Nursing journal assignment

Name:  Veronica Chen

 Pt. Encounter Number: 1

Date: 9.5.23

Age: 12

Sex: Female

SUBJECTIVE

CC: 

“I have a stomachache right now” 

HPI: 

This is a 12-year-old female who presents to the office today accompanied by her mother complaining of abdominal pain. She reports the pain began slowly last year during the school year. She reports the pain worsened until the past summer when she had improvement, however after returning to school this fall, the symptoms returned and continue to worsen. Symptoms are constant but worse at nighttime before bed. She states the pain is generalized in the abdomen and does not radiate. She also reports associated symptoms including occasional headaches, nausea, diarrhea and difficulty sleeping due to the pain. She states the pain is sometimes dull, sometimes sharp. She denies any factors that make the pain better or worse. She reports she has tried children’s Tylenol for the pain with some relief. She reports she was seen and evaluated by GI specialist in the past and x-rays and endoscopy were performed with negative results. Pt rates the pain as a 6/10 when it is at its worst. She reports she has missed some school due to the symptoms. She reports she is being bullied by another student at school and that this situation is causing anxiety and fear. Further details noted in social history.

Medications: Children’s Tylenol as needed. Benadryl as needed for insomnia

No prescription medications.

Allergies: NKDA

Past Medical History: Denies

Chronic Illnesses/Major traumas: Denies

Hospitalizations/Surgeries: Denies

Preventive: Vaccinations UTD

Family History

Denies any family history .

Social History

She is currently in the7th grade and states she does have a few close friends at school. She states she is maintaining passing grades. She reports that she does not feel safe at school. States that another student has been making fun of her for clothes she wears and for the fact that she has not started menstruating yet. She believes this student hates her and wishes teachers were around to witness her behavior. She has not spoken to any teachers or her parents about what is happening.

She lives at home with her parents and a younger brother. She reports she does feel safe at home.

She is not sexually active. Denies tobacco use. Denies use of drugs or alcohol.

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

General

Denies fever or chills.

Denies recent change in weight.

+fatigue

Cardiovascular

Denies chest pain or palpitations.

Skin

Denies complaints

Respiratory

Denies complaints

Eyes

Denies complaints 

Gastrointestinal

+ generalized abdominal pain

+nausea

Negative vomiting

+diarrhea, last episode today

+loss of appetite

Ears

Denies complaints.

Genitourinary/Gynecological

Denies complaints

Not sexually active

No menstruation

Head/Nose/Mouth/Throat

+headaches

Musculoskeletal

Denies complaints

Breast

Denies changes in her breasts.

Neurological

Denies weakness. Denies syncope

Heme/Lymph/Endo

Denies complaints

Psychiatric

Denies depression

+ anxiety

Denies SI

+difficulty falling asleep

OBJECTIVE

Weight   125lbs      BMI 22.9

Temp 36.7 C

BP 110/70

Height 5’2”

Pulse 70

Resp 20

General Appearance

Alert and oriented x 3, in no acute distress. She is not ill appearing. She is anxious when discussing situation at school with a peer. Interacting appropriately

Skin

Skin is warm, dry and intact.

HEENT

Head normocephalic.

PERLA. EOMs intact.

No congestion noted.

No lymphadenopathy or thyromegaly noted.

Cardiovascular

Heart with regular rate and rhythm, normal S1, S2 .

Respiratory

Lungs clear bilaterally. Normal respiratory effort.

Gastrointestinal

Abdomen flat, soft, non-tender. Bowel sounds active in all 4 quadrants. No hepatosplenomegaly. 

Breast

Deferred

Genitourinary

Deferred, unrelated to chief complaint.

Musculoskeletal

Normal ROM

Neurological

Normal gait observed.

Psychiatric

She is appropriately dressed, Speech clear. Responds appropriately. Appears anxious when speaking about the situation at school with a peer.

Lab Tests

None required

Assessment

· Include at least three differential diagnoses

· Provide rationale for each differential diagnosis

· Final diagnosis

· Pathophysiology of primary and rationale for choosing as final

· ***primary diagnosis should be psychosomatic abdominal pain due to bullying

Plan

· Medications—use levsin and bentyl****

· Non-pharmacological recommendations-complete pain diary***

· Diagnostic tests

· Patient education

· Culture considerations

· Health promotion

· Referrals-psych***

· Follow up in office 2 weeks***