Esther’s Focused Health Assessment Custom Essay
Esther’s Focused Health Assessment American Sentinel University Introduction “Esther Park(E, P), a seventy-eight-year-old female”, goes to Shadow health clinic for a chief complain of abdominal discomfort(belly pain, with difficulty going to the bathroom). Ms. Esther undergoes a health history examination and a physical health assessment. Also, we will get an inside on Esther’s family history. Furthermore, we will look into possible diagnoses and treatment plans. Mrs. Park will have additional testing and exams done. Esther’s Focused Health Assessment “Mrs. Park is an elderly female from Korean descend that comes into the clinic complaining about belly pain and having difficulties using the bathroom for a couple of days”. Esther stated that she went to the clinic more because her daughter(Jennifer) is very concerned about her health. Mrs. Park is a retired nurse, widower, and a mother of two adult children(timothy-age forty-eight and Jennifer-age forty-six). Esther vital signs on the exam were “blood pressure 110/70, heart rate 92, respiratory rate 16, temp 37 C, and a saturation of 99 % on room air”. Mrs. Park stated that the pain started five days ago, that she also had difficulties going to the bathroom, and had one day of diarrhea. Esther has no fever, did not take any medication for her belly pain or her diarrhea. The belly pain is located in her lower abdomen with no radiating pain to other areas as per Mrs. Park. Esther made known that the pain(dull crampy feeling) is general and in one place. As per Esther, the pain gets worse with eating, moving around too much and only feels better with rest. Esther got diagnosed with hypertension at the age of 54 years old, which she takes Accupril 10 mg daily by mouth. E. P stated that she has an allergy to latex which gets her an itching rash, no food, environment or medication allergies reported(Shadow health, 2019). Subjective Elements Esther noted the general pain in her lower abdomen about five days ago, with diarrhea two-three days ago lasting for one day. No blood was pointed out in diarrhea but as Esther reported no bowel movement since that day. E. P has pain six out of ten on the pain scale with the pain getting increasingly worse the last couple of days. Park has not taken any medication for belly pain or diarrhea. Esther reported no vomiting, nausea, headaches, difficulty breathing, or swallowing. No history was of depression just anxious about her illness. Esther has no vision problem or hearing but did mention had her memory(forgetful at times) is not like it used to be when she was younger. Reading 2-3 books a week is what keeps Esther young at heart. Park has no family history of a stomach problem(her father had heartburn on occasion) or a history of stomach problems before this episode. Esther appetite has been sparse these days for breakfast she had some toast, last night dinner was chicken broth, she usually would drink six glasses of water, but lately, she cannot drink that much(Shadow health, 2019). Esther never smoked a day in her life but did admit to a glass of white wine a week. Park is up-to-date with her immunization, had her last flu-vaccine a year or two ago. Esther had been admitted to the hospital for childbirth(C-section) and surgery(cholecystectomy) in the past. Esther has two adult children(Timothy and Jennifer), two older brothers, and her parents are deceased. Park resides with Jennifer who is a criminal defense lawyer; she has no grandkids. Esther helps Jennifer around the house(keeps the house tidy) and in the garden. Esther became a widow about six years ago when her husband Shin died from a brain bleed(Shadow health, 2019). Physical Findings On physical examination Esther an elderly female seems uncomfortable, cheeks slightly flushed, grimacing at times but appears in stable condition. On inspection, the face is symmetric; mucus membranes are moist and pink. The abdomen has a scar underneath the right breast (about 6 cm), and an injury in her lower abdomen midline in the suprapubic region(above10cm). The abdomen is flat, symmetric, with freckles, birthmarks, and some discoloration. No edema noted on the lower extremities. On auscultate S1, S2 audible with no murmurs or extra sounds. Bowel sounds are normoactive in all the quadrants, no bruit or friction sounds noted. Percussed of the abdomen found some dull and tympanic areas. Liver- 7 cm in the midclavicular line, no CVA tenderness indicated. On light palpitating on the abdomen soreness, tenderness noted in the left lower quadrant, no masses. On deep palpitating of the abdomen, a deep oblong palpable mass(2×4 cm) noted. Liver palpable, 1 cm below the right costal margin. Spleen/ bladder not palpable on exam. On skin exam warm and dry, no tenting noted. Pelvic exam no inflammation, irritation of vulva, no masses, no growth. Rectal exam no hemorrhoids, fissures, but strong the sphincter tone, fecal mass detected in rectal vault. Urinalysis- ketones found and urine was acidic(Shadow health, 2019). Differential diagnoses Esther can have either diverticulitis or constipation. “Diverticulitis is described as a localized in?ammatory response that can occur in two possible ways”. “One explanation is that a micro-perforation at the fundus of the diverticulum leads to a focal in?ammatory cascade”. Second in?ammation due to “impaction and entrapment of a fecolith within the mouth of a diverticulum and subsequent exposure of the lamina propria to fecal microbiota”(Razik & Nguyen, 2015). “Constipation is a disorder in the gastrointestinal tract, which can result in the infrequent stools, difficult stool passage with pain and stiffness”. “Acute constipation may cause closure of the intestine, which may even require surgery”. Constipation is common in elderly patient with hereditary, drugs, and diet in the pathophysiology of the disease(Forootan, Bagheri, & Darvishi, 2018). Esther’s Plan of care Mrs. Park should have laboratory testing done(CBC, WBC’s, electrolytes). CT abdomen to assess for obstruction. Further, would I recommend IV fluids, nothing by mouth to rest the stomach. Consult a gastroenterologist. If she has constipation, I would increase her fiber intake and activity as tolerated(Forootan, Bagheri, & Darvishi, 2018). Conclusion Esther would need to monitor her diet and make some dietary changes. She needs to drink more water, food with more fiber( fruits, vegetables), change of lifestyles, and nutritional habits. Follow up an appointment with the gastroenterologist. Monitoring the bowel movements for any changes. I would encourage her to stay physically active as much as she can. References Forootan, M., Bagheri, N., & Darvishi, M. (2018). Chronic constipation. A review of literature. Medicine, 97(20, e10631). https://doi.org/10.1097/MD.0000000000010631 Razik, R., & Nguyen, G. (2015). Diverticular disease: changing epidemiology and management. Drugs & aging, 32(5), 349-360. https://doi-org.americansentinel.idm.oclc.org/10.1007/s40266-015-0260-2 Shadow health. (2019). https://americansentinel.shadowhealth.com/
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