Abdominal assessment
39070CASE STUDY: ABDOMEN
Bill is a 58-year old man who presents at the medical clinic this morning complaining of intermittent abdominal pain and burning in the epigastric area 2 to 3 times daily for the past 2 weeks. The pain and burning last about an hour or more and are often accompanied by nausea and vomiting. He states that the discomfort is worse after eating certain foods, particularly spicy and highly acidic foods but can occur with or without eating. Antacids provide temporary relief from the discomfort.
Aside from this recent GI discomfort, Bill is in generally good health. He has no other known medical issues except mild arthritis in his left knee for which he uses OTC naproxyn as needed. He has no known allergies and is on no prescription medications. Medical history includes appendectomy at age 22. No other hospital admissions or surgeries. Family history is positive for diabetes (mother), lung cancer (father) and drug addiction (brother).
On physical exam you note the following: Symmetrical abdomen, no distention, skin intact without lesions or discoloration. Bowel sounds active in all 4 quadrants. Abdominal vessels auscultated with no bruits. No palpable masses. Tenderness noted in epigastric area and RUQ. Liver palpated and slightly enlarged. Liver span percussed at 14 cm in right midclavicular line. No ascites.
Labs are all WNL except Hct 9.5, Hgb 28, Chol 246, and LFTs elevated.
After questioning Bill further, he admits to drinking several beers every night, and that his use has increased since his wife left him 3 weeks ago. He denies any symptoms of alcohol withdrawal. He is employed as a mechanic and has been with the same company for 25 years. He has not been performing as well at work lately and was written up last week for arriving late. His last alcohol use was last night at 10 PM, and he had 6 beers.
QUESTIONS:
1. In addition to what you know about Bill thus far, list 4 more questions that you would add to the review of systems regarding his abdominal complaints.
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2. State 2 more questions you would ask regarding Bill’s alcohol use.
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2.
3. In the physical exam, what findings are significant?
4. What is the significance of the abnormal lab values?
5. State 3 nursing diagnoses for Bill.
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2.
3.
6. List the topics that you would include in your health teaching.
7. List the areas for health promotion.
8. What referrals would you recommend for Bill?
Note: Six months later, Bill returns to the clinic for a follow-up visit looking healthier. He is happy to tell you that he has cut down his drinking to 1 or 2 beers on weekends. He also just got a raise at work and was promoted to shift supervisor.
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