Student Documentation Model Documentation: Abdominal Pain Results | Turned In Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1
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Documentation / Electronic Health Record
Document: Provider Notes
Student Documentation Model Documentation
Subjective
Miss Park is a pleasant Korean 78 year old woman who presents to the clinic with complaints of abdominal pain for the past 5 days. She is oriented to person place and time. She answers the questions appropriately and maintains eye contact during the interview and exam. This with her daughter who assist with her Care at home. Pains are described as crampy, dull at her lower abdomen, with a pain scale of 6/10, mostly constant. Has had difficulty using the bathroom this past 5 days, which has affected her daily activites. She has been feeling more tired than usual, denies feeling fever chills or rectal pain. She drinks two glasses of water a day and eats well, although has had a decrease in appetite since her abdominal pain started. Her abominal pain Is aggravated with food and activity, pain is relieved with rest. Her stool is soft and brown, no current diarrhea. She has history of colonoscopy that was negative. She denies any vaginal bleeding or urinary difficulty. She denies any GERD, colon cancer or stomach issues. PMHx: HTN on accupril 10 mg daily Immunizations: updated: declines flu vaccination today. Surgical hx: choleystectomy at 42yo Cesarean delivery at 40yo: OB/GYN: G3P3L2: one stillbirth for cord accident. No hx of STI. Pap WNL 2010 Social hx: has a friend who she is intimate with, no tobacco use, no illicit drugs. Drinks once a week with white wine. Has stong family support. Visits her Son in Houston occasionally. Family Hx: Mother: DM and HTN: Deceased @ 88yo Father: HTN and hypercholestremia: deceased at 82yo MGP: HTN PGM: HTN/ CVA/obesity Brothers: HTN SOn: healthy daughter: Healthy
Ms. Park reports that she is “having pain in her belly.” She experienced mild diarrhea three days ago and has not had a bow 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 o 10, and describes it as dull and crampy. She reports her pain lev the onset at 3 out of 10. She is also experiencing bloating. She d not feel her symptoms warranted a trip to the clinic but her daug insisted she come. She describes her symptoms primarily as generalized discomfort in the abdomen, and states that her lowe abdomen is the location of the pain. She denies nausea and vomiting, blood or mucus in stool, rectal pain or bleeding, or rece fever. She denies vaginal bleeding or discharge. Reports no histo of inflammatory bowel disease or GERD. Denies family history of 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.
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Overview
Transcript
Objective Data Collection
Education & Empathy
Documentation
Student Survey
Document: Vitals Document: Provider Notes
Student Documentation Model Documentation
Objective
Alert and oriented x3: Some discomfort due to abdominal pain HEENT: moist mucus mambrane, normal skin turgor, no tenting Heart: S1 and S2 with no abnormal heart sounds Lungs; CTA Liver: 1cm below Rt costal margin: nontender Abdomen: BS present at all quads, normoactive, No bruits or friction sounds. Dullness on LLQ, Tender to touch, with guarding and distension. 2x4cm oblong mass palpated on LLQ. RUQ : with scar s/p choleystectomy, and al lower transverse abdominal scar from s/p cs no CVA tenderness Pelvic: neg Rectal: no hemorrhoids, strong spincter reflex, fecal mass detected in rectal vault Extremties: no edema: normal reflexes UA: clear but dark urine, neg for nitrites, wbc or ketones.
• General Survey: Uncomfortable and flushed appearing elderly woman seated on exam table grimacing at times. Appears stable 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 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 ma noted in the LLQ with mild guarding, distension; no organomega no CVA tenderness; liver span 7 cm @ MCL; no hernias. • Rectal: No hemorrhoids, no fissures or ulceration; strong sphinc tone, fecal mass in rectal vault. • Pelvic: No inflammation or irritation of vulva, abnormal discharg or bleeding; no masses, growths, or tenderness upon palpation. • Urinalysis: Urine clear, dark yellow, normal odor. No nitrites, WB RBCs, or ketones detected; pH 6.5, SG 1.017.
Assessment
Constipation causing abdominal mass Intestinal obstruction Diverticulitis Irritable bowel syndrome
Mrs. Park’s bowel sounds are normoactive in all quadrants, with 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 v 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 sympto and health history suggest she has constipation. Differential diagnoses are constipation, diverticulitis, and intestinal obstructi
Plan
stool for occult blood CBC/ ESR with CRP Metabolic panel serum amylase abdominal sonogram or abdominal x-ray for to locate mass; Bowel rest if diverticulitis : if neg: increase po fluids, increase fiber, increase activity as tolerated. Creating a bowel regimen is encouraged.
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 C scan to assess for obstruction. If Mrs. Park has diverticulitis I recommend IV fluids and bowel rest. If she has bowel obstructio recommend NPO, IV fluids, and general surgical consult. If she h constipation, I recommend that she increase fluids, increase fibe and increase activity as tolerated.
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