Nursing journal 2

Name:  Cassie Fisher

 Pt. Encounter Number: 1

Date: 9/20/23

Age: 52

Sex: Female

SUBJECTIVE

CC: 

“pain in belly that won’t let up”

HPI: 

Patient is a 52 yo female who presents to the office today with c/o abdominal pain. She states the pain began about 1 week ago. Reports that the pain began gradually, initially occurring a few times a day and lasting 1-2 hours then slowly resolving however the pain is now constant. She states the pain is in right upper abdomen under the rib cage and radiates to her back. Pain is described as sharp and stabbing. She states the pain became worse 2 days ago when she vomited. She does not identify any alleviating factors. She states she has been taking ibuprofen as needed for the pain since it started, which initially was helpful but is no longer relieving the pain. She states the pain began as a 3 out of 10 but now stays around a 7 out of 10. Associated symptoms include nausea, one episode of vomiting, decreased appetite. She has never had these symptoms before and has not sought any other treatment or had any diagnostic testing.

Medications: Simvastatin20mg once daily for hyperlipidemia

Glyburide 5mg once daily for diabetes

Metformin 1000mg twice daily for diabetes

Lithium 300mg once daily for bipolar

Quetiapine 400mg twice daily for bipolar

Allergies: NKDA

Medication Intolerances: none noted

Past Medical History:

Hypercholesterolemia

Diabetes

Uterine fibroids

  Past Psychiatric History:

Bipolar

Hospitalizations/Surgeries

  Partial hysterectomy secondary to fibroids

Childbirth x 2

Preventive

Immunizations are UTD

Last PAP 2022 normal.

Family History

Father deceased lung cancer

Mother alive diabetes, HTN

Social History

Pt is a high school graduate. Works as a professional actor and often travels. Lives alone and feels safe in her home. Divorced x2. She is not in a relationship currently and is not sexually active. Smokes ½ -1 ppd x 30 years. Has made multiple unsuccessful attempts at quitting. Denies current alcohol use, states she has been sober for 12 years. Denies current drug use, reports no use in 15 years.

ROS Student to ask each of these questions to the patient: “Have you had any…..”

General

Denies recent weight change, fever/chills and fatigue.

Cardiovascular

Denies CP, palpitations or edema

Skin

Denies rash, discoloration.

Respiratory

Denies cough or SOB

Eyes

Denies vision changes.

Gastrointestinal

+RUQ pain radiating to back. +nausea, +vomiting. Denies diarrhea or constipation +decreased appetite. Denies blood in stool

Ears

Denies complaints

Genitourinary/Gynecological

Denies urinary complaints

Nose/Mouth/Throat

Denies complaints

Musculoskeletal

Denies complaints

Breast

Performs SBE, no concerning findings.

Neurological

Denies syncope, weakness

Heme/Lymph/Endo

Denies complaints

Psychiatric

+bipolar, compliant with medications, denies current depression, denies SI.

OBJECTIVE

Weight         BMI

Temp 37.1

BP 138/84

Height

Pulse 92

Resp 16 O2 Sat 97%

General Appearance

Pt is alert and oriented and in no acute distress. Interacting appropriately.

Skin

Warm and dry. No rash or jaundice.

HEENT

Head normocephalic. No scleral icterus.

Oropharynx normal without erythema or exudate.

Mucus membranes moist.

Dentition intact.

Cardiovascular

Heart with regular rate and rhythm. Normal S1, S2 without murmur, gallop or rub. Normal pulses, no edema.

Respiratory

Lungs clear throughout. Normal effort.

Gastrointestinal

Abdomen soft. +voluntary guarding RUQ. +moderately severe tenderness RUQ and epigastric area. No rebound.. Active bowel sounds.

+Murphy’s sign

No hepatosplenomegaly. 

Breast

Deferred

Genitourinary

No CVA tenderness

Musculoskeletal

Normal ROM and gait observed.

Neurological

Alert and oriented x3.No focal deficits.

Psychiatric

Appropriately dressed, interacting appropriately.

Lab Tests

Abdominal Ultrasound:Spleen and pancreas with normal appearance. No focal liver lesion. Gallbladder normal with no gall stones. No intra or extra-hepatic duct dilatation. Common bile duct measures 4mm. Kidneys appear normal. Right kidney 11.7cm, left kidney 10.2 cm. Impression: Normal general abdominal ultrasound.

Amylase 50

CBC with differential

· HGB 12.2

· HCT 38.3

· MCV 90

· MCH 28.5

· MCHC 32.1

· RDW 13.1

· PLT 225

· Neutrophils 50

· Lymphs 35

· Monocytes 13

· Basos 0

· Neutrophils (absolute) 3.3

· Lymphs (absolute) 2.3

· Monocytes (absolute) 0.8

· Eos(absolute) 0.1

· Basos (absolute) 0

· Immature granulocytes 0

· Immature Grans (absolute) 0

· NRBC 0

CMP

· Glucose 95

· BUN 20

· Creatinine 1.0

· eGFR if non African Amer 90

· eGFR if African Amer 105

· BUN/Create ratio 20

· Sodium 140

· Potassium 4.0

· Chloride 99

· Carbon Dioxide, Total 25

· Protein, total7.0

· Albumin 4.5

· Globulin, total 2.5

· A/G ratio 1.8

· Bilirubin, total 1.0

· Alkaline Phosphatase 40

· AST(SGOT) 39

· ALT(SGPT) 42

· Carbon Dioxide, total 25

· Calcium 9.0

Assessment

· Include at least three differential diagnoses

· Provide rationale for each differential diagnosis

· Final diagnosis---******biliary colic******

· Pathophysiology of primary and rationale for choosing as final

Plan

· Medications *****antiemetics-zofran,reglan, try different NSAID ketorolac********

· Non-pharmacological recommendations

· Diagnostic tests

· Patient education

· Culture considerations

· Health promotion *********low fat diet************

· Referrals***********GI***************

· Follow up***********as needed w PCP************