Abdominal Discomfort: Focused Assessment, Esther Park

Introduction

Abdominal pain is a common complaint in healthcare settings. Since the diagnosis of abdominal pain is challenging, accurate diagnosis requires advanced assessment skillsets. Abdominal assessment is an essential component of physical examination as it assists in identifying abdominal pain, masses, distention, and enlarged organs. The nurse practitioner should develop a trustful therapeutic relationship with the patient to facilitate the collection of comprehensive data throughout the examination. The paper will thus discuss the focus of the assessment, analyze the collected objective data and subjective data, and develop a list of the relevant differential diagnoses. The paper will conclude by discussing a care plan for the patient.

Focus of the Assessment

The focus of this paper is to discuss the assessment of an elderly female patient (Mrs. Esther Park), who presents with a chief complaint about abdominal pain. The abdominal examination should thus also encompass a careful visual examination of the abdomen, including other essential body parts. The subjective data was collected by interviewing the patient while the objective data was collected by performing a physical assessment that included abdominal examination using a pre-determined sequence through auscultation, palpation, and percussion of the abdomen.

Subjective Component

The patient presented with complaints about abdominal pain and having difficulties going to the bathroom. She reported that the pain started five days ago when she started having difficulties going to the bathroom. The patient reported that she is not able to make bowel movements and she has not been able to go to the bathroom for almost a week. She further reported that the stomach pain and the location never change, but the pain fluctuates in intensity. She stated that the discomfort and the pain are located in the down-low in her stomach and the pain is more towards the from, down low. She reported that the pain fluctuates and rates the pain as 2 during the physical assessment. She describes the abdominal pain as a dull cramping feeling. The patient states that she has been using warm water and rest to relieve the pain, but has not taken any medication for the pain. She reports that eating and physical activity aggravate the pain. The pain has thus affected her ability to perform activities of daily living. She denies vomiting, diarrhea, mucus, and blood in the stool, but reports that she has been having constipation for the last five days. The patient further reports that she is less thirsty, the frequency of urination has reduced, and the urine has been darker than usual. However, she denied blood in the urine. She states that her gall bladder was removed, she has hypertension, and takes high blood pressure medication at 8.00 am every day. She denies taking over the counter medications, smoking tobacco, drinking coffee, and taking drugs. She takes alcohol once per week. She is physically active. She reports fatigue but denies breath shortness, weight changes, chills, night sweats, edema, history of stomach cancer, appendicitis, sleep problems, palpitations, chest pain, sore throat, problem swallowing, sore throat, nausea, or vaginal problem. She reports bloating, a slight increase in gas, and loss of appetite. Esther’s typical diet includes toast and fruit for breakfast; soup for lunch; and rice with fish or chicken for supper. She reports that she does not take fiber supplements or any extra fiber.

She is allergic to latex and has a history of hypertension. Surgical history includes a CS at 40 and cholecystectomy at age 42 years. She reports that the mother had a history of diabetes. She reports that she has had two colonoscopies, and the last one was 10 years ago. She has a partner and lives with her daughter. She reports annual check-ups, a pap smear more than ten years ago.

Objective Component

Vital signs: Hear rate 92: RR 16: blood pressure 110/70: Oxygen saturation 99%: Temp 37 C.

The patient appears uncomfortable during the interview, grimaces at times, slightly flushed cheeks, but she seems to be in stable condition.

Inspection reveals that the face is symmetric, and the mucus membranes are pink and moist. She has a scar on the abdomen under the right breast and an injury within the lower abdomen midline (suprapubic region). The abdomen is symmetric, flat, with some discoloration, and with birthmarks, and freckles. No edema in the lower extremities. Auscultation indicates S1, S2, audible without extra sounds or murmurs. There are normoactive bowel sounds within all quadrants, no friction or bruit noted. Percussion of the abdomen revealed some tympanic and dull areas. No CVA tenderness and abdominal palpitation indicated liver-7 within the midclavicular line. Palpitation of the abdomen indicates abdominal soreness, some tenderness within the left lower quadrant. However, no masses were identified. Deep palpitation of the abdomen revealed a deep oblong palpable mass. Liver palpable. The bladder and spleen are not palpable on examination. Skin examination indicates that the skin is warm, dry, without any tenting. The pelvic examination did not identify any inflammation, masses, growth, or irritation of the vulva. The rectal examination did not identify any hemorrhoids or fissures. However, a fecal mass was identified in the rectal vault and a strong sphincter tone was detected.

