Nursing Care Pl Nursing

HISTORY OF PRESENT ILLNESS: This 46-year-old gentleman with past medical history significant only for degenerative disease of the bilateral hips, secondary to arthritis, presents to the emergency room after having had three days of abdominal pain. It initially started three days ago and was a generalized vague abdominal complaint. Earlier this morning, the pain localized and radiated to the right lower quadrant. He had some nausea without emesis. He was able to tolerate p.o. earlier around

Breasts: no masses, no nipple retraction, no discharge. Heart: S1 and S2, no gallops, rubs, or murmurs appreciated. Abdomen is scaphoid, soft and non-tender with positive bubble sounds. Pelvic/ Rectal: deferred as patient has recently visited her GYN for a routine Pap smear. Neurologic exam reveals normal motor strength in all muscle

HISTORY OF PRESENT ILLNESS: This 46-year old gentleman with past medical history significant only for degenerative disease of the bilateral hips, secondary to arthritis presents to the emergency room after having had 3 days of abdominal pain. It initially started 3 days ago and was a generalized vague abdominal complaint. Earlier this morning the pain localized and radiated to the right lower quadrant. He had some nausea without emesis. He was able to tolerate p.o earlier around 6am, but he now

History of Present Illness: The patient is a 27-year-old male complaining of right lower-quadrant abdominal pain, nausea, and

The patient has no family history of heart disease or diabetes, however both her parents are on medication for high blood pressure. Her paternal grandmother died of breast cancer at age 47. Her maternal grandmother

On Exam:  BP today was 140/86. Head and neck exam was all clear. She had no oral or nasal ulcers. She had no lymphadenopathy or bruits. Heart sounds were normal and the chest seemed clear, as did the abdominal exam. Musculoskeletal exam disclosed widespread Heberden's and Bouchard's nodes. She had no swelling or stress pain at the MCPs. She was not tender at the CMC joints. She had no swelling in the wrist, elbows or shoulders. She had no soft tissue tender points. She has bilateral knee crepitus but only slight instability and no effusions. She had actually good range of movement of both hips. She was tender in the lumber spine and has a scar at the lower lumbar spine from her previous operations. Her feet are somewhat flat with tenderness across the

History of Present Illness: The patient is a 27-year-old male complaining of right lower-quadrant abdominal pain, nausea, and

T.B. is a 65-year-old retiree who is admitted to your unit from the emergency department (ED). On arrival you note that he is trembling and nearly doubled over with severe abdominal pain. T.B. indicates that he has severe pain in the right upper quadrant (RUQ) of his abdomen that radiates through to his mid-back as a deep, sharp boring pain. He is more comfortable walking or sitting bent forward rather than lying flat in bed. He admits to having had several similar bouts of abdominal pain in the last month, but “none as bad as this.” He feels nauseated but has not vomited, although he did vomit a week ago with a similar episode. T.B. experienced an acute onset of pain after eating fish and chips

Patient was in the ER room when first seen. PT was with her family members and family states that she speaks little English and that she has had abdominal pain for the past day along with bloody stools. Family states that she is on calcium supplements and no other medications. Last oral intake is 24 hours ago. Family states no known past medical history. Pt is in the hospital bed in the fetal position and towards the right side. Patient's airway is clear and breathing is normal. Skin is warm and dry. Patent is AAOx4. Assessment of head, neck, and chest show no signs of deformities. Abdominal area not assessed due to severe pain. Back is without deformity. The upper extremity shows no sign of deformities or trauma. The lower extremity shows

B.S. is an 81 year old Caucasian female presenting with abdominal pain, diarrhea, nausea and vomiting in the emergency room on February 3, 2013. B.S. has a history of glaucoma, hypothyroidism, degenerative arthritis and diverticulosis. She has allergies to iodine and vicodin. B.S. is admitted for diverticulitis with possible partial bowel obstruction and hydronephrosis. B.S. was admitted on February 3, 2013 here at Verdugo Hills Hospital.

M.C. is a 4 week old Caucasian male and was assessed on 2/3/2015. M.C. was awake and crying in his mother’s arms. He appeared to be well-nourished, well developed and in distress. M.C.’s mother stated his full name and date of birth, which matched his ID band. His mother was sitting in the hospital bed holding him in her arms and attempting to comfort him. His father was laying on the couch in the room. A complete head to toe assessment was not done during this time but the following results were obtained based on a focused assessment. M.C. was on contact-droplet isolation. M.C. had a temperature of 37.2C, his blood pressure was 33/47 with a MAP of 68 taken on his left leg. His respirations were 40 breaths per minute with an oxygen saturation of 100%. His pulse was 178 beats per minute. M.C. was on room air and had a PIV located in his left hand. There was no presence of tubes or drains. Pain was not assessed at this time however, M.C. was fussy and crying. The anterior and posterior fontanels were inspected. The anterior fontanel was soft and flat. M.C.’s lung sounds were clear to auscultation. His mother reported that he had some nasal congestion but had no

The patient complained of right lower quadrant pain and of feeling faint. Dr. O'Donnel documented a chief complaint, a brief history of present illness, and a systemic review of the gastrointestinal system and respiratory system. Dr. O'Donnel also documented a complete examination of all body systems, which included all required elements. Medical decision making was of moderate complexity.

Thus allowing me to form a differential diagnosis and rule out certain causes, such as; constipation, and indigestion. Subsequently, the physical examination enabled me to confirm a diagnosis of acute abdomen. As the patient was not experiencing any worrying (red flag) symptoms associated with abdominal emergencies, such as; appendicitis or pancreatitis. However, I did forget certain aspects of the physical examination and had to be prompted by the MO. Although with more practice such incidence would be reduced.

He was able to tolerate PO earlier around 6am. but now denies having an appetite. Patient had very small bowel movement earlier this morning that was not normal for him. He has not passes has the morning. 'he is voiding well. Denies fevers, chills or night sweats. The pain is localized to the RLQ without radiation at this point. He has never had a colonoscopy.