Focused Health Assessment- Esther Park
Physical examination plays a fundamental role in patient diagnosis and is a vital part of all clinical encounters with the physician. Abdominal examinations provide physicians with diagnostic cues on gastrointestinal and genitourinary pathologies while giving insight on abnormalities of nearby organ systems (Jaberi & Momennasab, 2019). A well-performed abdominal examination minimizes the need for detailed radiological investigations and plays a profound role in patient management. In this essay, the author explores a focused abdominal assessment of Esther Park, a 78-year-old woman visiting the shadow health clinic complaining of abdominal pains. The essay discusses the focus of the evaluation, subjective component, objective component, documented evidence to support clinical decision-making, and the patient’s care plan.
The Focus of the Assessment
The focus of Ms. Park’s focused assessment is to identify her abdominal pain source and initiate early treatment. Here the clinician will differentiate between normal and abnormal findings, an approach that will help the physician develop a list of differential diagnoses (Zambas et al., 2016). Conducting a focused health assessment will also be beneficial. It will allow the physician to provide care tailored to the patient’s individual needs and establish therapeutic communication to improve patient care.Focused Health Assessment- Esther Park
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Subjective Component
At the shadow health clinic, Ms. Park reported that she has been experiencing abdominal pain for the past five days and a lack of bowel movements. She states that the pain has been constant, but its severity fluctuates. However, the intensity of the pain has worsened in the past three days. At the moment, the patient rates her pain as a 2 out of 10 but states that it reaches as high as 8 out of 10. When asked to describe her pain, Ms. Park says that she experiences dull cramping and bloating. She notes that her symptoms did not warrant a medical appointment. Her daughter insisted that her primary care clinic was closed as it was on the weekend, prompting her to visit the shadow health clinic. Ms. Park describes her symptoms as generalized discomfort of pain and identifies the lower abdomen as the pain’s location.
When asked about her symptoms and medical history, Ms. Park denies any diarrhea, vomiting, nausea, blood in stool or urine, and recent fever. The client also denies vaginal bleeding, and she has no history of gastrointestinal disorders. She has reported reduced appetite in the past few days and ms. Park has been taking small amounts of fluids and water. The client had undergone a c- section and the age of 40 and Cholecystectomy at age 42. She revealed that she did not have any post-surgical complications.
When asked about her social history, Ms. Park reported that she typically eats three meals every day, with no fiber supplements, as she believes her diet provides enough fiber. She reports a reduced intake of fluids in the past few days, no illicit drug use, and moderate alcohol consumption. Ms. Park also reports annual health check-ups and believes that her health and activity levels are suitable for her age.
Objective Component
A general survey revealed that Ms. Park was uncomfortable and flush, appearing elderly woman seated at the examination table. She was grimacing at times, looking stable but mildly distressed. After the HEENT examination, it was discovered that her mucous membranes with moist, with no skin tenting and normal skin turgor.Focused Health Assessment- Esther Park
Cardiovascular: S1 and S2 were audible, with no murmurs, rubs, or gallops. No S3 or S4 rubs. No lower extremity edema.
Respiratory: her breathing was quiet and unlabored. Ms. Park could speak in full sentences, and her breathing sounds were clear to auscultation.
Abdominal: 6 cm scar in RUQ and 10 cm scar at the midline in the suprapubic region. Abdominal examination revealed no discoloration, and normoactive bowel sounds in all quadrants, no bruits, no friction sounds over the spleen and liver, and tympany presides with scattered dullness over LLQ; abdomen soft in all quadrants. A long oblong mass was observed in the LLQ with mild guarding and rebound tenderness; no organomegaly; no CVA tenderness; no hernias.
Rectal: no fissures, hemorrhoids, or ulceration, and the sphincter tone was strong.
Urinalysis: dark yellow urine with no nitrates, ketones, white blood cells, or red blood cells. The PH was 6.5, and the specific gravity was 1.017.
Techniques used in the assessment were auscultation, general observation, palpation, and inspection.
Documented Evidence to Support Clinical Decision Making
After a focused abdominal examination of Ms. Park, the physician can formulate a list of differential diagnoses. Differential diagnoses include diverticulitis, constipation, and internal obstruction.
Constipation
Constipation occurs when bowel movements are infrequent, and passing stool becomes difficult. Often, constipation occurs due to diet changes, physical activity, and inadequate intake of fiber (Forootan et al., 2018). Other risks of constipation are older age, being a woman, and taking specific medical examinations. Symptoms include blood in the stool, few bowel movements, abdominal cramps, nausea, and bloating. Ms. Park is experiencing some of these symptoms, making constipation a likely diagnosis.Focused Health Assessment- Esther Park
Diverticulitis
It is an inflammation of pouches that form along the digestive tract. The condition is more common after the age of 40, and symptoms include abdominal pain, cramping, change in bowel habits, and cramping.
Internal Obstruction
It is a gastrointestinal condition where digested materials are prevented from passing through the bowel due to blockage. The disease can be caused by a fibrous tissue compressing the gut, usually after abdominal surgery. Symptoms include severe abdominal pain, nausea, vomiting, and inability to pass stool.
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Plan of Care
Research suggests that patient’s plans of care should be tailored to individualized patient considerations. From the abnormal findings observed, the physician needs to tailor Ms. Park’s care plan to the client’s individualized results. The physician should recommend a digital rectal exam and urinalysis. Ms. Park should also be educated on the significance of increasing her fluid intake to avoid being dehydrated. Patient education is essential as it allows informed decision making (Paterick et al., 2017). Diagnostic examination of the patient’s red and white blood cells should be conducted to obtain an accurate diagnosis. Additionally, the diagnosis of internal obstruction can be confirmed through abdominal x-rays.
Conclusion
To sum up, focused health assessments are crucial in obtaining an accurate and timely diagnosis. It allows the physician to identify the root cause of illness and initiate early treatment. Although constipation is a likely diagnosis for Ms. Park, further tests are required to rule out diverticulitis and internal obstruction. Esther Park should be encouraged to increase her fluid intake to prevent dehydration associated with most of her symptoms. Patient education is a vital component of her care plan, and the client should be directed to return to the clinic after a few weeks for follow-up care. Focused Health Assessment- Esther Park
References
Forootan, M., Bagheri, N., & Darvishi, M. (2018). Chronic constipation. Medicine, 97(20), e10631. https://doi.org/10.1097/md.0000000000010631
Jaberi, A., & Momennasab, M. (2019). Effectiveness of standardized patient in abdominal physical examination education: A randomized, controlled trial. Clinical Medicine & Research, 17(1-2), 1-10. https://doi.org/10.3121/cmr.2019.1446
Paterick, T. E., Patel, N., Tajik, A. J., & Chandrasekaran, K. (2017). Improving health outcomes through patient education and partnerships with patients. Baylor University Medical Center Proceedings, 30(1), 112-113. https://doi.org/10.1080/08998280.2017.11929552
Zambas, S. I., Smythe, E. A., & Koziol-Mclain, J. (2016). The consequences of using advanced physical assessment skills in medical and surgical nursing: A hermeneutic pragmatic study. International Journal of Qualitative Studies on Health and Well-being, 11(1), 32090. https://doi.org/10.3402/qhw.v11.32090
Focused Health Assessment- Esther Park