Case Study

Case Study

B.R. is a 50-year-old man who presents to the gastroenterologist with cramping and diarrhea.

Subjective Data

Pain level is a 6/10 location = right and left lower abdomen
Works as a union construction worker, has missed 1 day of work
States he has been going to the bathroom about 8 to 10 times a day for past 2 days
Appetite is decreased
PMH: Crohn’s disease, depression, anxiety

Objective Data

Vital signs: T 37 P 80 R 14 BP 120/68
Bowel sounds hyperactive in all four quadrants
Medications: Infliximab (Remicade) infusions every 6 weeks, fluoxetine (Prozac) 25 mg per day

Weight = 145, last visit weight = 152

Questions
1.What other assessments should be included for this patient?
2.What questions should the nurse ask with regard to the abdominal pain?
3.From the readings, subjective data, and objective data, what is the most probable cause of the abdominal pain?
4.Develop a problems list from the subjective and objective findings.

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