Exam (elaborations) NR 509 SHADOW HEALTH Abdominal Pain Physical Assessment Assignment Results Completed

Exam (elaborations) NR 509 SHADOW HEALTH Abdominal Pain Physical Assessment Assignment Results Completed ocumentation / Electronic Health Record This study source was downloaded by from CourseH on :26:30 GMT -05:00 This study resource was shared via CourseH 12/10/2018 Abdominal Pain Physical Assessment Assignment | Completed | Shadow Health Student Documentation Model Documentation Respiratory: Patient denies any coughing or sore throat. Denies any difficulty breathing or chest pain. Objective Ms. Park seemed to be in distress and pain, but she was alert and answered questions fully. She seemed to be in good hygiene and was pleasant. HEENT: Skull and facial features were symmetric. Patient's face was flushed. Nose and mouth muscus membranes were pink and moist. Normal turgor of skin with no tenting. RESPIRATORY: Breath sounds were present and clear in all areas, with no adventituous sounds. Breathing did not seem labored and she was speaking well. CARDIO: No lower extremity edema. S1 and S2 heart sounds audible, with no extra sounds. No S3 or S4 rubs. ABDOMINAL: Abdomen was symmetrical and flat. Some scarring is evident from past cholecystectomy (RUQ) and caesarean section (midline suprapubic area). Abdominal aorta had no bruit. Bowel sounds were normoactive in all quadrants. All arteries had no bruit. No friction rub in liver or spleen. Percussed abdomen found some dull areas and some tympanic areas. Spleen was tympanic. Liver was between 6 and 12 cm. No CVA tenderness. Palpation found tenderness in the lower left quadrant with guarding and distension. Palpable mass was found in lower left quadrant. Aortic width was 3cm or less. Liver palpable. Spleen not palpable. Bladder not palpable. Kidneys not palpable. Rectal exam: No hemorrhoids, no fissures, no ulcers, strong sphincter tone, fecal mass located in fecal vault Pelvic exam: No inflammation or irritation of vulva, no abnotmal discharge, no bleeding, no growths or masses, no tenderness. Urinalysis: Urine was clear and dark yellow, normal odor, No abnormal findings, pH was 6.5, SG was 1.017. • General Survey: Uncomfortable and flushed appearing elderly woman seated on exam table grimacing at times. Appears stable but mildly distressed. • HEENT: Mucus membranes are moist. Normal skin turgor; no tenting. • Cardiovascular: S1, S2, no murmurs, gallops or rubs; no S3, S4 rubs. No lower extremity edema. • Respiratory: Respirations quiet and unlabored, able to speak in full sentences. Breath sounds clear to auscultation. • Abdominal: 6 cm scar in RUQ and 10 cm scar at midline in suprapubic region. An abdominal exam reveals no discoloration; normoactive bowel sounds in all quadrants; no bruits; no friction sounds over spleen or liver; tympany presides with scattered dullness over LLQ; abdomen soft in all quadrants; an oblong mass is noted in the LLQ with mild guarding, distension; no organomegaly; no CVA tenderness; liver span 7 cm @ MCL; no hernias. • Rectal: No hemorrhoids, no fissures or ulceration; strong sphincter tone, fecal mass in rectal vault. • Pelvic: No inflammation or irritation of vulva, abnormal discharge, or bleeding; no masses, growths, or tenderness upon palpation. • Urinalysis: Urine clear, dark yellow, normal odor. No nitrites, WBCs, RBCs, or ketones detected; pH 6.5, SG 1.017. Assessment Lower left quadrant abdominal mass. 1. Constipation: the mass in the LLQ and the fecal matter in the rectal vault point toward constipation. 2. Obstruction: The tenderness that the patient felt, along with the constipation and the episode of diarrhea, could point toward an intestinal obstruction. 3. Diverticulitis: The tenderness and constipation could be signs of diverticulitis, but as the patient is not running a fever or vomiting, I believe that this is less likely. LLQ abdominal mass. Differential diagnoses include constipation, diverticulitis, and intestinal obstruction. This study source was downloaded by from CourseH on :26:30 GMT -05:00 This study resource was shared via CourseH 12/10/2018 Abdominal Pain Physical Assessment Assignment | Completed | Shadow Health Student Documentation Model Documentation Plan Diagnostics: I would like to order a CT scan or an x-ray to identify the mass in the patient's LLQ. I would also like to order a CBC as this can help diagnose diverticulitis if the white blood cell count is elevated. Medication: Depending on the test results, I might prescribe an over the counter nonstimulant laxative like Miralax to help the patient with constipation. Education: I educated the patient on the importance of a fiber rich diet. This included information on foods high in fiber like fruits and vegetables, as well as a suggestion for the use of supplements like Metamucil to keep her regular. I also educated the patient on the importance of remaining hydrated and the effects that dehydration can have on the gastrointstinal system. I asked her to keep track of all the water she drank in a day so that she could remind herself to stay hydrated. Referral: Depending on the test results, like a possible diagnosis of diverticulitis, she might need a referral to a gastrointeroligist for further testing. Follow up: I educated the patient on worsening symptoms that should prompt her to seek mergency care including a fever, vomiting, or if the pain worsens significantly. If nothing changes, I would like to see her back in a week. If it is simply constipation and she is able to have normal bowel movements again and the pain has subsided, she should be okay until her next check-up. Diagnostics • Abdominal x-rays or CT scan to assess for obstruction • CBC to assess for elevated WBCs associated with diverticulitis and electrolyte profile to evaluate electrolyte and fluid status Medication • None at this time Education • Educate to increase/maintain fluid intake • Diet is important in maintaining colon health. Pending diagnostic test results, educate Ms. Park to eat a diet rich in fiber such as whole wheat, pears, and many other fruits, vegetables and oats Referral/Consultation • Pending diagnostic test results, may need GI or surgical referral Follow-up Planning • Instruct the patient that is she develops a fever, nausea, vomiting, and worsening abdominal pain, she should seek immediate medical attention • Revisit clinic in 5-7 days for follow up and evaluation Comments Olivia Mgbeokwere (01 Dec 2018, 09:45 AM CST): Dear Student, Congratulations! You did a good job with this case study. Of course, there is always room for improvement. Please take time to review your results and the feedback provided by Shadow Health. Compare your performance with the model note. It is important to understand where you may have missed opportunities to be more effective or enhance your skills. Be sure to use" OLDCART" How confident are you in your diagnosis? How did you determine the severity of Esther's complaints? What findings from the history and physical exam helped you to make your diagnosis? Have you ruled out bowel obstruction completely? What about ordering an abdominal series x-ray or CT scan? Be prepared to discuss your responses to these questions during the Debriefing Session for Week 5. Let me know if you have any questions or concerns. Dr. O This study source was downloaded by from CourseH on :26:30 GMT -05:00 This study resource was shared via CourseHer