History & Physical
08/4/2011
History:
Mrs._Tuskaderro_ is a _58_yr old female who presented to the ER with abdominal pain, bloating, nausea, and vomitting.
Medical History: Pt has been hospitalized 3 times in the past 2 yrs with small bowel obstructions; hospitalizations included bowel resection x 1, hiatal hernia repair, and chronic back problems.
Current Medications: Include frequent use of Ibuprofen OTC for back pain; also includes use of Lortab 10/500 1-2 tabs PO q 6hrs for severe pain.
History of present illness:
Mrs._Tuskaderro_ states that she has been "vomiting a whole bunch in the bast 3 hours. There's nothing left to come up!" She states that abdominal pain started yesterday evening after a large meal at a local restaurant. Upon examination, her vital signs were stable; her pain level is at a "6" on a 0-10 scale.
Mentation: Pt is alert, oriented, cognition level appropriate for age. No history or memory loss or dementia.
ENT: PEERLA, CNs III, IV, and VI intact. Conjunctiva clear; no JVD noted, no lymphs or s/s of thyroid issues; carotids palpable; negative for bruits.
Heart: Heart sounds normal; no S3 or S4, no murmurs or rubs noted. Pt denies CP or discomfort.
Lungs: Lung fields clear in all lobes.
GU/GI: Pt denies difficulty urinating; bowel sounds hypoactive on ausculation; abdomen with moderate distention noted; pt states generalized pain on palpation x 4 quadrants; nausea continues; no emesis noted on examination.
Reproductive: Pt denies pathologies of reproductive system.
Plan of Care:
CT and KUB of abdomen ordered, also an EKG. Plan to r/o small vs large bowel obstruction; will medicate for pain. CBC and CMP ordered to r/o liver envolvement.
Dr. D. Youngblood |