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Documented Evidence to Support Clinical Reasoning

Differential Diagnosis

  • Constipation: This is a GIT disorder that reduces bowel movement leading to infrequent stool or difficulties and pain when passing stool (Forootan et al., 2018). Acute constipation can lead to the closure intestines. Constipation is a common condition among older adults due to factors such as hereditary factors, medications, as well as diet in the disease pathophysiology (Forootan et al., 2018). The patient reported dull and cramping pain on the left lower abdomen as well as reduced bowel movement, which is an indication of constipation.
  • Diverticulitis: This is a localized inflammatory response that occurs when micro-perforation at the diverticulum fundus results in a local inflammatory cascade or when there is impaction of a fecalith in the diverticulum mouth and subsequently exposes the lamina propria to fecal microbiota (Swanson & Strate, 2018). Diverticulitis is characterized by symptoms such as lower abdominal pain, general malaise, and abdominal tenderness (Rezapour et al., 2018). The patient reports lower abdominal pain, and the physical assessment revealed abdominal tenderness.
  • Urinary tract infection/sexually transmitted infection: Mrs. Park reported decreased urine output, dark-colored urine, and lower abdominal pain which may be suggestive of STI or UTI (Behzadi et al., 2019). Mrs. Park reported having unprotected sex. However, the examination did not note any abnormal vaginal discharge or lesion in the vaginal area.
  • Renal colic: The generalized abdominal discomfort, cramping, and reduce urine output, as well as concentrated urine, may be suggestive of renal colic. The patient reports that movement aggravates the pain, while rest relieves the pain. Additionally, she reports reduced thirst and reduced fluid intake, which can also be attributed to the diagnosis of renal colic (Alelign & Petros, 2018).

Diagnosis

Constipation: The patient reported reduced bowel movement, left lower quadrant pain, and reduced fluid and food intake. Guarding to light touch at the left lower quadrant present during the examination. Additionally, deep palpation identified a 2x4cm mass in the lower left quadrant.  A significant fecal mass was noticed within the rectal vault. All these findings confirm the diagnosis of constipation.

Plan of Care

Pharmacology: The patient will be administered with 1 bottle in 24 hours. She will also continue to take hypertension medications as prescribed.

Further tests: A laboratory testing (CBC, WBC’s electrolytes) will be ordered for Mrs. Park. A CT scan will be ordered to examine the abdominal obstruction. She will also be referred to a gastroenterologist for further assessment. A high intake of fiber will be recommended, and activity as tolerated.

Patient education: The patient will also be advised to have a high intake of fluids (Prichard & Bharucha, 2018). She will also be advised to increase fiber intake in her diet.

Conclusion

Mrs. Park presented to the clinic with complaints about lack of bowel movement for the last five days and abdominal pain and discomfort. The differential diagnosis includes diverticulitis and constipation. She will be advised to monitor her diet and then make some dietary modifications. She will be advised to increase intake of fruits and vegetable, and water. A follow-up with a gastroenterologist will be done, and also her bowel movements will be monitored closely.  The patient will be encouraged to stay physically active as possible.

References  

Alelign, T., & Petros, B. (2018). Kidney Stone Disease: An Update on Current Concepts. Advances in urology, 2018, 3068365. https://doi.org/10.1155/2018/3068365

Behzadi, P., Behzadi, E., & Pawlak-Adamska, E. A. (2019). Urinary tract infections (UTIs) or genital tract infections (GTIs)? It’s the diagnostics that count. GMS hygiene and infection control, 14, Doc14. https://doi.org/10.3205/dgkh000320

Forootan, M., Bagheri, N., & Darvishi, M. (2018). Chronic constipation: A review of the literature. Medicine, 97(20), e10631. https://doi.org/10.1097/MD.0000000000010631

Prichard, D. O., & Bharucha, A. E. (2018). Recent advances in understanding and managing chronic constipation. F1000Research, 7, F1000 Faculty Rev-1640. https://doi.org/10.12688/f1000research.15900.1

Rezapour, M., Ali, S., & Stollman, N. (2018). Diverticular Disease: An Update on Pathogenesis and Management. Gut and liver, 12(2), 125–132. https://doi.org/10.5009/gnl16552

Swanson, S. M., & Strate, L. L. (2018). Acute Colonic Diverticulitis. Annals of internal medicine, 168(9), ITC65–ITC80. https://doi.org/10.7326/AITC201805010

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Assignment Instructions:

For this 4-5 pages assignment, you will conduct a focused health history and physical assessment based upon your Practice Experience work in Shadow Health. Particularly, you will complete a focused assessment on Esther, an elderly patient who is complaining of abdominal discomfort. Please submit your summary documentation in MS Word. Use the submission parameters and rubric below to guide you in completion of this written assignment.

Submission Parameters:

For this written assignment, please use the following guidelines and criteria. Also, please refer to the rubric for point allocation and assignment expectations. The expected length of the paper is approximately 4-5 pages, which does not include the cover page and reference page(s).

Introduction (including purpose statement)

Focus of the assessment

Describe the focus of this particular assessment on the patient complaining of abdominal discomfort.

Subjective Component
Describe the ROS, PMH, and other relevant data in this section.

Objective Component
Describe the physical examination findings including techniques of examination
Documented evidence to support clinical reasoning

Describe the list of differential diagnoses

Plan of care

Describe the plan of care individualized to findings, life-span stage of development with culturally specific considerations for each focused area of assessment.

Conclusion

References (use primary and/or reliable electronic sources)

In regards to APA format, please use the following as a guide:

Include a cover page and running head (this is not part of the 4-5 pages limit)
Include transitions in your paper (i.e. headings or subheadings)
Use in-text references throughout the paper
Use double space, 12 point Times New Roman fonta
Apply appropriate spelling, grammar, and organization
Include a reference list (this is not part of the 4-5 pages limit)
Attempt to use primary sources only. That said, you may cite reliable electronic sources (i.e. NCSBN, AANP)

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