NR 511 Week 5 iHuman Virtual Patient Encounter; Abdominal Pain in 54-Year-Old Female - Dorothy Jones

Good overall health except this recent issue. Feeling “lousy”. Denies Fever or chills. No recent weight loss or night sweats, appears uncomfortable and in pain 2. HEENT/neck Denies headache, visual changes, sore throat, ear pain or neck stiffness. 3. Cardiovascular Denies chest pain, palpitations, or dizziness. 4. Respiratory Denies shortness of breath, cough, or recent respiratory illness 5. Gastrointestinal Abdominal rated 8-9/10, described as cramping and squeezing in character, pain is periumbilical and non-radiating, which is worsen with palpation, reports nausea and vomiting since yesterday, vomitus is greenish in color, states vomiting relieves some of the pain temporarily, eating triggers vomiting, early satiety noted. Last bowel movement 2 days ago which was watery and not her normal pattern. Normally patient has 1-2 bowel movements per day. Report bloating for the past day. Denies hematemesis, melena, or hematochezia. Has poor appetite, unable to eat due to nausea and pain. 6. Genitourinary Denies urinary frequency, urgency, dysuria, or hematuria. 7. Musculoskeletal Denies any joint pain or muscle ache. 8. Neurologic Alert and oriented, denies headache, visual changes or syncope. 9. Intergumentary/breast Denies any rash or jaundice. 10. Psychiatric Anxious about current symptoms, no history of depression or psychiatric illness. 11. Endocrine Denies polyuria, polydipsia, or recent bruising. 12. Hematologic/lymphatic Denies easy bruising, bleeding tendencies, or lymphadenopathy 13. Allergic/ immunologic Denies any allergies. Past medical history 1. Past medical history High cholesterol, Hx of gallstones, no significant childhood history, 1 pregnancy and has 1 daughter 2. Hospitalization/surgeries cholecystectomy 12 years ago, fibroids removal 5 years ago and 1 year ago, female part taken (hysterectomy) 1 year ago. 3. Preventative health Last physical- unknown Colonoscopy 3 years ago- normal Mammogram- date unknown but was normal per patient Pap smear – date unknown Up to date with flu and covid shots 4. Medications quadrants, moderate periumbilical tenderness to palpation. No bulge or mass upon palpation of abdomen or groin areas. No involuntary guarding. 6. GU/rectal No CVA or suprapubic tenderness. Normal external rectal exam. No hemorrhoids or skin lesions. DRE without masses and hemoccult negative. 7. Musculoskeletal Gait steady. Full range of motion in all extremities. No joint swelling, deformity, or tenderness. 8. Neurologic Alert, oriented x 4, cooperative. Intact thought process. 9. Skin warm and dry with no lesions, pallor, or jaundice. Back of hand skin turgor snaps back rapidly. Capillary refill less than three seconds. 10. Lymphatic Cervical, axillary, inguinal and epitrochlear lymph node non-tender, mobile, pea- sized and soft bilaterally. 11. Psychiatric Appearance appropriate for age and setting. Thought process logical. No depression, anxiety or cognitive impairment noted. Key findings 1. Early satiety, not able to eat 2. Periumbilical pain—intermittent pain 3. Cramping and now squeezing pain—visceral pain 4. High severity pain 8-9/10, worsen with palpation 5. Nausea and greenish vomiting—relief after vomiting 6. Bowel pattern changes- no BM for 2 days, last BM watery 7. Abdominal bloating 8. No fever or chills 9. Abdomen distended, absent bowel sounds- no rebound, guarding, or peritonitis 10. Surgical scar w/ history of abdominal surgery