NURS 6512 Week 6 Assignment

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Patient Information: Initials: JR Age: 47 Sex: Male Race: Caucasian Subjective Data Chief Complaint: “My stomach hurts! I have diarrhea, and nothing seems to help.” HPI: JR, 47 yo WM, with c/... o of generalized acute abdominal pain for three days. Denies that he has taken medications. He rates the abdominal pain is a 5/10 today but at worst the pain has been a 9/10 during the initial onset of the abdominal pain. He reports that he is able eat with some nausea afterwards, denies vomiting. Current Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs Allergies: NKDA PMHx: HTN, Diabetes, hx of GI bleed 4 years ago Soc Hx:. Denies tobacco use; occasional ETOH, married, 3 children (1 girl, 2 boys) Fam Hx: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD O. 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 1. Differential Diagnoses: LLQ abdominal pain: Gastroenteritis [Show More]

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