Larry Orlander "Abdominal Pain" iHuman Latest Updates (NR667 iHuman) Latest, Exams of Nursing

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Larry Orlander "Abdominal Pain" iHuman Latest Updates (NR667 iHuman) 16 Are you unable to pass gas? 17 Can you tell me about any current or past medical problems you’ve had? 18 Do you have a history of bowel obstruction? 19 Have you or any family member had a history of inflammatory bowel disease? 20 Have you had the pain in your abdomen before? 21 Do you have heart disease and/or have you ever had a heart attack? 22 Have you lost weight? 23 Have you been vomiting anything that looks like blood or coffee grounds? 24 Do you have any black tar or foul-smelling stools? 25 Have you ever been hospitalized? 26 Do you have diarrhea? 27 Do you have a history of volvulus? 28 Do you avoid eating because you are worried about the pain? 29 How long does the pain in your abdomen last? 30 Is there any blood in your stools or with your bowel movements? 31 How often does this abdominal pain occur? 32 Have you been diagnosed with chronic mesenteric ischemia? 33 Do you now, or have you ever had cancer? FYI – The electronic health record is not listed on the rubric as being graded, check with your professor before spending the time completing the EHR. Some professors still wanted to see that itwas completed, some did not require it – the EHR information is here for you just in case. Neck: Patient denies any stiffness, no pain, no tenderness, no noted masses. Electronic Health Record – History Reason forEncounter Aanbddinoambiliitny atol pPaassingas or have a BM. Denies any hematochezia or melena in stool, diarrhea, fever, chills, or night sweats. Last BM: 2 days ago. GHePneIral Patient den iePs faetvieer/nchtilplsr, uenseexnpltasinewdiwtehighat lposrso, fgartieguses,invigeht3s- wdeaatys HhEisEtNoTr/Nyeockf Head: Patient denie hseeavdeacrheesc, nroavmerptigino,gnoainbjduroy.minal pain 5/10 with associated Enyaesu: sNeoarm, avl ovimsioint,innogteoarningu, nnodsicgoetosmtaetda, nfoo opadin. Ears: Patient denies any change in hearing, no tinnitus, no bleeding, no vertigo. Nose: Patient denies any epistaxis, no coryza, no obstruction, no discharge. Cardiovascular Patient denies chest pain, palpitations, edema, syncope, decrease in exercise Respiratory tolerance Patient denies expectoration, dyspnea with rest or exertion, , Psych Patient denies increased or decreased sleep, mood changes, anxiousness, panic attacks, decreased energy, forgetfulness, hallucinations, suicidal or homicidal ideation Endocrine Patient denies skin or hair changes, intolerance to heat or cold, fatigue, tremor polydipsia, polyphagia, or polyuria Heme/Lymph Patient denies bleeding, bruising, swollen lymph nodes Allergic/ Immunologic denies any allergies denies any food or drug allergies or any immunologic issues PMH Diverticulitis Hospitalizatio ns -Appendectomy at 10 years of age -Inguinal hernia repair at 20 years of age Preventative Health Immunizati o ns UTDNeeds colonoscop y Medications None Allergies NKDA Social History -Single, lives alone in an apartment. No Kids -Works as a bus driver for the city -Drinks 1-2 beers -Denies any tobacco, vaping, or recreational drug use Family History -Father, 75 y/o, healthy -Mother, 73 y/o, T2DM Cognitive status: alert and oriented x Weight: 175.0 lbs. Blood pressure: 119-60, normotensive, left and right TIR: 128, r ar, normal RR: 12, regular, unlabored Temp: 98.6 SpO2: 97% ct skin overall Inspect nails Capillary refill Inspect eyes Inspect mouth/orophar; Palpate all lymph nodes Auscultate lungs Auscultate heart Visual inspection of the abdomen Auscultate abdomen Percuss abdomen Palpate abdomen Inspect extremities for perfusion Rectal inspection Rectal exam Electronic Health Record - Physical Exam General Well developed, well nourished, alert and cooperative, and appears to be in some discomfort HEENT/Neck Head: normocephalic, atraumatic Eyes: PERRLA, EOMI. Fundi normal, vision is grossly intact. Ears: External auditory canals and tympanic membranes clear, hearing grossly intact. Nose: No nasal discharge. Throat: Oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition. Neck: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly. Cardiovascular