Patient Information
- Name: James Lebron
- Age: 40 years
- Gender at Birth: Male
- Gender Identity: Male
- Source:
- Allergies: None
- Current Medications: None
PMH
- Immunizations: The patient reports that all immunizations are up to date.
- Preventive Care: The patient reports not taking alcohol and foods low in fat content.
- Surgical History: The Patient does not have any history
- Family History: Married with three sons and a daughter. No history of chronic illness in the family. However, the mother died at the age of 93 due to arthritis, and the father is alive.
- Social History: He does not smoke but used to drink alcohol in previous years.
- Sexual Orientation: He reports being sexually active and loyal to his partner.
- Nutrition History: The patient has a normal BMI of 20.5 and adheres to a balanced diet.
Subjective Data
Chief Complaint: ‘‘I have been experiencing acute abdominal pain in the last two months, nausea and vomiting and discomfort which is on and off.’’
Symptom analysis/HPI
The patient is a 40-year-old American who arrives at the clinic, reporting acute abdominal pain, which started three weeks ago. Pain is located at the upper central part of the abdomen. He also states having experienced three episodes of vomiting clear in color. Discomfort sets in once performing an activity and goes off upon resting.
Review of Systems (Ros)
NEUROLOGIC: The patient denies experiencing headaches, loss of consciousness, dizziness, and confusion.
HEENT: The patient denies having headaches, dizziness. The patient states that the visual acuity is clear and denies experiencing itching, pain, and burning sensation in the eyes, otalgia, and dysphonia.
RESPIRATORY: The patient denies experiencing shortness of breath, wheezes during breathing, chest tightness, and snoring.
CARDIOVASCULAR: The patient denies having chest pains, palpitations, exertional dyspnea, and leg pain on exertion.
GASTROINTESTINAL: Patient states having experienced nausea and three episodes of vomiting clear in color. Patient further reports experiencing acute pain in the abdomen on the upper central region of the abdomen. The patient denies having constipation, food intolerance, and dysphagia.
GENITOURINARY: The patient denies having dysuria, hematuria, and anuria. No odor in urine nor suprapubic pain.
MUSCULOSKELETAL: The patient denies experiencing muscle pain and swelling of the joints and is full of motion.
SKIN: The patient denies having lesions and skin rashes.
Objective Data
VITAL SIGNS: Temp 37.4 degrees Celsius, Pulse 76 b/min, Respiratory rate 24 b/min Bp 132/84MmHg.
GENERAL APPEARANCE: Patient is fully alert, dressed knightly, well oriented, fatigued, and has dry mouth and lips.
NEUROLOGIC: Orientation X 3. Slight lightheadedness with no headache and loss of consciousness.
HEENT: Normal cephalic head with Brown hair evenly distributed. Mouth and lips dry, slight lightheadedness, visual acuity is clear, No sore throat, hearing problem, and nasal discharge.
CARDIOVASCULAR: No abnormal breath sounds. S1 and S2 heard upon auscultation.
RESPIRATORY: Upon auscultation, no abnormal Lung sounds, both lungs clear on both anterior and superior
GASTROINTESTINAL: On inspection, the abdomen is rounded, slightly distended, umbilicus inverted and pigmentation evenly distributed. Upon palpation, tenderness is elicited on the upper left side of the abdomen. Bowel sounds present.
MUSCULOSKELETAL: Full range of motion on both upper and lower extremities. No joint and muscle tenderness.
INTEGUMENTARY: No lesions, masses, skin injury, and loss of hair.
ASSESSMENT: “Pt came into our clinic presenting complaints of acute abdominal pain located at the upper central region, three episodes of vomiting clear in color, started three weeks ago. Discomfort on and off depending on the activity done. On examination, I noted the patient showing facial grimacing, slight lightheadedness, having dry mouth and lips well oriented, and tenderness upon palpation on the abdomen.
Main Diagnosis
K85.9- Acute Pancreatitis (Patient experiencing acute abdominal pain on the left upper region of the abdomen and three vomiting episodes in the last three weeks (2021 ICD-10-CM Diagnosis Code E10.36, 2021). On a physical exam, facial grimacing, dry mouth and lips, and tenderness on the abdomen’s palpation.
Differential diagnosis
A09- Gastroenteritis (The patient presenting complains of pain in the abdomen, experiencing episodes of vomiting. Examination reveals dry mouth and lips).
K80.80- Cholethiasis (the patient complaining of abdominal pain and tenderness experienced on palpation (physical examination)).
K37- Appendicitis (the patient describes the pain as being the central upper of the abdomen. Low-grade fever of 37.4 degrees Celsius and clear vomitus of three episodes).
Plan
Labs and Diagnostic Test to be ordered (if applicable)
- Serum amylase and lipase levels.
- X-ray studies of the abdomen and chest.
Pharmacological treatment
Meperidine (Demerol) is often prescribed because it is less likely to cause spasms of the sphincter. Antiemetic agents may be prescribed to prevent vomiting (Hinkle & Cheever, 2017). Histamine antagonists such as cimetidine and ranitidine may be prescribed to decrease pancreatic activity by inhibiting HCl secretion.
Non-Pharmacologic treatment
Education: The patient was educated on the need of establishing and maintaining a gut barrier function. The patient was also given a rationale as to why enteral feeding is most preferred compared to parenteral feeding (Janisch & Gardner, 2016). Examples of foods with low-fat content were listed and reasons why they are most tolerated and effective.
Follow-ups/Referrals
Gastroenterologist for review of the patient’s condition and follow up to monitor the progress of the condition.
References
ICD-10 Data. (2021). 2021 ICD-10-CM Diagnosis Code E10.36. Web.
Hinkle, J. L., & Cheever, K. H. (2017). Brunner and Suddarth’s textbook of medical-surgical nursing (14th ed.). LWW.
Janisch, N. H., & Gardner, T. B. (2016). Advances in the management of acute pancreatitis. Gastroenterology Clinics, 45(1), 1-8. Web.