Esther Park is a 78-year-old Korean woman presenting with abdominal pain in the ED. the abdominal pain is a 6 and described as a constant dull, crampy feeling low low in her abdomen that began as a general discomfort about 5 days ago when the patient states she began having difficulties going to th...
esther park is a 78 year old korean woman presenting with abdominal pain in the ed the abdominal pain is a 6 and described as a constant dull crampy feeling low in her abdomen that
Abdominal pain Esther Park shadow health
Esther Park is a 78-year-old Korean woman presenting with abdominal pain in the
ED. the abdominal pain is a 6 and described as a constant dull, crampy feeling low low in her abdomen that began as a general discomfort about 5 days ago when the patient states she began having difficulties going to the bathroom and has not had a bowel movement for several days. The pain worsens when she moves around a lot or eats something. The only s urgeries she has had is gallbladder removal and C-section, both in her 40s. She takes 10mg of Accupril
daily. She has pain in her LLQ of her abdomen when percusses. Upon palpation of
the LLQ a firm, oblong mass approximately 2X4cm was noted.
Scored Items
Experts selected these topics as essential components of a strong, thorough
interview with this patient.
Patient Data
Not scored
a combination of open and closed questions will yield better patient data. The
following details are facts of the patient's case.
History of Presenting Illness
•
Finding:
Established chief complaint
•
Finding:
Reports abdominal pain
(Found)
Pro Tip: Abdominal pain can be caused by problems in the underlying organs, peritoneum, muscles, or blood vessels, changes
in electrolytes or other blood contents, or even anxiety. Asking for
details about the pain helps to determine the origin.
Example Question:
Do you have any abdominal pain?
•
Finding:
Reports difficulty "going to the bathroom"
(Found)
Pro Tip: Understanding all of a patient's reason for visiting is an important foundation to establish. If there are multiple symptoms,
follow up on each one during your interview.
Example Question:
Are you able to make a bowel movement?
•
Finding:
Asked about onset of the pain
•
Finding:
Reports a feeling of discomfort for the past five days
(Found)
Pro Tip: Whenever you are assessing a symptom or a health condition, inquiring about onset assesses the severity and the
progression of the problem.
Example Question:
How long have you had stomach pain?
•
Finding:
Reports pain with gradual onset that worsened 2-3 days ago
(Available)
Pro Tip: Whenever you are assessing a symptom or a health condition, inquiring about onset assesses the severity and the
progression of the problem.
Example Question:
Has the stomach pain changed?
•
Finding:
Asked about location of the pain
•
finding:
Reports pain in lower abdomen
(Found)
Pro Tip: Identification of the location of your patient's discomfort can
provide important clues about its cause and how it should be best treated.
Example Question:
Where is your discomfort located?
•
Finding:
Reports pain is not localized
(Found)
Pro Tip: Identifying the location of your patient's pain provides
important clues about its cause and how to treat it best.
Example Question:
Is the pain in a specific spot?
•
Finding:
Reports no flank pain
(Available)
Pro Tip: Flank pain often occurs with disorders of the urinary tract.
When a patient complains of flank pain, assess for co-occurring symptoms such as fever, chills, hematuria, and dysuria.
Example Question:
Do you have pain on your sides?
•
Finding:
Confirmed pain rating on a scale
•
finding:
Reports pain rating of 6/10
(Found) Pro Tip: For many people, it is difficult to clearly describe pain.
Asking your patient to rate her pain on a scale from zero to 10 develops a consistent measure of pain severity.
Example Question:
How would you rate your pain on a scale of one to ten?
•
Finding:
Asked about character of the pain
•
finding:
Describes pain as dull and crampy
(Found)
Pro Tip: Asking your patient to describe her pain helps identify its cause and the severity. Patients may not know how to answer, so you may need to suggest words like sharp, dull, burning, throbbing,
or shooting.
Example Question:
Can you describe the pain?
•
Finding:
Reports pain is intermittent with aggravating factors
(Found)
Pro Tip: It's important to ask your patient if her pain is constant or
intermittent in order to determine her level of discomfort and identify the cause of the pain. Constant pain is often best managed
with around-the-clock pain medications.
Example Question:
Is your pain constant?
•
Finding:
Asked about treatment and relieving factors
•
Finding:
Reports that resting helps
(Available)
Pro Tip: It's important to assess the nature of pain by asking about
relief. If you know your patient is taking pain medication, asking
about the medication's effectiveness can help you adjust treatment
as needed.
Example Question:
What relieves your pain?
•
Finding:
Reports attempts to treat pain by drinking small sips of warm water
(Available)
Pro Tip: Asking about how your patient has been managing her pain
assesses her current condition and her approach to self-care. The results of her previous treatment may be helpful in your diagnosis
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