Initial Post

Assessing the Abdomen

DQ Week 7 NURS 6512, Wilson, L.
Patient Initials: JC

Age: 12

Gender: Female

SUBJECTIVE DATA:
Chief Complaint: malaise with abdominal pain
History of Present Illness: JC is a 12 year old American Indian female brought into the ER by
her parents. The girl complaints of nausea, vomiting, for several days, with gradual abdominal
that has been worsening. When asked its location, she points to the right lower quadrant of her
abdomen. The parents report the child has lost her appetite and has had a fever for the past three
nights. Questioning of the girl and parents were started: Patient reports vomiting 10 times with
the last one just prior to arrival. She rates her pain on a scale from 0-10, at a 6. She describes the
pain as dull, cramping, all over her tummy that is constant and nothing seems to make it feel
better. Any movement or touching makes her abdomen hurt worse. Her last bowel movement
was three days ago, described as small amount. Her parents reported their daughters temperature
was 103.6 each time they took it. They gave her Tylenol 325 x 2 tabs po which relieved the fever.
They report not having a primary physician.
Medications: Tylenol 325 mg x 2 tabs po PRN
Allergies: NKDA, no food or environmental allergies
Past Medical History:

Mother reports child has never been sick. She has always been healthy.
Past Surgical History:
None
Sexual/Reproductive History:
Patient began menses 2 months ago which lasted 3 days and began her next menses in 32 days
following which lasted 3 days with light flow. She has beginning breast development, breast are
budding and sore per mother.
Personal/Social History:
Denies use of cigarettes, ETOH, or illicit drugs
Immunization History:
Patient has had all the childhood immunizations, including; DTaP x 5, MMR x Hep A x2, Hep B
x3, MCV4 x2, PCV13 x 3, RV x3, IPV x 4, Varicella x 2, Hib x 3, HPV x 3 and she receives her
yearly influenza vaccine (Atkinson, Wolfe, and Hamborsky, 2011).
Significant Family History:
Patient has two brothers that are older, one is 15 and one is 17; both have been healthy and
athletic. Her grandmother and grandfather are both living in their own home, still working
outside of the home. The grandfather has hypertension that has been controlled with medication
and exercise. The grandmother has mild anxiety and takes Xanax PRN but she is very active,
exercises daily. The patients father has hypertension that is uncontrolled, high cholesterol, and
he is an alcoholic. He is compliant with his medications and controls his weight. Her mother is
pre-diabetic and controlling this with diet and exercise.
Lifestyle:
The patients is from a two income family of five. They are considered mid to high income,
living in a quiet country neighborhood. She has a dog, cat and a horse that she enjoys riding daily
after school. She does practice rodeo events and next year plans to enter into the barrel racing
event at the local rodeo. She is very active in her local 4H chapter and is the chapter secretary.
Review of Systems:
General:
Patient has been weak, staying home from school, since Tuesday when the abdominal pain
began. She has not eaten since Wednesday but has been drinking water.
HEENT:
No changes in vision or hearing, She does have routine teeth cleaning procedures every 6 months
and yearly dental exams. Her mother denies patient ever having a sore throat or seasonal
allergies.
Neck:

No pain, deformities, or difficulty with movement.

Breasts:
Beginning development stage: budding, no masses or rashes.
Respiratory:
Denies problems with breathing, no cough, or difficulty breathing.
CV:
No chest discomfort or palpitations, no history of heart murmurs or arrhythmias.
GI:
Has had nausea and vomiting for the past three days, approximately ten times. Abdominal pain
that is a 6/10 on pain scale, described as dull, cramp, all across abdomen, continuously. Last
bowel movement was three days ago that she considered small.
GU:
No changes in urinary pattern or incontinence or regression.
MS:
Patient is experiencing generalized muscle weakness and pain. Reports generalized malaise.
Psych:
No history of ADD/ADHD or depression.
Neuro:
Having dizziness upon standing and reports a headache
Integument/Heme/Lymph:
No rashes, itching, or bruising. No bleeding disorders, clotting disorders, or history of blood
transfusions.
Endocrine:
No endocrine symptoms or hormone therapies.
Allergic/Immunologic:
Denies history of seasonal allergies, no immune deficiencies.

OBJECTIVE DATA:
Physical Exam:
Vital signs: B/P 92/60 , right arm, lying; P 125 and regular; T 103.0 oral; RR 18, mild dyspneic;
Wt: 90 lbs; Ht: 5 2; BMI 15.9 underweight

General:
A&O x 4, in obvious pain with any movement, appearance is sick.
HEENT:
PERRLA, EOMI, oronasopharynx is clear
Chest/Lungs:
Diminished in the bases due to guarding but otherwise clear
Heart/Peripheral Vascular:
Tachycardia, regular, no murmurs noted; no peripheral edema, PPP, bilaterally
ABD:
Firm to touch and very painful to patient with gentle touch, no bowel sounds noted in all 4 quads
Musculoskeletal:
Symmetric muscle development for age; muscle strengths are 4/5 due to lack of nutrition and
illness
Neuro:
CN II XII grossly intact.
Skin/Lymph Nodes:
No clubbing or cyanosis; lymph nodes swelled in the groin area approx. 2 cm dia x 3 (2 on the
right and one on the left), skin intact, hot and dry to touch.
ASSESSMENT:
CBC with differential WBC 13,000 with a shift to the left
Diagnostics:
Lab: CBC with differential
Radiology:
CXR atelectasis in the bases, bilaterally.
CT with IV contrast of the abdomen and pelvis