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Assessing the Abdomen
The chief complaint of JR is that his “stomach hurts” and he is experiencing diarrhea, from which he has been unable to obtain any relief. His pain in his abdomen started 3 days earlier and he has taken no medication for it. The pain is midrange, though it was very high today when it began. He ate but experienced nausea afterwards. JR is 47, suffers from hypertension, diabetes and had an issue of gastrointestinal bleeding four years ago. He is on a number of medications to address his high blood pressure and diabetes. He has no known drug allergies, no history of colon cancer. His father and mother both had hypertension; his father has type 2 diabetes; his mother suffered from Gastroesophageal reflux disease and high fatty concentration in the blood (hyperlipidemia).
JR occasionally imbibed alcohol. He is overweight at 248 lbs with a 5’10” height. He has a regular heart rate but soft, hyperactive bowel sounds and pain in his left lower quadrant.
What History Should be Collected
A history of how long he has been taking the medications he is currently on should be obtained. Metformin is one drug he is taking for his diabetes, but one of the...
However, some other information could be collected, such as the story behind his gastro-intestinal bleeding from 4 years ago. What caused the GI bleed is something that should be asked: was it caused by peptic ulcers, which are a common cause of GI bleed, or was it caused by enlarged veins in the esophagus that tore? If JR has a history of peptic ulcers, an ulcer could very easily be considered as a differential diagnosis in this case, since stomach ulcers can cause cramps and pain in the lower abdomen as well.
Other questions should be asked about stress levels, as stress can inflame an ulcer and make the symptoms feel much worse over time (Mustafa et al., 2015). If the patient is experiencing a high level of stress at work or in his home life, an ulcer could be bleeding more and causing him to experience sharp pains in his stomach. A question about whether he experienced stress or anxiety today or the day before…
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