SHADOW HEALTH FOCUSED EXAM:ABDOMINAL PAIN - WEEK 9 (ESTHER PARK), Exams of Biology

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SHADOW HEALTH FOCUSED

EXAM:ABDOMINAL PAIN -

WEEK 9 (ESTHER PARK)

[Document subtitle]

[DATE]

[COMPANY NAME] [Company address]

SUBJECTIVE DATA COLLECTION

Patient Data

1. Chief Complaint o Established chief complaint: Abdominal pain & difficulty with bowel movements o Empathy statement: "I'm sorry you're having these symptoms. It's good you came in today."
2. Orientation o Asked: "Do you know where you are?" o Patient oriented to person, place, situation, time
3. History of Present Illness o Onset/Duration : Discomfort ×5 days, worsened 2-3 days ago o Location : Lower abdomen, non-localized o Pain Rating : 6/ o Characteristics : Dull, cramping, fluctuates o Relieving Factors : No pain meds/laxatives o Aggravating Factors : Eating, activity o Impact : Reduced daily activities, low energy
4. Bowel Habits o Constipation ×5 days (no treatment attempted) o Diarrhea episode 6mo ago (1 day, watery) o No blood/mucus in stool
5. Urinary Symptoms o Slightly decreased frequency, dark urine o No blood in urine
6. Fluid Intake o 1 - 2 glasses water/day (recent decrease) o No caffeine o Education: Encouraged increased water intake

o No financial/transportation barriers

14. Support System o Lives with daughter o Strong support network
15. Diet & Lifestyle o Meals : 3/day (toast, soup, chicken/fish + rice) o Fiber : Low intake (veggies 1-2x/week, fruit 3-4x/week) o Education: Fiber recommendations (28g/day)
16. Substance Use o No smoking/illicit drugs o Alcohol: 1 glass white wine/week
17. Abuse Screening o Denied abuse Review of Systems
18. Constitutional o No fever/chills/weight changes o Reports exhaustion
19. Gastrointestinal o Bloating, gas, decreased appetite o No nausea/vomiting/GI disorders
20. Genitourinary o Menopause onset at 54 o No urinary/GYN issues
21. Cardiovascular o No palpitations
22. Respiratory o No SOB/cough/chest tightness

OBJECTIVE DATA COLLECTION

Vital Signs

23. Measurements o Temp: 37.0°C (98.6°F) o BP: 111/ o HR: 92 o RR: 16 o SpO₂: 99% o Pain: 2/ Physical Exam
24. HEENT o Symmetric skull/facial features o Moist/pink oral/nasal mucosa
25. Abdomen o Inspection : Flat, scarring (RUQ/suprapubic) o Auscultation : ▪ Normoactive bowel sounds ▪ No bruits (aorta/renal/iliac/femoral) o Percussion : ▪ Mixed tympany/dullness (LLQ) ▪ Liver span 7cm MCL o Palpation : ▪ LLQ tenderness, guarding, palpable mass ▪ No organomegaly
26. Cardiovascular o S1/S2, no murmurs/gallops
27. Respiratory