Admission Diagnosis : The Emergency Room ( Er )

Decent Essays

Admission Diagnosis:
Patient N.L. was brought into the emergency room (ER) and was admitted to the medical-surgical unit on Tuesday at 1700 complaining of sudden onset of diffuse contraction-like peri-umbilical pain radiating all over her abdomen on and off for an hour after having lunch at home. Patient was a 9/10 on a pain scale with nausea and vomiting x 2. Her admitting diagnosis was small bowel obstruction and systemic inflammatory response with leukocytosis.

History of Present Illness:
N.L. has history of constipation and fecal impaction several years ago. Patient also has history of Diabetes Mellitus type 2 for 9 years, Hypertension for 15 years, and Chronic Obstructive Pulmonary Disease (COPD) for 5 years. Patient has also had laparoscopic appendectomy 5 years ago for erupted appendicitis and total hysterectomy 3 years ago due to uterine fibroids. N.L. smoked half a pack of cigarettes for 20 years and recently cut down to 2 cigarettes per day. N.Ll also drinks alcohol occasionally, approximately 2 drinks per month. Chest X-Ray Result: Normal
A picture of the chest taken to show the heart, lungs, airway, blood vessels, and lymph nodes. It’s used to search for problems inside the chest that relate to symptoms such as cough, shortness of breath, or chest pain. Problems such as pneumonia, enlarged heart, and lung cancer may also be detected. (John Hopkins Medicine Health Library).

Family History:
Patient’s younger brother also has Diabetes Mellitus type 2 as well

Get Access