• Urinalysis: Urine clear, dark yellow, normal odor. No nitrites, WBCs, RBCs, or ketones detected; pH 6.5, SG 1.017.
5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health 4/5 Student Documentation Student Documentation Model Documentation Model Documentation left upper quadrant with deep pressure no masses noted. Palpated right lower quadrant with deep pressure no masses noted. Palpated lower left quadrant with deep pressure firm oblong mass (2x4cm) Aortic palpation: aortic palpation wide is 2 cm no lateral pulsation Liver palpation: palpable one centimeter below right costal margin Spleen palpation: not palpable bladder palpation: not palpable no distention or tenderness Kidney palpation: bilateral kidneys palpated not palpable Skin turgor: skin warm and dry no tenting Pelvic exam: no inﬂammation or irritation of the vulva, abnormal discharge, or bleeding, no masses, growth, or tenderness upon palpation. Digital rectal exam: no hemorrhoids, fissures, or ulcerations. Strong sphincter tone, fecal Mass detected in rectal vault. Urinalysis: urine clear, dark yellow, normal odor. No nitrates, WBC, RBC, or ketones detected; PH 6.5, SG 1.017 Assessment Dx: Fecal impaction Differential diagnosis 1. Constipation 2. Irritable bowel syndrome 3. Rectal Mass LLQ abdominal mass. Differential diagnoses include constipation, diverticulitis, and intestinal obstruction.
5/28/2018 Focused Exam: Abdominal Pain | Completed | Shadow Health 5/5 Student Documentation Student Documentation Model Documentation Model Documentation Plan Plan: 1. CT scan of abdomen 2. guiac stool test 3. CBC and CMP 4. Refer to gastroenterology for colonoscopy for standard recommended colon cancer screening Medication: Fleet Cinema one bottle per rectum x 1 dose now in oﬃce 2. Psyllium 8oz ;liquid 1- 3 times per day Education: on psyllium for new users Fecal impaction recommended high fiber diet at least 20 to 35 grams per day Referral: to gastroenterologist for colonoscopy Follow up: return to clinic in one to two days after CT scan or any blood in stool increased abdominal pain nausea or vomiting or just not feeling better Diagnostics • Abdominal x-rays or CT scan to assess for obstruction • CBC to assess for elevated WBCs associated with diverticulitis and electrolyte profile to evaluate electrolyte and ﬂuid status Medication • None at this time Education • Educate to increase/maintain ﬂuid intake • Diet is important in maintaining colon health. Pending diagnostic test results, educate Ms. Park to eat a diet rich in fiber such as whole wheat, pears, and many other fruits, vegetables and oats Referral/Consultation • Pending diagnostic test results, may need GI or surgical referral Follow-up Planning • Instruct the patient that is she develops a fever, nausea, vomiting, and worsening abdominal pain, she should seek immediate medical attention • Revisit clinic in 5-7 days for follow up and evaluation Comments If your instructor provides individual feedback on this assignment, it will appear here. © Shadow Health 2018 ®
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