JK is a 56 year-old male who came to the emergency department with his girlfriend for severe abdominal pain, headache, hiccup, emesis and non-stop diarrhea
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CLIENT HISTORY
JK is a 56 year-old male who came to the emergency department with his girlfriend for severe abdominal pain, headache, hiccup, emesis and non-stop diarrhea. He reports that he has been feeling like this for the past 3 days. He is alert and oriented x4, and appeared severely dehydrated. Bowel sounds are present in all four Quadrants and Abdomen appears to be soft.Breath sounds are clear but diminished in the bases bilaterally. JK has a history of respiratory distress, substance abuse, and hypertension. JK reports no allergies. JK medication include Acetaminophen,aspirin and Bismuth subsalicylate. He is currently taking Tylenol for pain. His vital signs were taken and the result shows: BP 154/73, Temp 36.14C, HR 72, RR 18, sp02 97% and pain 5/10. He is receiving IV fluids in his left hands. He is receiving Ondansetron(Zofran) IV every 4 hours as needed for nausea. JK is very cooperative and talk in calm voice
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