CASE STUDY

Case Study

Case Study

Case Background

John is a 23 year old gentleman who was admitted two days ago with severe abdominal pain, nausea and vomiting. The pain has subsided and John is waiting for the results of various tests and a definitive diagnosis.

In this paper we will discuss about John's abdominal pain, nausea and vomiting and its cure suggested by Sally, a nurse and how Sally convinced John to stay, asking 'what if the results reveal something that requires treatment'?

Case Discussion

In initial assessment of this patient he is found to be alert an oriented to person, place, and time. Speech is appropriate and cranial nerve function is grossly intact. Patient is weak but has full range of motion with +4 strength to all extremities, gait is steady and patient has no complaint of vision deficit, hearing deficit or vertigo. Breathing pattern is deep and even with respiratory rate 18, chest is symmetrical and expansion is normal. No adventitious breath sounds are heard. No cough, no pain, or dyspnea observed. Pulse oximetery is 97% on room air and supplemental o2 is not needed. Heart rate and rhythm are even and clear with no S3 detected, no murmur or gallop heard, lungs are clear, apical and peripheral pulses are positive and regular, homans sign is negative, no jugular vein distention is observed and no edema is noted. Teeth are intact without caries, mucus membranes are dry, no abdominal bruits or pulsations are noted, abdominal contour is not symmetrical related to lower left surgical intervention, JP drain is present to the left lower quadrant of the abdomen draining cloudy amylase rich fluid verified by lab testing. Bowel habits are regular at this time with no diarrhea in 3 days. Pt has Dophoff feeding tube to left nare with insertion length of 87cm. This feeding tube is on hold for use until placement is verified. Bowel sounds are positive all quadrants. Patient has no complaints of nausea or vomiting and denies pain. Patient is voiding without difficulty clear yellow no odor. Genital exam is deferred no flank pain no incontinence no hematuria is observed or reported. Extremities show no deformities and patient is ambulating in the hallway without difficulty. Skin is warm and dry, skin turgor is poor and patient is receiving Intravenous fluids for rehydration. Generally skin is intact with exception of left lower quadrant surgical incision which is well approximated with no drainage, steri strips are in place and dry. JP drain is intact and draining as is expected. Patient shows pleasant effect, displays appropriate mentation related to disease process and prognosis of terminal illness. Family is excellent support system and is at bedside frequently.

Patient is unable to tolerate oral intake at this time and is to receive Vionexx tube feeding via Dobhoff. Patient will be receiving pancreatic enzymes for digestion, weight loss is expected and patient and family is aware of this area of the disease process and is actively involved with a nutritionist for ways to slow this process and maintain ...