NURS 6512 Week 6 Health Assessment Assignment - Walden University

NURS 6512 Week 6 Health Assessment Assignment - Walden University Patient Information: Initials: JR Age: 47 Sex: Male Race: Caucasian Subjective Data Chief Complaint: Abdominal Pain 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:. Neg 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: CBC with differential: An elevated WBC count greater than 12,000/microliter indicates an infectious or inflammatory condition (Dains et al, 2016), for possible infection 1. Differential Diagnoses: LLQ abdominal pain: Gastroenteritis Current Diagnosis Supported The diagnosis of gastroenteritis is sufficiently supported. Symptoms of the working diagnosis gastroenteritis include diarrhea, abdominal pain, vomiting, headache, fever and chills. Common problems associated with gastroenteritis is dehydration, this is related to the inability to drink enough fluids to replace what you lose through vomiting and diarrhea (ne , 2018). Dehydration as a complication of gastroenteritis can be seen most often in babies, young children, the elderly and people with weak immune systems. J.R. presents with a low-grade fever and diarrhea, although he is not vomiting he does report nausea, so this diagnosis can be supported as a working diagnosis. Medline Plus (2018) reports that the diagnosis of viral gastroenteritis is the second leading illness in the U.S. The most common cause is norovirus infection (ne , 2018). This type of infection can be spread through spread through contaminated food or water, as well as contact with an infected person (ne , 2018). Health promotion for this diagnosis is often hand washing hygiene and frequent handwashing (ne , 2018). Additional Information Needed Additional information .................................................................................................................CONTINUED