Exam (elaborations) NR 509 Focused Abd Exam

Exam (elaborations) NR 509 Focused Abd Exam Chief complaint: patient complains of abdominal pain, diarrhea for one day with 3-4 episodes during that day followed by no bowel movement in five days History of present illness: patient states she started with abdominal pain that started 5 days ago. Patient complaining of diffuse abdominal pain the most painful area is the lower left quadrant and lower right quadrant. Patient states the pain is constant in nature. Patient states he pain is dull and crampy. Patient states pain is currently 6 out of 10. Patient states movement in eating exacerbates the pain. Alleviating factors include rest. Treatment includes rest and small sips of warm water. Current medications include accupril 10 mg PO daily. Allergies include latex which causes pruritic skin rash. Past medical history includes: hypertension diagnosed at age 54 3 pregnancies surgical history includes C-section at age 40 cholecystectomy at age 42 reports hospitalizations for 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 This study source was downloaded by from CourseH on :24:57 GMT -05:00 This study resource was shared via CourseH NR 509 Focused abd Exam the prior surgeries and after childbirth Patient is postmenopausal with last menstrual period Occurring 20 years ago Social history patient is a retired nurse. Patient Gardens takes walks attends exercise classes at the community center which includes water aerobics and also has recently started working out with Pilates. Patient states she does not drink often patient denies tobacco use. Patient states she uses her seatbelt while in the car and has working smoke detectors at home. Patient states her diet consist of low-fat foods also includes healthy proteins on holidays she makes traditional Korean dishes but usually eats very light. patient states she tries to supplement fiber intake by eating at least one vegetable a day. patient states she is currently sexually active with a male partner. Family history includes mother deceased at age 88 history of hypertension and Diabetes Type 2 father deceased at age 82 history of hypertension hypercholesterolemia Maternal grandparents family history of coronary artery disease and Diabetes Type 2 paternal grandparents family history of obesity of water and fluids. Previously she reports regular brown soft stools every day to every other day. This study source was downloaded by from CourseH on :24:57 GMT -05:00 This study resource was shared via CourseH CVA hypertension siblings brother 80 history of hypertension hypercholesterolemia prostate cancer Brother 81 history of HTN. Son and daughter are age 48 and 46 respectively and both are healthy. Review of systems constitutional: positive for fatigue and chills patient denies weight loss and weakness. Heent patient denies visual loss blurred vision double vision yellow sclera no hearing loss sneezing congestion runny nose or sore throat Integumentary positive for intermittent dryness of the skin Patient denies rash or itching Cardiovascular patient denies chest pain, chest pressure or discomfort. No palpitations were edema. Respiratory patient denies shortness of breath, cough or sputum production. Gastrointestinal patient positive for abdominal pain, diarrhea, nausea and anorexia. Patient denies vomiting or bloody stools. Genitourinary patient denies dysuria patient states last menstrual period was 20 years ago. Neurological: patient denies headaches, dizziness, syncope, processes, Ataxia, numbness or tingling in the extremities. No change in bowel or This study source was downloaded by from CourseH on :24:57 GMT -05:00 This study resource was shared via CourseH bladder control. Musculoskeletal patient positive for joint stiffness early in the morning but the subsides over the day patient denies muscle pain or back pain and joint pain. hematological: patient denies anemia, bleeding, or bruising Lymphatics patient denies enlarged lymph nodes no history of splenectomy Psychiatric no history of depression or anxiety Endocrine patient denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia Allergies: positive for latex Objective Vital Signs temperature 37° C heart rate 92 respiratory rate of 16 blood pressure 110/70 spo2 99% on room air. Skull is symmetrical facial features are symmetrical no abnormalities noted. Nares are moist and pink bilaterally. Oral mucosa is moist and pink Abdomen is flat in symmetrical with scarring noted to the right upper quadrant and above the pubic symphysis Lower extremities are symmetrical with no edema present. S1 S2 and S3 noted patient has an audible • 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 This study source was downloaded by from CourseH on :24:57 GMT -05:00 This study resource was shared via CourseH gallop. Lung sounds clear to auscultation in all fields patient on room air speaking in full sentences no respiratory distress noted. No aortic bruit noted Bowel sound normo active quadrants No bruises noted in the abdominal arteries bilaterally No friction rubs noted over the spleen or liver. All areas of the abdomen are generally tympanic. Tympany noted over the spleen. Liver span is 7 cm in the midclavicular line negative CVA tenderness bilaterally. Patient with tenderness to the left lower quadrant upon light palpation with positive guarding. All other quadrants are palpable with no guarding distention or masses noted up on light palpation. 2x4 cm oblong Mass which is firm in nature noted upon deep palpation in the left lower quadrant. All other quadrants are without abnormality noted upon deep palpation. Aorta 2 cm with no lateral pulsation liver palpable 1 cm below right costal margin. Spleen not palpable. Bladder not palpable. Kidneys not palpable. Skin warm and dry with no tenting noted. Diagnostic tests 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. This study source was downloaded by from CourseH on :24:57 GMT -05:00 This study resource was shared via CourseH no abnormalities noted on pelvic exam. fecal Mass noted in rectal Vault upon digital rectal exam. Urine clear dark yellow normal odor no nitrates wbc's rbc's or ketones detected pH is 6.5 specific gravity is 1.017. Assessment Problem list includes: abd pain, nausea, HTN. Differential Diagnosis: diverticulitis (K57) secondary to the anorexia, LLQ abd pain with palpable mass, nausea, fecal mass noted in rectal vault. abd pain and nausea. Small bowel obstruction (K56.60) secondary to nausea, anorexia, and fecal mass noted in rectal vault. LLQ abdominal mass. Differential diagnoses include constipation, diverticulitis, and intestinal obstruction. Plan A CT of the abdomen will be ordered with contrast. This test provides the most information about presents, location, and extent of information presence of complications such as bowel obstruction. CBC to rule out leukocytosis BMP to evaluate 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 This study source was downloaded by from CourseH on :24:57 GMT -05:00 This study resource was shared via CourseH electrolyte function in kidney function Urinalysis was already performed in the office. Pregnancy test is not clinically indicated as patient is 20 years post menopausal EKG will be obtained prior to administering Zofran to evaluate patients QT interval MEds: previous medications will be continued patient will be started on Cipro 500mg bid for 7 days flagyl will be started 500mg Q 8 hours for 7 days. Zofran ODT 4mg Q8hrs prn nausea. Education provided on diagnosis given to patient as well as education about medications and their side effects and to stay away from alcohol and over the counter medications while she is taking these. Educated patient on signs and symptoms that should alert her to worsening situation inform patient if she develops fever or worsening pain nausea and vomiting that does not allow her to eat that she should a seek emergent medical attention or call this office Referrals to gastroenterology will be made six weeks after resolution of symptoms for a potential 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 fo