lOMoAR cPSD| 11700591
lOMoAR cPSD| 11700591
6512 WEEK 6 Abdomen Case Study ANALISYS ABDOMINAL ASSESSMENT Subjective: •
CC: "My stomach hurts, I have diarrhea, and nothing seems to help."
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HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago.
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He has not taken any medications because he did not know what to take.
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He states the pain is a 5/10 today but has been as much as 9/10 when it first started.
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He has been able to eat, with some nausea afterward.
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PMH: HTN, Diabetes, hx of GI bled 4 years ago
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Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs
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Allergies: NKDA
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FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
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Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
Objective: •
VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs
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Heart: RRR, no murmurs
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Lungs: CTA, chest wall symmetrical
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Skin: Intact without lesions, no urticaria
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Abd: soft, hyperactive bowel sounds,
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pos pain in the LLQ