Normal S1 and S2. No $3, $4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits. Chest/Respiratory Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds. Abdomen Hyperactive bowel sounds. Abdomen is distended, mildly tender to deep palpation throughout. No rebound tenderness or guarding. No ascites or behaviors during the examination. Patient is not suicidal History of diverticulitis Abdominal pain x3 daysAbsenc e of gas Periumbilica l pain No blood in stoolNo stool x 2 days History of abdominal surgery Nausea Vomiti n g Weak ne ss Tachy ca rdia Inability to urinate Mr. Orlander is a 50 y/o African American male that presents to the clinic with a 3-day history of intermittent abdominal pain, nausea and vomiting that has been progressively getting worse. PMH: diverticulitis. Currently on no medications. Deniesany hematochezia, hematuria, hematemesis, fever, chills, or night sweats. Physical exam reveals hyperactive bowel sounds, tenderness to palpation on abdomen and “drum” like sounds heard on percussi on. Sigmoid Volvulus XX Small bowel neoplasm X Inflammatory bowel disease X Acute pancreatitis X Lactose intolerance X Acute megacolon X Constipation X Peritonitis X Peritonitis, spontaneous X Peptic ulcer disease X Small intestinal overgrowth X Colitis, infectious X Crohn’s disease X Liver abscess X Pancreatic abscess X Pancreatic cancer X CT Abdomen Bowel obstruction due to mass in transverse colon Lactic Acid Upper GI barium Series Normal Diagnosis – 100% Large bowel obstruction Exercise Answers – 100% 1 Pancreatitis 2 Calcification of the pancreas Plan Refer to emergency departments for management of LBO and hypokalemia. IV fluid for rehydration. Zofran Q6 PRN for N/V NG tube for bowel rest and colonic decompressionNPO for bowel rest and possible surgery Surgical consult Referral to gastroenterology https:// Case Summary Photos: https://www.aafp.org/pubs/afp/issues/2018/0915/ p362.html#treat ment Prescribers' Digital Reference. (n.d.). Zofran ODT Orally Disintegrating Tablets, Oral Solution, and Tablets(ondansetron); (ondansetron hydrochloride)https://pdr.net/drug-summary/Zofran- ODTOrallyDisintegrating-Tablets--Oral-Solution--and- Tablets- ondansetron---- ondansetronhydrochloride244.2904 DeLI Approach Ree Sy conten —> EE Rank Differential Diagnosis Test & Intorprot ered Treat DeLI Describing Abdominal Pain PQRST Mnemonic for Characterizing a Symptom * Symptom characterization — Provocative & palliative — Quality, Quantity — Region, Radiation — Severity, Setting — Temporal: Onset, Duration & Frequency  DeL q Limit (pivotal) Questions for Abdominal Pain 1. Specific clinical findings 2. Location 3. Time course Abdominal Pain Diagnostic Approach € Identify specific clues Unexplained hypotension Gl bleeding Peritonitis Significant distention Palpable mass Review Location 5 Course [ | Abdominal Pain is like Real Estate ...Location, Location, Location Pivotal features Pain diffuse * Distended * Tympanitic PUD * No flatus or BM eiiy Ca eases Spier inary * Acute _— Bilary Disease enal colic Renal colic Diverticulitis J Diverticulitis Ovarian disease PID Ruptured ectopic pregnancy Bowel obstruction Large bowel obstruction (LBO) * Colon cancer * Volvulus * Diverticular disease + Extrinsic compression from metastatic cancer * Other ~ DDX of Large & Small Bowel Obstruction @q Follow-up Given concern of obstruction, a CT scan performed > Large bowel obstruction with a mass in the sigmoid colon «i UD Bowel Obstruction: Classic Presentation Patient is classically a middle aged patient who presents with hours of incapacitating waves of diffuse, poorly localized, severe crampy pain, with nausea, vomiting, inability to pass stool or flatus. Bowel Obstruction: Fvidence-Based Dx * Clinical findings insensitive — Vomiting, 75% — Abdominal distention, 63% — Constipation, 44% * Certain findings fairly specific. — Constipation, 95%: LR+, 8.8 — Prior abdominal surgery, 94%; LR+, 11.5 — Abdominal distention, 89%; LR+, 5.7 Bowel Obstruction: Evidence-Based Dx * Combinations uncommon but specific — Abdominal distention with vomiting, constipation or prior surgery very suggestive (+ LR = 10) but infrequent (27 — 48%) — Increased bowel sounds with prior surgery or vomiting also very suggestive (+LR 11 & 8)