NUR 634 Topic 6 Shadow Health Assignment; Focused Exam; Abdominal Pain
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Chief complaint
“Pain in my belly and difficulty going to the bathroom” History of Presenting Illness
Esther Park is a 78 y/o, Korean American women with a history of hypertension presenting to the clinic complaining of abdominal pain and difficulty going to the bathroom. She reports the pain started as a general discomfort five days ago which was about the same time, she noticed difficulty having a bowel movement. Her discomfort has gradually gotten worse the past three days. Her daughter encouraged her to come to the clinic although, the patient did not feel like her symptoms were of concern enough to be seen. The pain seems to be worse when she is moving around the house and gardening, and she has been avoiding her exercise classes due to the pain. The pain improves slightly with rest. She describes the pain as crampy and dull, localized in her lower belly and does not report any radiation. Her pain is constant, and she rates it a 6/10. Prior to five days ago, she reports bowel movements every day or every other day. She denies nausea, vomiting, diarrhea, and blood in her stool. She denies coming on contact with anyone who is sick.
Medical History
Hypertension: Diagnosed at 54 y/o. Treated with PO medications, a low-fat diet, and active lifestyle
Surgical History
Cesarian section @ 40 y/o. No complications. No anesthesia complications. Cholecystectomy @ 42 y/o. No complications. No anesthesia complications. Hospitalizations:
Hospitalized after two healthy childbirths. Hospitalized after one stillbirth.
Hospitalized after non-complicated cholecystectomy. Family History
Mother: Passed away at 88 y/o from pneumonia and a stroke. History of type two diabetes and hypertension.
Father: Passed away at 82 y/o from old age. History of hypertension, hypercholesterolemia, and overweight.
Paternal Grandfather: Passed away in his 90’s due to old age. Healthy.
Paternal Grandmother: Passed away due to cancer when patient was young. History of hypertension.
Maternal Grandfather: Passed away due to a heart attack when patient was young. History of CAD.
Maternal Grandmother: Passed away when patient was young. History of diabetes.
Brother: 80 y/o. History of hypertension, hypercholesterolemia, and current prostate cancer........ Continue
