Patient Case Study: Chronic Abdominal Pain in a 45-year-old Female, Exams of Nursing

Download Patient Case Study: Chronic Abdominal Pain in a 45-year-old Female and more Exams Nursing in PDF only on Docsity! I HUMAN: KAREN FLOYD ABDOMINAL PAIN 2024 GRADED A+ Questions –yields 90% How can I help you? My stomach hurts Do you have any other symptoms or concerns we should discuss? I occasionally feel “bloated” although I’m not sure my belly is actually bigger when I feel that way. I…well pass a lot of gas and… even belch a lot compared to other people I know. Sort of embarrassing for a woman you know. Do you think that’s related to all of this? Is your pain affected by what, when, or how much you eat? It seems to be worse with rich foods. I haven’t really noticed it as associated with when or how much. Do you now or have you ever smoked or chewed tobacco? No, I never have. Are you taking any over the counter or herbal medications? I take a multivitamin daily, and acetaminophen from time to time for stress headaches Are you taking any prescription medications? No prescription medications Do you have any allergies? Not that I know of Have you ever been hospitalized? Just for the c-section and the bike accident thing Any previous medical, surgical, or dental procedures? I had a c-section at 27 without any complications. When I was 17, I had a bike accident and had a complicated fracture of my right tibia. They had to fix that with surgery. Can you tell me about any current or past medical problems you have had? I don’t know really what’s important. The only thing besides this stomach problem is that lately I’ve been getting occasional hot flashes and my skin is sort of dry. I also get headaches now and then which isn’t new and that probably isn’t important anyway. Is that the kind of things you want to know? Tell me about your work I am a manager at a local restaurant. I have very long workdays… I usually work late into the night. Have you had a recent endoscopy, colonoscopy, or biopsy? Uh… No. When and what was the result of your last mammogram? I haven’t had one yet. Too busy. Physical Exam Blood pressure 120/60, normal, normotensive Cognitive Alert and oriented x 4 Pulse 60, regular, normal RR 14, regular, unlabored Temp 98.6 Inspect skin overall Dry skin, otherwise unremarkable Inspect hair color, distribution, thickness Thickness and distribution pattern typical for patient gender and age Inspect nails Nails without ridging, pitting, or peeling Test capillary refill Normal capillary reflow Inspect eyes Normal Inspect face Normal expression. No lesions, scars, or abnormal pigmentation. Ocular motor test Normal Examine pupils R – NR, L – NR Inspect/Palpate Head Normocephalic, atraumatic. No deformities. Facial features symmetric. Temporal arteries non-tender to palpation. Frontal and maxillary sinuses non- tender. Inspect/Palpate scalp No visible scaliness, edema, masses, lumps, deformities, scars, rashes, nevi, or other lesions. Non-tender. Inspect neck No visible scars, deformities, or other lesions. Trachea is midline and freely mobile. Inspect mouth/pharynx Oropharynx not injected, clear mucosa, tonsils without exudate. Tongue pink, symmetrical. No swelling or ulcerations. Smell breath No unusual odor Palpate neck Thyroid firm, an acceptable size for patient gender and age. No nodules palpated. Ask patient to swallow Normal exam. Thyroid moves with swallowing. Palpate all lymph nodes No pathologically enlarged lymph nodes in the cervical, supraclavicular, axillary, or inguinal lymph chains. Lung sounds Normal Heart sounds Normal Visual inspection of the abdomen Abdomen is flat and symmetric with no scars, deformities, striae, or lesions Auscultate abdomen Normal Auscultate femoral/abdominal arteries Done Palpate abdomen Mild tenderness with deep palpation of the lower abdomen on both sides. Percuss abdomen Normal Measure girth Appropriate girth for age and gender Visual inspection of the extremities No swelling or deformity. No cyanosis, clubbing, or edema. Palpate extremities There is no tenderness, muscular resistance, rigidity, or deformity. Visual inspection of the rectal area No visible fissures, induration, or lesions. Rectal exam Normal Genitourinary female exam Normal external genitalia, no masses or tenderness, normal pelvic exam. Deep tendon reflexes Triceps 2/2 Biceps 2/2 Brachioradialis 2/2 Knee/Patella 2/2 Ankle/Achilles 2/2 Assess pharynx movement and phonation Soft palate moves up symmetrically, speech phonation and articulation appropriate. Hearing No hearing deficits, normal Weber and Rinne tests. Monofilament test Normal sensory test Assess gait and stance Normal gait and posture Babinski Normal 4 Dyspepsia, functional X 5 GERD X 6 Peptic ulcer disease X 7 Cholelithiasis X 8 Colon cancer X X 9 Biliary colic X 10 Irritable bowel syndrome X 11 Crohn’s Disease X 12 Colitis, ulcerative X 13 Diverticulitis X 14 Large bowel obstruction X X 15 Hemorrhoids X 16 Colon neoplasm X 17 Small bowel obstruction X 18 Small bowel neoplasm X 19 Hypothyroidism X 20 Hyperthyroidism X 21 Diabetic neuropathy X 22 Generalized anxiety disorder X 23 Major depressive disorder X 24 Giardiasis X 25 Salmonellosis X 26 Shigellosis X 27 C. Diff X 28 E. Coli X 29 Campylobacteriosis X 30 Pelvic inflammatory disease X 31 Endometriosis X 32 Ovarian neoplasm X 33 Appendicitis X X 34 Microscopic colitis X 35 Colitis, infectious X 36 Lymphoma, non-Hodgkin’s X 37 Stomach cancer X 38 Adrenal insufficiency, primary X 39 DMT1 X 40 DMT2 X 41 Diarrhea, medication associated X 42 Constipation X 43 Tropical sprue X 44 Gastroenteritis X 45 Perforated viscus X 46 Pancreatitis, chronic X 47 Colitis, ischemic X 48 HIV X 49 Somatic symptom disorder X 50 Pancreatic insufficiency X 51 Parkinson’s X 52 MS X 53 Anemia X 54 AAA X 55 Abdominal abscess/infection X 56 Cholecystitis, acute X 57 Celiac X 58 Mesenteric ischemia, chronic X 59 Mesenteric ischemia X 60 Pancreatitis, acute X 61 Colitis, non-infectious X 62 Anemia, lead poisoning X 63 Hypercalcemia X 64 Hyperthyroidism, graves X 65 Hyperthyroidism, thyrotoxic crisis X 66 Arthritis, IBD associated X 67 Abdominal neoplasm X 68 Pancreatic cancer X 69 Choledocholithiasis X 70 Somatostatinoma X 71 Gastric ulcer X 72 Colonic ulcer X 73 DKA X 74 Ectopic pregnancy X 75 MI, acute X 76 Ovarian torsion X 78 Nephrolithiasis/kidney calculi X 79 Peritonitis X 80 Peritonitis, spontaneous (NOS) X 81 Splenic rupture X 82 Splenic abscess X 83 Hepatitis, viral X 84 Follicular cyst X 85 Ascending cholangitis X 86 Hepatic venous outflow obstruction X Diagnostic Tests – 100% 1 Tissue glutaminase antibody (IgA-tTG) Negative