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Esther Park and digital clinical environment

Esther Park and digital clinical environment…..Shadow Health Questions ; SBAR……situation, background, assessment recommendation.

Esther Park is a 78-year-old woman who is presenting with persistent, generalized abdominal pain. She rated the pain at 6/10 and said it is dull and crampy. …………………………

Esther Park  reports a decrease in appetite and activity over the last week, and lack of regular bowel movements after mild diarrhea three days ago. She reports a diet that is low in fiber. …………………………

The physical exam of Esther Park indicated abnormalities of the abdomen including asymmetry due to localized distension in the LLQ, as well as tenderness, scattered dullness, and a palpable rope-like mass consistent with

fecal matter in the same quadrant. ……………………………

Based on my findings, I recommend that Esther Park be scheduled for a digital rectal exam, pelvic exam, and urinalysis. Mrs. ………………..

Chief Complaint of Esther Park :

  • Do you have any abdominal pain?
  • Are you able to have a bowel movement? ……………….

Orientation of  Esther Park :

  • Can you tell me who you are?
  • Do you know where you are right now?
  • Do you know why you are here today?
  • What is the date and year?…………………

History of Presenting Illness  ;

  • How long have you had stomach pain?
  • Has the stomach pain changed?………………………

Past Medical History of Esther Park; 

  • Are you typically constipated?
  • How many bowel movements do you typically have per week?
  • Are your stools typically brown?…………………

Social History  of Esther Park;

  • Do you have difficulty getting on and off the toilet?
  • Do you have difficulty dressing yourself?………………

Review of Systems ; 

  • Have you had any recent weight changes?
  • Have you had a fever recently?………………..

Objective data of  Esther Park; 

  • Inspected Head and face:
  • Skull symmetry: symmetric
  • facial features symmetry: symmetric
  • Appearance: she has flushed appearance
  • Nasal mucosa, and oral mucosa are moist and pink.
  • Inspected abdomen:
  • Inspected for edema in lower extremities:
  • No edema in right, left, lower extremities.
  • Auscultated heart sounds:
  • Heart sounds, S1 and S2 are audible. No extra sounds…………………

Subjective data of Esther Park; 

The patient reports a decrease in appetite and activity over the last week, and lack of regular bowel movements after mild diarrhea three days ago. She reports a diet that is low in fiber………………..

For many people, it is difficult to clearly describe pain. Asking your patient to rate her pain at its highest on a scale from zero to 10 develops a consistent measure of pain severity. 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.

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. 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.

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