Exam (elaborations) Abdominal Pain Physical Assessment Assignment Results Completed

Abdominal Pain Physical Assessment Assignment Results | Completed Advanced Health Assessment - Chamberlain, NR509-October-2018 Return to Assignment Your Results Turrn IIn Laab Paassss Document: Vitals Document: Provider Notes Document: Provider Notes Student Documentation Model Documentation Subjective Patient Info: Esther Park, 78 years, Asian female CC: Patient states that they are "having pain in her belly" and that she is having trouble "going to the bathroom." HPI: The patient, Ms. Park, came into the office complaing of abdominal pain and not being able to have a bowel movement. She states that this pain started 5 days ago and has gotten worse over the past 2 to 3 days. The pain is in the lower abdomen and does not radiate. She does not have pain anywhere else. She states that her current abdominal pain could be rated a 6 out of 10. She describes the pain as "dull and crampy." She states that it does get worse sometimes, especially after physical activity or eating. She states that resting does help, but the only treatment she has pursued is "taking small sips of warm water," a method her friend infromed her of. This has not been an effective treatment. She states that she is not being able to go about her normal daily activities due to the pain. She also reports a low energy level. She is currently constipated, and issue that she has no history of. She has been constipated for about 5 days, but has not pursued any treatment. She had a bout of diarrhea about 3 days ago that she described as "loose and watery." It lasted for one day. Before the onset of the abdominal pain 5 days ago, the patient states that they had normal bowel habits, but has not had a movement in 3 days. No mucus or blood in stool. Patient states that the frequency of her Ms. Park reports that she is “having pain in her belly.” She experienced mild diarrhea three days ago and has not had a bowel movement since. She reports that she has been feeling some abdominal discomfort for close to a week, but the pain has increased in the past 2-3 days. She now rates her pain at 6 out of 10, and describes it as dull and crampy. She reports her pain level at the onset at 3 out of 10. She is also experiencing bloating. She did not feel her symptoms warranted a trip to the clinic but her daughter insisted she come. She describes her symptoms primarily as generalized discomfort in the abdomen, and states that her lower abdomen is the location of the pain. She denies nausea and vomiting, blood or mucus in stool, rectal pain or bleeding, or recent fever. She denies vaginal bleeding or discharge. Reports no history of inflammatory bowel disease or GERD. Denies family history of GI disorders. Her appetite has decreased over the last few days and she is taking small amounts of water and fluids. Previously she reports regular brown soft stools every day to every other day. Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Self-Reflection Documentation / 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.