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Gastrointestinal System Assignment

Alex Smith, is a 24-year-old African American male presenting with GI distress.  

He states he has emesis, loose stool, and upper right abdomen pain. The Patient reports symptoms started two days ago after eating grilled chicken for lunch. The Patient reports that he vomited four times in the last four hours and has had multiple bowel movements since the symptom started and the most recent of which occurred an hour ago. Stools were reported as being brown and of a liquid consistency, and vomit was described as having a greenish-yellow tint. He describes the pain as sharp and burning and claims it is primarily felt in the upper left quadrant of his abdomen. On a scale of 1 to 10, the pain was rated as 6. The patient claims that eating causes intense pain and that lying down reduces the pain to a level of 4 on a scale of 1 to 10. He adds that he is feeling nauseous, fatigued, and anxious and stated that his appetite has decreased, and had been on a liquid diet for the past 24 hours due to his nausea. He denies any recent travels or weight changes. The Patient states that he is currently taking Tylenol as needed for pain management and prescriptions for Thiamine, Vitamin B, and Folate supplements medications. He reports being allergic to Penicillin. He reports being an alcoholic since he was 22 but does not smoke cigarettes. His respirations are 16, BP 170/90, and Temperature is 99.9. His weight is 90.9 kg, down from 95.5kg (from last checkup). He claims no history of GI problems, but his mother had a history of peptic ulcers, and his father died of a heart attack.   

 

ontent: 

Use of three sections:o Subjective Objective 

Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them
 

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