Amanda M Jones NURS 6512 Week 6 Assignment Patient Information: Initials: JR Age: 47 Sex: Male Race: Caucasian SUBJECTIVE. CC : “My stomach hurts, I have diarrhea, and nothing seems to help.” HPI : JR, 47-year-old white male, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards. Current Medications : Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units at bedtime Allergies: NKDA PMHx : HTN, Diabetes, hx of GI bleed 4 years ago Soc Hx : Denies tobacco use; occasional beer, married, 3 children (1 girl, 2 boys) Fam Hx : No hx of colon cancer, Father hx DM type 2, HTN, Mother hx HTN, Hyperlipidemia, GERD OBJECTIVE. VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs Heart: RRR, no murmurs Lungs: CTA , chest wall symmetrical Skin: Intact without lesions, no urticaria Abd: soft, hyperactive bowel sounds, positive pain in the LLQ on palpation Diagnostics: None ASSESSMENT .
Differential Diagnoses: Left lower quadrant pain, Gastroenteritis Is the Current Diagnosis Supported by the Current Information? Gastroenteritis cannot be supported by current information; additional subjective and objective information is needed to complete a thorough assessment. In addition, diagnostic testing is needed to rule out any other possible diagnoses. Additional Subjective Information Needed The patient is very vague about his abdominal pain. The practitioner must ask more detained question to identify the location and description of his abdominal pain. Is the pain sharp, cramping, aching, shooting, stabbing or throbbing? What was the patient doing when the pain started? What aggravates the abdominal pain or cause it to flare up? How long does the pain last when it starts? Is there anything that makes your abdominal pain better? Do you have any problems urinating?
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- Summer '15
- Bowel obstruction