Shadow Health Abdominal Pain Esther Park (2022/2023) Already Graded A

Shadow Health Abdominal Pain Esther Park (2022/2023) Already Graded A chief complaint -reports abdominal pain -reports difficulty with bowel movement asked about orientation -oriented to own person -oriented to place -oriented to situation -oriented to time asked about onset, frequency, and duration of pain -reports discomfort for the past 5 days -reports pain with gradual onset that worsened 2-3 days ago asked about location of pain -reports pain in lower abdomen -reports pain is not localized asked about pain rating on scale -reports 6/10 pain asked about characteristics of pain -describes pain a dull and cramping -pain fluctuates in severity asked about non-pharmacological relieving factors -denies taking pain medication -denies taking laxatives asked about aggravating factors -reports pain is aggravated by eating -aggravated by physical activity asked about impact on daily life -recent difficulty participating in usual activities -reports low energy followed up on constipation -constipation most of last 5 days -denies any attempt to treat constipation asked about diarrhea recent diarrhea followed up about diarrhea -about 6 months ago -sudden onset -lasted one day -loose and water asked about substances in stool -denies mucus and blood in stool asked about urination -recent, slight decrease in frequency of urination -darker urine recently -denies blood in urine asked about fluid intake -decreased thirst -decreased fluid intake for last few days -typical fluid intake is 1-2 glasses water/day -denies drinking caffeine asked about contact with illnesses -denies recent travel and exposure to food poisoning asked about history of constipation denies history asked about typical bowel movements -typically has BM almost every day -stools usually brown, formed, soft asked about allergies -reports latex allergy -denies med allergies -denies food allergies asked about pre-existing health conditions -reports high BP -diagnosed at 54 asked about relevant history of surgery -c section at 40 -gall bladder removal at 42 -no post op complications asked about home meds -meds for high BP -10 mg accupril daily at 8 am -no OTC meds asked about access to healthcare -annual checkup with HCP -last pap smear over 10 years -level of health and activity is good -denies STI testing -last colonoscopy over 10 years -denies finances as a barrier -denies transportation as a barrier asked about family and support system -reports living with daughter and strong family support asked about diet -last meal was toast at breakfast -typically eats 3 meals a day -denies snacks -typical breakfast is toast -typical lunch is soup -typical dinner is chicken or fish with rice asked about fiber intake -denies fiber supplements -denies efforts to incorporate fiber in diet -reports eating veggie every 1-2 days -reports eating fruit ever 3-4 days asked about typical activity level -typically high level of mobility and independence -reports typically having a moderated activity level asked about substance abuse -denies illicit drug use; smoking -low alcohol consumption followed up on alcohol -drinks 1 night a week -drinks 1 drink per sitting -white wine asked about constitutional health -denies recent weight changes -denies fever, chills, night sweats -short term feeling of exhaustion ROS for GI system -reports bloating -reports slight increase in gassiness -reports loss of appetite -denies nausea, vomiting ROS for GU system -reports onset of menopause at age 54 -denies history of bladder problems -denies painful urination; burning; incontinence -denies hx of UTIs -denies GYN problems -denies vaginal bleeding/discharge ROS for cardiovascular system denies palpitations, chest discomfort, racing heartbeat subjective Ms. Park reports that she is "having pain in her 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 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. objective • 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 Mrs. Park'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 discovered in LLQ. No CVA tenderness; liver span 7 cm @ MCL; no splenic dullness. Digital rectal exam revealed a fecal mass in the rectal vault. No abnormalities were noted during the pelvic exam, so pelvic inflammatory disease is not suspected. Ms. Park's urinalysis was normal, which rules out a urinary tract infection. No signs of dehydration or cardiovascular abnormalities. Mrs. Park's symptoms and health history suggest she has constipation. Differential diagnoses are constipation, diverticulitis, and intestinal obstruction. plan Mrs. Park should receive diagnostic tests to rule out differentials: CBC to assess for elevated WBCs associated with diverticulitis, electrolyte profile to evaluate electrolyte and fluid status, and a CT scan to assess for obstruction. If Mrs. Park has diverticulitis I recommend IV fluids and bowel rest. If she has bowel obstruction, I recommend NPO, IV fluids, and general surgical consult. If she has constipation, I recommend that she increase fluids, increase fiber, and increase activity as tolerated.