smoking tobacco can affect a patient’s gastrointestinal health in numerous ways. Asking Tina about her use of any tobacco will help you contextualize the functioning of her abdominal system.

Example Question:

Do you smoke tobacco?

Finding:

Denies vaping

(Available)

Pro Tip: Smoking tobacco can affect a patient’s gastrointestinal health in numerous ways. Asking Tina about her use of any tobacco will help you contextualize the functioning of her abdominal system.

Example Question:

Do you vape?

Finding:

Asked about alcohol intake

Finding:

Reports last alcoholic drink was a few weeks ago

(Available)

Pro Tip: Confirming when a patient had her last alcohol intake is important, because she will receive medications while admitted, and alcohol is often contraindicated.

Example Question:

When was your last alcoholic drink?

Finding:

Reports no more than 2 or 3 alcoholic drinks in one sitting

(Available)

Pro Tip: Finding out how many alcoholic drinks a patient has in a single day or sitting is essential to uncover any binge-drinking habits that can be unhealthy for your patient, including to the abdominal system.

Example Question:

How many alcoholic drinks do you typically have in one sitting?

Finding:

Reports no more than 1 or 2 nights a week drinking alcohol

(Available)

Pro Tip: Finding out how many alcoholic drinks a patient has per week is essential to uncover any binge-drinking habits that can be unhealthy for your patient, including to the abdominal system.

Example Question:

How many alcoholic drinks do you typically have in a week?

Finding:

Asked about illicit drugs

Finding:

Reports history of smoking recreational marijuana

(Found)

Pro Tip: Determining any recent or past history of drug use is essential to revealing any substance abuse issues, and if the patient is likely to seek drugs while admitted.

Example Question:

Have you ever smoked marijuana?

Review of Systems

Finding:

Asked about additional stomach and bowels

Finding:

Reports recent weight loss

(Found)

Pro Tip: Foundational questions about general health and wellbeing can help you to determine how your patient perceives her health. Asking Tina if her weight changed recently can indicate whether Tina has concerns about changes in weight.

Example Question:

Have you had any recent changes in your weight?

Finding:

Denies excessive burping

(Available)

Pro Tip: Increased burping can be a result of heartburn, acid reflux, or indigestion. Asking Tina if she’s been burping more would indicate that Tina has been swallowing more air recently.

Example Question:

Have you been burping?

Finding:

Denies difficulty swallowing

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like difficulty swallowing, details the way her individual symptoms and pain manifest.

Example Question:

Have you had difficulty swallowing?

Finding:

Denies rectal bleeding

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like rectal bleeding, details the way her individual symptoms and pain manifest.

Example Question:

Have you had rectal bleeding?

Finding:

Denies ulcers

(Available)

Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient’s symptoms. Asking Tina if she ever had any ulcers will allow her to describe any historical concerns or problems she’s had.

Example Question:

Have you ever had an ulcer?

Finding:

Followed up on weight change

Finding:

Reports losing about 10 lbs

(Found)

Pro Tip: Weight change can occur for a variety of reasons, some healthier than others, and can impact the functioning of the gastrointestinal system. Asking Tina about her recent weight loss allows you to determine its magnitude and whether her health could be affected.

Example Question:

How much weight did you lose?

Finding:

Asked about organs of the gastrointestinal system

Finding:

Denies history of gall bladder problems

(Found)

Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient’s symptoms. Asking Tina if she has a history of gall bladder problems will allow her to describe any historical concerns or problems she’s had.

Example Question:

Do you have a history of gall bladder problems?

Finding:

Denies history of pancreas problems

(Available)

Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient’s symptoms. Asking Tina if she has a history of pancreas problems will allow her to describe any historical concerns or problems she’s had.

Example Question:

Do you have a history of pancreas problems?

Finding:

Denies history of liver problems

(Available)

Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient’s symptoms. Asking Tina if she has a history of liver problems will allow her to describe any historical concerns or problems she’s had.

Example Question:

Do you have a history of liver problems?

Finding:

Denies history of kidney problems

(Available)

Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient’s symptoms. Asking Tina if she has a history of kidney problems will allow her to describe any historical concerns or problems she’s had.

Example Question:

Do you have a history of kidney problems?

Finding:

Denies history of bladder problems

(Available)

Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient’s symptoms. Asking Tina if she has a history of bladder problems will allow her to describe any historical concerns or problems she’s had.

Example Question:

Do you have a history of bladder problems?

Family History

Finding:

Asked family history of gastrointestinal issues

Finding:

Denies family history of bowel disease

(Found)

Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking about any bowel disease in Tina’s family might reveal a predisposition to gastrointestinal disorders.

Example Question:

Does IBS run in your family?

Finding:

Denies family history of liver disease

(Available)

Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina has a family history of liver cancer might reveal a predisposition to gastrointestinal issues.

Example Question:

Does liver cancer run in your family?

Finding:

Asked family history of colon cancer

Finding:

Reports paternal grandfather died of colon cancer

Objective Data Collection: 12 of 12 (100%)

•  Correct
•  Partially correct

•  Incorrect
•  Missed

 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, birthmarks, or moles
•  Excessive hair growth
•  Scarring
•  Laceration, lesion or wound
•  Bruising
•  Redness
•  Jaundice
•  Prominent veins

 Auscultated bowel sounds

1 of 1 point

 

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 aorta

1 of 1 point

 

Sound (1/1 point)

•  No bruit
•  Bruit

 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

1 of 1 point

 

Observations (1/1 point)

•  All areas 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 for liver span

1 of 1 point

 

Size (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 kidneys

1 of 1 point

 

Right (1/2 point)

•  Not palpable
•  Palpable

Left (1/2 point)

•  Not palpable
•  Palpable

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