ShadowHealth Abdominal Pain Esther Park Exam
ROS for cardiovascular system - ANSWER denies palpitations, chest discomfort, racing
heartbeat
subjective - ANSWER Ms. Park reports, "I'm having pain in my belly." She has not had a
bowel movement in about five days; she has not had any diarrhea since a food poisoning
incident six months ago. She reports having had some abdominal discomfort for almost
a week, but over the past 2-3 days, the pain has progressively worsened. She describes
her current pain as being 6 out of 10 and as dull, crampy. Initially, she had described
pain as 3 out of 10. She also describes 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.
objective - ANSWER • General Survey: Uncomfortable and flushed appearing elderly
woman seated on exam table grimacing at times. Appears stable but in mild distress. •
HEENT: Mucous membranes xerotic. 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. No discoloration on abdominal examination; 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, fissures, or
ulceration. Good sphincter tone with presence of stool mass within the rectal vault. •
Pelvic: No inflammation or irritation to the vulva, no abnormal discharge or bleeding
noted. None tender to palpation, without masses or growths. • Urinalysis: Color-clear
dark yellow, with a normal odor. Negative nitrites, white blood cells, red blood cells, or
ketones; pH 6.5, SG 1.017.
, ASSESSMENT - ANSWER Ms. Parks's bowel sounds are normoactive in all quadrants,
with no bruits or friction sounds. Scattered dullness in LLQ during percussion is
suggestive of feces in the colon; otherwise her abdomen is tympanic. Her abdomen is
soft to palpation; mild guarding and oblong mass suggesting feces were found in LLQ.
No CVA tenderness; liver span 7 cm @ MCL; no splenic dullness. Digital rectal revealed
a fecal mass in the rectal vault. Pelvic exam was unremarkable, therefore, pelvic
inflammatory disease is not suspected. Ms. Park's urinalysis was normal and thus rules
out a urinary tract infection. No signs of dehydration or cardiovascular abnormalities.
Mrs. Park symptoms and health history suggest that she has constipation. Differential
diagnoses are constipation, diverticulitis and intestinal obstruction.
plan ANSWER Diagnostic studies to rule out differentials for Mrs. Park: CBC-to evaluate
for elevated WBCs associated with diverticulitis. Electrolyte profile-to evaluate
electrolyte and fluid status. CT- to evaluate for obstruction. If diverticulitis I recommend
IV fluids and bowel rest. If bowel obstruction-I recommend NPO, IV fluids and general
surgical consult. In cases of constipation, I recommend increasing fluids, increasing
fiber, and increasing activity as tolerated.
chief complaint ANSWER describes abdominal pain
describes difficulty with bowel movement
asked about orientation ANSWER oriented to own person
oriented to place
oriented to situation
oriented to time
asked about onset, frequency, and duration of pain ANSWER describes having
discomfort for the past 5 days
describes pain which had a gradual onset and has worsened over the past 2-3 days
asked about location of pain ANSWER describes pain in the lower abdomen
describes pain as not localized
ROS for cardiovascular system - ANSWER denies palpitations, chest discomfort, racing
heartbeat
subjective - ANSWER Ms. Park reports, "I'm having pain in my belly." She has not had a
bowel movement in about five days; she has not had any diarrhea since a food poisoning
incident six months ago. She reports having had some abdominal discomfort for almost
a week, but over the past 2-3 days, the pain has progressively worsened. She describes
her current pain as being 6 out of 10 and as dull, crampy. Initially, she had described
pain as 3 out of 10. She also describes 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.
objective - ANSWER • General Survey: Uncomfortable and flushed appearing elderly
woman seated on exam table grimacing at times. Appears stable but in mild distress. •
HEENT: Mucous membranes xerotic. 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. No discoloration on abdominal examination; 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, fissures, or
ulceration. Good sphincter tone with presence of stool mass within the rectal vault. •
Pelvic: No inflammation or irritation to the vulva, no abnormal discharge or bleeding
noted. None tender to palpation, without masses or growths. • Urinalysis: Color-clear
dark yellow, with a normal odor. Negative nitrites, white blood cells, red blood cells, or
ketones; pH 6.5, SG 1.017.
, ASSESSMENT - ANSWER Ms. Parks's bowel sounds are normoactive in all quadrants,
with no bruits or friction sounds. Scattered dullness in LLQ during percussion is
suggestive of feces in the colon; otherwise her abdomen is tympanic. Her abdomen is
soft to palpation; mild guarding and oblong mass suggesting feces were found in LLQ.
No CVA tenderness; liver span 7 cm @ MCL; no splenic dullness. Digital rectal revealed
a fecal mass in the rectal vault. Pelvic exam was unremarkable, therefore, pelvic
inflammatory disease is not suspected. Ms. Park's urinalysis was normal and thus rules
out a urinary tract infection. No signs of dehydration or cardiovascular abnormalities.
Mrs. Park symptoms and health history suggest that she has constipation. Differential
diagnoses are constipation, diverticulitis and intestinal obstruction.
plan ANSWER Diagnostic studies to rule out differentials for Mrs. Park: CBC-to evaluate
for elevated WBCs associated with diverticulitis. Electrolyte profile-to evaluate
electrolyte and fluid status. CT- to evaluate for obstruction. If diverticulitis I recommend
IV fluids and bowel rest. If bowel obstruction-I recommend NPO, IV fluids and general
surgical consult. In cases of constipation, I recommend increasing fluids, increasing
fiber, and increasing activity as tolerated.
chief complaint ANSWER describes abdominal pain
describes difficulty with bowel movement
asked about orientation ANSWER oriented to own person
oriented to place
oriented to situation
oriented to time
asked about onset, frequency, and duration of pain ANSWER describes having
discomfort for the past 5 days
describes pain which had a gradual onset and has worsened over the past 2-3 days
asked about location of pain ANSWER describes pain in the lower abdomen
describes pain as not localized
