Karen Floyd Abdominal Pain Assessment, Exams of Nursing

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KAREN FLOYD

ABDOMINAL PAIN LATEST

2023-2024 100% GRADED

Karen Floyd "Abdominal

Pain"

iHuman Abdominal Pain

Do you have diarrhea? Occasionally. Sometimes I’d say my bowel movement is loose and watery. Does that count? Is there any blood in your stools or with your bowel movement? Anything red? Not that I have noticed Do you have a problem with constipation? Definitely. For as long as I can recall in my adult life, I have alternating periods of constipation and just the opposite if you know what I mean that lasts several days. When I am constipated, I feel like I cannot get everything out, even after a BM. Have you been having fevers? I don’t think so, can you check that for me How often does this abdominal pain occur? It’s been coming and going for years now. It never really goes away entirely, but then it also doesn’t seem to be getting a lot worse. It’s just there all the time. So

frustrating.

Do you have heart disease and/or have you ever had a heart attack? No, I do not have heart problems. No, I do not have heart problems.

the EHR

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.

Hearing No hearing deficits, normal Weber and Rinne tests. Monofilament test Normal sensory test Assess gait and stance Normal gait and posture Babinski Normal

Assess head rotation against resistance/shoulder elevation Symmetric muscle movement without weakness bilaterally Assess for muscle bulk and tone Normal bulk and tone, no rigidity. Look for involuntary movements None of the following movements:

• Fibrillations
• Fasciculations
• Asterixis
• Tics, myoclonus
• Dystonia’s
• Chorea
• Athetosis
• Hemiballismus
  • Nor seizures Test strength Strength 5/5 bilaterally Visual inspection AP chest Chest is symmetrical and the AP diameter is normal. The excursion with respiration is symmetrical and there are no abnormal retractions or use of accessory muscles. No distension, scars, masses, or rashes. Palpate AP chest No tenderness, masses, heaves, thrills, or crepitus Percuss AP chest The anterior lung fields are resonant. The left anterior chest and right lower chest are dull to percussion. The rest of the lung fields are resonant and are not hyper- resonant. MS A P Stomach pain Stabbing/cramping abdominal pain Feels bloated Flatulence worse with rich foods Stress headache C-Section Bike riding accident, right tibia fracture Hot flashes Dry skin Occasional diarrhea Incomplete bowel movements Constipation Pain improved with bowel movements

2 Small intestinal bacterial overgrowth

X

3 Laxative abuse X

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 1 5 Hemorrhoids X 1 6 Colon neoplasm X 1 7 Small bowel obstruction X 18 Small bowel neoplasm X 1 9 Hypothyroidism X 20 Hyperthyroidism X 2 1 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 3 1 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

Parkinson’s X 5 2

MS X

Anemia X 5 4

AAA X

Abdominal abscess/infection X 5 6 Cholecystitis, acute X 5 7 Celiac X 5 8 Mesenteric ischemia, chronic X 5 9 Mesenteric ischemia X 6 0 Pancreatitis, acute X 6 1 Colitis, non-infectious X 6 2 Anemia, lead poisoning X 6 3 Hypercalcemia X 6 4 Hyperthyroidism, graves X 6 5 Hyperthyroidism, thyrotoxic crisis

X

Arthritis, IBD associated X 6 7 Abdominal neoplasm X 6 8 Pancreatic cancer X 6 9 Choledocholithiasis X 7 0 Somatostatinoma X 7 1 Gastric ulcer X 7 2 Colonic ulcer X 7 3

DKA X

Ectopic pregnancy X 7 5 MI, acute X 7 6 Ovarian torsion X 7 8 Nephrolithiasis/kidney calculi X 7 9 Peritonitis X

Peritonitis, spontaneous (NOS)

X

8 Splenic rupture X