NUR 5153 ihuman Case Study Brenda James CC abd Pain, Gallbladder

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IHuman Lt Brenda James 48y/o Reason for encounter: Abdominal pain :Questions 1. How can I help you today? a. “My stomach has really been hurting and I havent been able to go to work.” 2. Wh... ere more precisely is your abdominal pain? a. Right side, under ribs 3. How severe is your abdominal pain? a. Starts as 2-3, gets up to 2-7/10. Currently a 3-4/10. 4. When did the abdominal pain start? a. 2 weeks ago 5. Does the pain in your abdomen radiate someplace else? Where a. Right shoulder ache 6. Anything makes the pain in your abdomen better or worse? a. Worse: eating (fast food) b. Antacids made no difference 7. Do you have any allergies a. NKDA 8. Are you taking any over the counter or herbal medications a. Antacids, ibuprofen, multivitiams i. Ibuprofen 400mg TID prn for knee stiffness 9. Have you been having fevers a. On and off the last 2 days 10. Do you drink alcohol? If so, what do you drink and how many per day a. Glass of wine with dinner Qnight b. None the last 2 days 11. Do you have any other symptoms or concerns we should discuss? a. Vomited 2 times in last 2 days 12. What does the pain/ discomfort in your abdomen feel like? (cramping, burning, etc) a. Crampy, gnawing, ache 13. What are the events surrounding the start of your abdominal pain? 14. How often does this abdominal pain occur? a. Q2-3months 15. Can you tell me about your diet? What do you normally eat 16. Do you experience shortness of breath, wheezing, difficulty catchying your breath, chronic cough or sputum production 17. Do you experience chest pain discomfort or pressure; pain/pressure/ dizziness etc 18. Do you have problems with muscle or joint pain, redness, swelling, muscle cramps, etc 19. Do you have problems with dizziness, fainting, spinning room, seizures, weakness, numbness, tingling, tremor 20. Any new medical issues or diagnoses since your last visit · 5 more in Associated Symptoms DDx Choledocholithiasis : lead, MNM - [Show More]

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