|Name: P.K||Pt. Encounter Number:|
|Date: 5/5/2017||Age: 72 years old||Sex: Male|
|CC: P.K reached the hospital complaining of severe abdominal pain. He says, “I am feeling a sharp pain in my stomach. It seems like someone is pricking inside.”|
|HPI: P.K has never suffered from any abnormalities of the abdomen. However, he has arthritis, and he confirms that he has been using ibuprofen over the counter to manage the joint pains. P.K confirms that he drinks wine every time he takes dinner. Three weeks ago, he started feeling abdominal pain that was accompanied by bloating. He did not seek any treatment and continued consuming alcohol and using ibuprofen to manage his arthritis pain. Yesterday evening, he felt a sharp pain in the abdomen that persisted despite the use of ibuprofen. Currently, he is in the hospital to seek intervention for abdominal pain.|
|Medications: Ibuprofen 400 mg orally three times per day and methotrexate 2.5 mg orally two times per day.|
Allergies: No history of allergy to food or drugs.
Drug Intolerances: No drug intolerance.
Chronic Disease or Traumas: He has arthritis, but he has never suffered from any major trauma.
Surgeries and Admissions: No positive surgical history, but he has been admitted to hospital due to meningitis when he was three years old.
|Family History: P.K is the only child in the family. His parents separated when he was three years old. He lived with his mother until he became an adult. No family history of any chronic disease in the maternal side.|
|Social History: P.K has a high school diploma and owns a boutique. His wife and daughter help him run it. He lives with his wife, but the daughter lives alone. He has been drinking alcohol for 30 years now, but he neither smokes nor uses any illicit drug.|
|General: Claims to have fatigue and insomnia due to abdominal discomfort.||Cardiovascular: Denies dyspnea, faintness, chest pain, or any chest tightness. No history of claudication or edema.|
|Skin: No history of rashes and denies any current skin lesions.||Respiratory: Denies a cough, wheeze, or dyspnea on excertion.|
|Eyes: Denies eye pain, scotomas, or the use of any visual aids.||Gastrointestinal: Positive for sharp generalized abdominal pain that has persisted for three weeks. Denies obstipation, diarrhea, or ever having hematemesis.|
|Ears: Denies tinnitus or any experiences of abnormal ear discharge.||Genitourinary: Denies flank pain, any recent history of dysuria, or urinary incontinence.|
|Nose/Mouth/Throat: Denies gingival bleeding, glossodynia, rhinorrhea, or sinusitis. No mouth ulcerations. Denies ever doing a dental exam.||Musculoskeletal: Positive for arthritis and severe joint pain. Denies back pain or crepitus.|
|Breast: Denies dimpling or lumps on the breasts.||Neurological: Denies visual or hearing problems. No recent history of paresthesia or weakness.|
|Heme/Lymph/Endo: Denies ever being transfused with blood or ever having lymphadenopathy.||Psychiatric: Denies paranoia, depression, or ever having suicidal ideation.|
|Temp: 98.8 F||BP: 117/78mmHg|
|Height : 5’ 6”||Pulse: 78 bpm||Resp: 20bpm|
|General Appearance: An alert elderly male patient who is well-oriented and provides appropriate responses to questions.|
|Skin: Free from rashes, warm, and uniform in color.|
Head: Normocephalic head with well-distributed short hair.
Ears: No masses seen. Auditory canal is patent.
Nose: No epistaxis noted. He has normal turbinates.
Neck: Full ROM with weak carotid pulses.
Mouth and Throat: 32 teeth seen with a non-inflamed pharynx.
|Cardiovascular: No irregularities or murmurs heard.|
|Respiratory: Regular and shallow breathing. No ronchi or crackles heard in the lungs bilaterally.|
|Gastrointestinal: Slightly distended abdomen.|
|Breast: No wrinkling, dimpling, or masses noted.|
|Genitourinary: Mons veneris has coarse pubic hair. The bladder is not distended. Testes are descended.|
|Musculoskeletal: Has joint stiffness due to arthritis but no fractures. Limited ROM is the lower extremities noted.|
|Neurological: All cranial nerves intact.|
|Psychiatric: Kempt and attentive.|
Stool tests results show the presence of H. pylori. Chuah et al. (2014) ascertain that H. pylori in the stool signifies an abnormality in the gut.
|Special Tests: Endoscopy is necessary to examine stomach lining for abnormalities. According to Chuah et al. (2014), the endoscopy method is efficient as it can confirm the presence of ulcers. The test results show an ulcerated stomach lining.|
| Differential Diagnoses
Chung, Chiang, and Lee (2015) describe diagnoses that can have similar symptoms to peptic ulcers. They are appropriate for this patient because he has the same presentations. They include:
· 1- Acute gastritis due to increased pain that does not end with analgesics, which began today.
· 2- Inflammatory bowel disease due to generalized abdominal pain.
· 3- Chronic gastritis due to the prolonged use of alcohol.
Peptic Ulcer Disease. The subjective data shows that P.K has generalized sharp abdominal pain. The objective data shows a slightly distended abdomen due to bloating. The laboratory test shows the presence of H. pylori in the stool. According to Chuah et al. (2014) and Chung et al. (2015), patients that have abdominal pain, H. pylori in the stool, and an ulcerated stomach lining have peptic ulcers.
|Plan Including Education
Further testing: A blood test for H. pylori is necessary to confirm peptic ulcer disease.
Medication: The subjective data indicates abdominal pain, while the objective data shows that P.K has H .pylori. Therefore, he needs antibiotics to kill H. pylori and acid blockers to reduce stomach irritation. Mustafa et al. (2015) recommend a combination of metronidazole, Ranitidine bismuth citrate, and clarithromycin. In this case, the nurse can give amoxicillin 1000 mg, Ranitidine bismuth citrate 400 mg, and clarithromycin 500 mg twice a day as an effective therapy for the illness.
Education: The nurse can teach P.K to adhere to the drugs and avoid consuming spicy foods that can trigger stomach acid. The nurse can further advise P.K to stop drinking alcohol during treatment (Kennedy-Malone, Fletcher, & Martin-Plank, 2014). The nurse can also tell him to stop using anti-inflammatory drugs during treatment.
Non-medication treatments: The nurse can advise P.K to control psychological stress. Chung et al. (2015) indicates that stress control is an effective non-medication management of peptic ulcers.
Follow-up: The nurse should schedule a follow-up in three days to assess P.K symptomatically to see whether the condition is improving.
Self-Assessment and Clinical Guidelines: The subjective and objective assessments show that abdominal pain and bloating are symptoms of peptic ulcers. In the guideline by Mustafa et al. (2015), abdominal pain and bloating are discussed as important symptoms of peptic ulcers. The plan has a combination of three antibiotics and acid blockers, which are discussed in the guideline. However, the guideline suggests switching to different analgesic, and thus, next time, I will use another analgesic.
|Delivery of Culturally Competent Care||SOAP Note: Diabetes Mellitus|