Focused Health History Assessment Esther Park Abdominal Pain

ByLeon Kiprotich Leon Updated on

Focused Health History Assessment Esther Park Abdominal Pain

Introduction

Patients at times present with symptoms specific to various organ systems and that require focused assessment. In focused assessment, the nurses do a comprehensive assessment of a patient’s system involved in the patient’s presenting problem to ascertain the specific diagnosis. In this case, Ms. Park presents with abdominal discomfort accompanied by moderate pain that she rates as 6/10. A focused gastrointestinal, renal, and partially reproductive systems assessment will ensue to ascertain the underlying condition in Ms. Esther Parks’ case. The focused examination includes inspection, palpation, percussion, and auscultations of the suspected affected organ system. The findings of the assessment shall determine the patient’s diagnoses and consequently inform the plan of care.

History of presenting illness

Ms. Park presents with complains of pain in the abdomen. She had experienced mild diarrhea 3 days ago, and bowel movement ceased with the cessation of diarrhea. She reports that the pain began five days ago. She has been with the abdominal discomfort for the past one week. The pain was initially mild but increased 2-3 days ago. She rates the pain she is experiencing right now as 6 on a scale of 1-10. She reports her pain to be dull and crampy. She rates her pain during onset of the pain at 1 or 2 out of 10. She is bloating and has reduced appetite. She was reluctant to seek medical attention due to low perceived severity of symptoms until her daughter insisted that she comes for checkup.

PMH

She reports a history of caesarian section and cholecystectomy during her early 40s. She has no history of inflammatory, bowel disease, GERD, or other GI disorders. She has not been previously admitted and does not report any known allergy. The patient is not currently on any medication and has not yet taken any medication for constipation nor abdominal pain.

Focused ROS

For abdominal pain and discomfort, the patient might have underlying conditions from various body systems (GIT, renal, and partially the reproductive system). A focused review of systems was performed. The patient reports generalized abdominal discomfort and localized pain in the left lower quadrant. She has no nausea or vomiting. She denies blood or mucus in stool. She reports no rectal pain or rectal bleeding. She has had fever recently.

She reports no vaginal bleeding or any vaginal discharge. She reports a decreased appetite in the last few days and reports decreased water and fluid intake in the last few days. Ms. Park says her normal stool is soft and brown in color. Her micturition pattern is normal. She reports no blood in urine, no pain urinating, and no abnormal urine color. She reports no flank pain and reports no edema.

Physical Examination

General Survey: Ms. Park is an elderly woman who exhibits mild distress, but she is relatively stable. She has a flashy appearance and she looks rather uncomfortable while seated on the examination table. She appears to grimace in pain at times.

HEENT: The mucous membranes are not dry (they are moist). Her skin has normal turgor without tenting.

Cardiovascular system: S1, S2 heart sounds present. She has no extra heart sound or any other abnormalities. No bruits over the abdominal arteries.

Respiratory: Respiratory system assessment reveals normal respirations, the patient can speak fluently without strain, and auscultation reveals clear breath sounds in all areas.

Abdomen: She has a scar in RUQ (cholecystectomy scar) and another scar (Caesarian scar) at the midline above the pubis. On inspection, there is no discoloration, bowel activity is normal, and bowel sounds are evenly distributed in all quadrants (normoactive). There are no bruits auscultated over spleen or liver. Tympanic sound elicited on abdominal percussion, and scattered dullness over the LLQ noted. The abdomen is soft on palpation. An abnormal oblong mass is palpated in the left lower quadrant. The abdomen is distended and tender with mild guarding. The abdominal organs are normal (no organomegaly). The liver is normally situated and exhibits no hepatomegaly. There is no abdominal herniation. On rectal examination, she has no hemorrhoids, no fissures or ulceration.

Focused Physical Examination

At this point, a focused physical examination of the three organ systems should be performed (Schoenwald & Douglas, 2017). On auscultation, normal bowel sounds in all quadrants are detected. There are neither bruits nor friction sounds auscultated. On percussion, scattered dull sounds are elicited in the LLQ. This is suggestive of scattered fecal matter in the colon. The abdomen, however, elicits a tympanic sound. The patient exhibited guarding suggestive of tenderness during palpation and an oblong mass was detected in the LLQ. The oblong mass prompted a digital rectal exam. After a digital rectal exam, fecal matter was found in the rectum. The patient exhibited no splenomegaly or hepatomegaly. The pelvic examination findings were normal thus ruling out pelvic inflammatory disease. Ms. Park had normal urinalysis findings thus ruling out renal system abnormalities and urinary tract infections. Ms. Park is not dehydrated and there are no detectable cardiovascular abnormalities. The physical examination findings coupled with the health history information are suggestive of constipation.

