Subjective:•CC: “My stomach hurts, I have diarrhea and nothing seems to help.”• HPI: JR, 47 y/o WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.• PMH: HTN, Diabetes, hx of GI bleed 4 years ago •Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs• Allergies: NKDA•FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD •Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
Objective:•VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs•Heart: RRR, no murmurs• Lungs: CTA, chest wall symmetrical• Skin: Intact without lesions, no urticaria • Abd: soft, hyperactive bowel sounds, pos pain in the LLQ• Diagnostics: None
Assessment:•Left lower quadrant pain •Gastroenteritis
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Episodicnotecasestudy.docx
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