NUR 608-I human case study-Damian Henderson -abdominal pain-2022-2023.

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iHuman SOAP Damian Henderson Abd Pain CC: “abdominal painx 8 hrs” HPI: Mr Henderson is a 22 yo male who presents with diffuse non-radiating umbilical pain 6/10 which started 8 hrs ago. Pain was... reported to be exacerbated by coughing and movement of any sort causing pt to prefer to lay in a still position to avoid added pain. He denies recent infection, hx of GI surgeries or diseases, previous pain of this sort, weightloss, trauma, changes in bowel/bladder habits or fever. He denies SOB, palpitations, and nausea. He reports his general health to be good and without significant childhood illness hx. Pt is unable to identify external triggers for current symptoms. His last bowel movement was prior to the onset of his current symptoms; His appetite and oral intake of fluids are poor. He has not been in contact with anyone exhibiting these symptoms. ROS: Cons/Gen: Denies any headache, fever, weight loss; denies abd trauma; c/o mild distress CV: Denies CP Lungs: Denies SOB Abdomen: c/o midabdominal pain 6/10 without radiation since 8hrs ago; pain is exacerbated by movement and coughing. denies abd trauma GI/GU: Denies any changes to bowel and bladder function; c/o diminished appetite M/S: Denies joint pain Psych: Denies changes in mood All: NKDA Meds: none CONTINUED.... [Show More]

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