Larry Orlander "Abdominal Pain" iHuman Latest Updates (NR667 iHuman), Exams of Nursing

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Larry Orlander

"Abdominal

Pain" iHuman

Latest Updates

(NR

Larry Orlander

"Abdominal

Pain" iHuman

Latest Updates

(NR667 iHuman)

iHuman)

3 eat? 1 4 Any change in the frequency of your bowel movements? 1 5 Any previous medical, surgical, or dental procedures?

16 Are you unable to pass gas? 17 Can you tell me about any current or past medical problems you’ve had? 18 Do you have a history of bowel obstruction? 19 Have you or any family member had a history of inflammatory bowel disease? 20 Have you had the pain in your abdomen before? 21 Do you have heart disease and/or have you ever had a heart attack? 22 Have you lost weight? 23 Have you been vomiting anything that looks like blood or coffee grounds?

28 Do you avoid eating because you are worried about the pain? 29 How long does the pain in your abdomen last? 30 Is there any blood in your stools or with your bowel movements? 31 How often does this abdominal pain occur? 32 Have you been diagnosed with chronic mesenteric ischemia? 33 Do you now, or have you ever had cancer? FYI – The electronic health record is not listed on the rubric as being graded, check with your professor before spending the time completing the EHR. Some professors still wanted to see that it was completed, some did not require it – the EHR information is here for you just in case. Electronic Health Record – History Reason for Encounter Abdominal Pain HPI Patient presents with a progressive 3-day history of severe cramping abdominal pain 5/10 with associated nausea, vomiting on undigested food Neck: Patient denies any stiffness, no pain, no tenderness, no noted masses. and inability to pass gas or have a BM. Denies any hematochezia or melena in stool, diarrhea, fever, chills, or night sweats. Last BM: 2 days ago. General Patient den ies fever/chills, unexplained weight loss, fatigue, night sweats HEENT/Neck Head: Patient denies headaches, no vertigo, no injury. Eyes: Normal vision, no tearing, no scotomata, no pain. Ears: Patient denies any change in hearing, no tinnitus, no bleeding, no vertigo. Nose: Patient denies any epistaxis, no coryza, no obstruction, no discharge. Cardiovascular Patient denies chest pain, palpitations, edema, syncope, decrease in exercise Respiratory tolerance Patient denies expectoration, dyspnea with rest or exertion, orthopnea, PND, GI Patient endorses abdominal pain, nausea, vomiting, constipation, decreased appetite, and inability to pass gas. Last BM:2 days ago. Denies dyspepsia, GU Patient denies dysuria, frequency, urgency, hematuria, nocturia, MS incontinence, dribbling, hesitancy, retention, flank pain Patient denies new weakness, arthralgias, myalgias, swelling, stiffness,

wheezing belching, melena or bloody stools. cramps, or weakness

Psych Patient denies increased or decreased sleep, mood changes, anxiousness, panic attacks, decreased energy, forgetfulness, hallucinations, suicidal or homicidal ideation Endocrine Patient denies skin or hair changes, intolerance to heat or cold, fatigue, tremor polydipsia, polyphagia, or polyuria Heme/Lymph Patient denies bleeding, bruising, swollen lymph nodes Allergic/Immunologic denies any allergies denies any food or drug allergies or any immunologic issues PMH Diverticulitis

Hospitalizations - Appendectomy at 10 years of age

• Inguinal hernia repair at 20 years of age Preventative Health Immunizatio ns UTD Needs colonoscopy Medications None Allergies NKDA Social History - Single, lives alone in an apartment. No Kids
• Works as a bus driver for the city
• Drinks 1 - 2 beers
• Denies any tobacco, vaping, or recreational drug use Family History - Father, 75 y/o, healthy
• Mother, 73 y/o, T2DM

hepatomegaly. Tympanic “drum-like” sounds heard upon percussion. Abdomen/femoral arteries intact. GU/Rectal Rectal inspection: No visible fissures, induration, or lesions. Rectal exam: Normal. No masses or stools on the rectal exam. Heme-occult negative. No palpable masses o GU: deferred MS 100% for differential diagnosis, ranking, and MNM. Adequately aligned spine. ROM intact spine and extremities. No joint Large bowel obstruction erythema or tenderness. Normal muscular development. Normal gaiX X t. Ne throughout. X X Skin Abdominal Aortic Aneurysm Several small dark patches on the dorsal aspect of both hands otherwise, skin X X of normal color, texture and turgor; no lesions or eruptions. Mesenteric Ischemia X X Lymph No pathological lymph nodes in the cervical, supraclavicular, axillary or Retroperitoneal Hemorrhage X X clavicular chains. Small Bowel Obstruction X X Psych The mental examination revealed the patient was oriented to person, place, and time. The patient was able to demonstrate good judgment and reason, without hallucinations, abnormal affect or abnormal

behaviors during the examination. Patient is not suicidal Key Findings History of diverticulitis Abdominal pain x3 days Absence of gas Periumbilical pain No blood in stool No stool x 2 days History of abdominal surgery Nausea Vomitin g Weakne ss Tachyca rdia Inability to urinate Pro m St Mr. Orlander is a 50 y/o African American male that presents to the clinic with a 3-day history of intermittent abdominal pain, nausea and vomiting that has been progressively getting worse. PMH: diverticulitis. Currently on no medications. Denies any hematochezia, hematuria, hematemesis, fever, chills, or night sweats. Physical exam reveals hyperactive bowel sounds, tenderness to palpation on abdomen and “drum” like sounds heard on percussion.

Acute pancreatitis X

Pancreatitis, acute alcoholic X Irritable bowel syndrome X Pancreatitis, chronic X Diverticulitis X Gastric outlet obstruction X

Lactose intolerance

X

Acute megacolon X Constipation X Peritonitis X Peritonitis, spontaneous X Peptic ulcer disease X