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NURS 6512 Homework Help – Advanced Health Assessment and Diagnostic Reasoning

Subjective:

CC: “My stomach has been hurting for the past two days.”

HPI: LZ, 65 y/o AA male, presents to the emergency department with a two days history of intermittent epigastric abdominal pain that radiates into his back. He went to the local Urgent Care where was given PPI’s with no relief. At this time, the patient reports that the pain has been increasing in severity over the past few hours; he vomited after lunch, which led his to go to the ED at this time. He has not experienced fever, diarrhea, or other symptoms associated with his abdominal pain.

PMH: HTN

Medications: Metoprolol 50mg

Allergies: NKDA

FH: HTN, Gerd,  Hyperlipidemia

Social Hx: ETOH, smoking for 20 years but quit both 2 years ago, divorced for 5 years, 3 children, 2 males, 1 female

 

Objective:

  • VS: Temp 98.2; BP 91/60; RR 16; P 76; HT 6’10”; WT 262lbs
  • Heart: RRR, no murmurs
  • Lungs: CTA, chest wall symmetrical
  • Skin: Intact without lesions, no urticaria
  • Abd: abdomen is tender in the epigastric area with guarding but without mass or rebound.
  • Diagnostics: US and CTA

Assessment:

  1. Abdominal Aortic Aneurysm (AAA)
  2. Perforated Ulcer
  3.  Pancreatitis
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