Focused Exam: Abdominal Pain | Esther Park shadow

health assignment | Complete Solution

Esther Park is a 78-year-old Korean woman presenting with abdominal pain in the

ED. the abdominal pain is a 6 and described as a constant dull, crampy feeling

low low in her abdomen that began as a general discomfort about 5 days ago

when the patient states she began having difficulties going to the bathroom and

has not had a bowel movement for several days. The pain worsens when she

moves around a lot or eats something. The only surgeries she has had is

gallbladder removal and C-section, both in her 40s. She takes 10mg of Accupril

daily. She has pain in her LLQ of her abdomen when percusses. Upon palpation of

the LLQ a firm, oblong mass approximately 2X4cm was noted.

Scored Items

Experts selected these topics as essential components of a strong, thorough

interview with this patient.

Patient Data

Not scored

a combination of open and closed questions will yield better patient data. The

following details are facts of the patient's case.

History of Presenting Illness



Finding:

Established chief complaint



Finding:

Reports abdominal pain

(Found)

Pro Tip: Abdominal pain can be caused by problems in the

underlying organs, peritoneum, muscles, or blood vessels, changes

in electrolytes or other blood contents, or even anxiety. Asking for

details about the pain helps to determine the origin.

Example Question:

Do you have any abdominal pain?



Finding:

Reports difficulty "going to the bathroom"

(Found)

Pro Tip: Understanding all of a patient's reason for visiting is an

important foundation to establish. If there are multiple symptoms,

follow up on each one during your interview.

Example Question:

Are you able to make a bowel movement?



Finding:

Asked about onset of the pain



Finding:

Reports a feeling of discomfort for the past five days

(Found)

Pro Tip: Whenever you are assessing a symptom or a health

condition, inquiring about onset assesses the severity and the

progression of the problem.

Example Question:

How long have you had stomach pain?



Finding:

Reports pain with gradual onset that worsened 2-3 days ago

(Available)

Pro Tip: Whenever you are assessing a symptom or a health

condition, inquiring about onset assesses the severity and the

progression of the problem.

Example Question:

Has the stomach pain changed?



Finding:

Asked about location of the pain



finding:

Reports pain in lower abdomen

(Found)

Pro Tip: Identification of the location of your patient's discomfort can

provide important clues about its cause and how it should be best

treated.

Example Question:

Where is your discomfort located?

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