Symptoms And Treatment Of The Emergency Room

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Code Status___No Code__ Allergies__Penicillin____________

Temp (C/F Site) Pulse (Site) Respiration Pulse Ox (O2 Sat) Blood Pressure Pain Scale 1-10
98.3 F Orally 92 Radial 26 94% RA 168/98 9

History of Present Illness Including Admission Diagnosis
Relevant Physical Assessment Findings (normal & abnormal) Relevant Diagnostic Procedures/Results & Surgeries
(include dates. If not found, state so.)
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 were 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.

Family History:
Patient’s younger

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