Epigastric Case Study Essay

1. What health history would be appropriate to elicit from Paula regarding her epigastric pain?

It is very important to get the proper information from Paula about the epigastric pain she is feeling. The information needed are:
• Paula’s medical history
• Is she experiencing any loss of appetite?
• Did she lose weigh from a certain period of time? Is it involuntary losing of weight or is it because of diet?
• Is she experiencing any difficulty in swallowing (dysphagia)?
• Does she have any aversions or intolerance in eating specific food? If yes, What are those?
• Do you experience any episodes of nausea and vomiting?
• Is there any change in her bowel movements?
• Is she experiencing any pain? Ask about o Is the pain provocative or palliative?

2. What focused physical assessment should be preformed to obtain a complete picture of Paula is digestive system?

To assess the abdominal area (digestive system), a focused physical examination should be done. First is the inspection. Inspect the left epigastric, left umbilical, left suprapubic, epigastric, suprapubic, right epigastric, right umbilical, right suprapubic, umbilical, left upper quadrant, left lower quadrant, right upper quadrant and the right lower quadrant.

Put Paula in the supine position and inspect for bulges, masses, hernia, ascites, spider nevi, veins, pulsations or movement and the inability to lie flat.

Then, do the auscultation. Check for bowel sounds. Listen to the bowel sound for a full minute before determining if they are normal, hypoactive, hyperactive or absent.
Next is do the percussion and palpation. Percuss the abdomen for general tympani, liver span, and splenic dullness. For palpation, press the skin about ½ inch to ¾ inch with the pads of the fingers. Palpation will allow for the assessment of the texture, tenderness, temperature, moisture, pulsations, masses, and internal organs. When palpating the abdominal region, be sure