Subjective: CC: ‘My stomach has been hurting for the past two days’ HPI: LZ 65

Subjective: CC: ‘My stomach has been hurting for the past two days’ HPI: LZ 65

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: Abdominal Aortic Aneurysm (AAA) Perforated Ulcer  Pancreatitis PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.