Differential diagnoses

Differential diagnoses for this patient are Constipation, Diverticulitis, and intestinal obstruction. Constipation impacts negatively on the quality of life and should be managed promptly because it is not a complicated condition. A person with constipation presents with an inability to empty the rectum sufficiently, the presence of hard lumpy stool, abdominal pain, and few or absent bowel sounds (Lucak, Lunsford & Harris, 2017). A patient with Diverticulitis often presents with “pain in the left lower quadrant, fever, and leukocytosis” (Young, 2018). Mrs. Packs has no fever and only requires a CBC to rule out Diverticulitis. Imaging studies could also help rule out Diverticulitis. A patient with intestinal obstruction presents with “nausea, emesis, colicky abdominal pain, and cessation of the passage of flatus and stool” (Jackson & Cruz, 2018). Most of these signs and symptoms of intestinal obstruction are absent in the case of Mrs. Packs. Further, an ultrasound can be instrumental in ruling out intestinal obstruction.

Plan Of Care

Mrs. Park should be scheduled for diagnostic tests to rule out differential diagnosis: CBC to rule out Diverticulitis, electrolytes profile for fluid status, and a CT scan for intestinal obstruction. For management of diverticulitis, she can be started on intravenous fluids and bed rest. For management of an intestinal obstruction, the patient oral feeding should be withdrawn, and intravenous fluids initiated. The patient should also be considered for surgery. For management of constipation, fluids should be increased, the patient should take a high fiber diet and promote increased activity. Use of rectal enema in the event the client cooperates and when constipation does not resolve is recommended.

Analgesic administration, most preferably NSAIDs, to minimize pain and encourage bowel clearance because they are not known to cause constipation (Serra et al., 2017)

Encouraging fluid intake, which is much decreased in this patient to enhance bowel activity and reduce fecal impaction.

To reduce the impacted fecal matter, I will administer polyethylene glycol (an osmotic laxative), then docusate sodium (stool softener), and lastly, Bisacodyl, a stimulant laxative (Emmanuel et al., 2017). I shall closely monitor the patient for drug side effects.

Educating the patient on her condition to promote informed decision-making, minimizing anxiety, and fostering collaboration during care is also essential.

Routine assessment should be scheduled to assess the patient’s recovery and detect any complications during care delivery.

Conclusion

Management of Ms. Park requires a focused examination to determine the underlying condition and treat it accordingly. An in-depth assessment of the affected organ systems and focused management can be instrumental in the management of this patient. She must also be evaluated and necessary adjustments to care made to optimize therapy and ensure recovery. Several considerations such as age and cultural constructions have to be made during care of this patient. Care of a patient requires a collaborative effort between the patient and healthcare providers, and the recovery of the patient is also dependent on her cooperation during care.

References

  • Emmanuel, A., Mattace‐Raso, F., Neri, M. C., Petersen, K. U., Rey, E., & Rogers, J. (2017). Constipation in older people: a consensus statement. International Journal Of Clinical Practice, 71(1), e12920. https://doi.org/10.1111/ijcp.12920
  • Lucak, S., Lunsford, T. N., & Harris, L. A. (2021). Evaluation and Treatment of Constipation in the Geriatric Population. Clinics in Geriatric Medicine, 37(1), 85-102. https://doi.org/10.1016/j.cger.2020.08.007
  • Jackson, P., & Cruz, M. V. (2018). Intestinal obstruction: evaluation and management. American Family Physician, 98(6), 362-367.
  • Schoenwald, A., & Douglas, C. (2017). Undertaking a focused assessment: Physical assessment of body systems. Potter and Perry’s Fundamentals of Nursing – Australian Version, 5th Edition, 578-621.
  • Serra, J., Mascort-Roca, J., Marzo-Castillejo, M., Aros, S. D., Santos, J. F., Rubio, E. R. D., & Manrique, F. M. (2017). Clinical practice guidelines for the management of constipation in adults. Part 2: Diagnosis and treatment. Gastroenterología y Hepatología (English Edition), 40(4), 303-316. https://doi.org/10.1016/j.gastre.2017.03.013
  • Young-Fadok, T. M. (2018). Diverticulitis. New England Journal of Medicine, 379(17), 1635-1642. DOI: 10.1056/NEJMcp1800468