Health Assessment Check-off project
Chief Complaint: Abdominal pain
History of Present Illness: A 55-year-old woman visits the outpatient clinic with abdominal pain as the chief complaint. The patient states that she started experiencing the pain three days ago, and it worsens after eating or engaging in moderate walks. She feels the pain near the lower abdomen and rates it as five on a ten-point scale, with ten being the most severe. However, the client describes the pain as not localized. The pain lasts for a few minutes and subsides. As a result of the pain, the patient notes that she has been finding it challenging to engage in usual daily activities. She reports decreased thirst, reduced food intake, and difficulty in passing stool.
Past Medical History (Hx): the patient suffers from hypertension, which she was diagnosed ten years ago. She is currently taking hypertension medications. Health Assessment Check-off project
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Past Surgical Hx: at the age of 30, the patient underwent a C-section, which was successful. She did not experience any post-surgical complications.
Family Hx: the patient lives with her three children, who she says provide strong familial support. Her husband died five years ago.
Social Hx: Typically, the patient consumes three meals a day, comprising carbohydrates, proteins, and vegetables. She consumes fruits once every week. However, she does not integrate any fiber supplements into her diet. Inadequate intake of fluid and water has been linked to chronic constipation (Munch et al., 2016). She does not smoke or take illicit drugs but confirms the occasional consumption of alcohol. Walking is her primary form of exercise.
Allergies: no known allergies.
Medications: The patient is currently taking Accupril to control her high blood pressure.
Review of symptoms by system: No notable recent weight changes, fever, chills, or night sweats. However, the patient reports feeling exhausted and fatigued day by day. Bloating and loss of appetite have been experienced in the past few days.
Physical Exam: HEENT, respiratory, cardiovascular, abdominal, and urinalysis assessments were conducted with normal results, except the abdominal evaluation, which revealed an oblong mass in the LLQ with mild guarding.
Assessment: scattered dullness in the LLQ and the oblong mass are indicative of feces in the colon. The three likely differential diagnoses for this patient are constipation, diverticulitis, and internal obstruction. Further tests have ruled out obstruction and diverticulitis. From the assessment, the patient likely has constipation. Common symptoms are dull and cramping abdominal pain, and difficulty passing stool (Forootan et al., 2018). Health Assessment Check-off project
Treatment Plan: The treatment plan should encompass patient education. She should be educated on the significance of increasing her fluid and fiber intake (Childs &John, 2015).
References
Childs, A. A., & John, R. M. (2015). Pooping shouldn’t be this hard. ICAN: Infant, Child, & Adolescent Nutrition, 7(5), 287-302. https://doi.org/10.1177/1941406415601193
Forootan, M., Bagheri, N., & Darvishi, M. (2018). Chronic constipation. Medicine, 97(20), e10631. https://doi.org/10.1097/md.0000000000010631
Munch, L., Tvistholm, N., Trosborg, I., & Konradsen, H. (2016). Living with constipation—older people’s experiences and strategies with constipation before and during hospitalization. International Journal of Qualitative Studies on Health and Well-being, 11(1), 30732. https://doi.org/10.3402/qhw.v11.30732
Health Assessment Check-off project