Documentation Of Problem-Based Assessment Of The Gast 835008

Documentation of problem based assessment of the gastrointestinal system

Clients Presentation: Alex Smith, 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 reported being brown and of a liquid consistency, and vomit was described as 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, 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.

Subjective

Alex Smith, a 24-year-old African American male, reports experiencing acute gastrointestinal distress characterized by vomiting, diarrhea, and epigastric pain. The onset of symptoms occurred two days prior, immediately following a meal of grilled chicken, raising suspicion of foodborne illness or infection. The patient describes the vomit as greenish-yellow, indicative of bile, and the stool as liquid and brown, pointing toward gastrointestinal upset.

He reports persistent vomiting occurring four times over the last four hours and multiple bowel movements within the same period. The abdominal pain is sharp and burning, localized mainly in the upper left quadrant but with some discomfort in the epigastrium, with pain intensity fluctuating between 4 and 6 on the pain scale. Pain worsens with eating and is alleviated somewhat by lying down, indicating a possible relation to gastric or duodenal pathology. He describes associated nausea, fatigue, and anxiety, with decreased appetite and a liquid diet for the past 24 hours due to nausea.

Biographical data reveal a history of alcohol use since age 22, with no prior gastrointestinal problems reported. The patient is taking Tylenol for pain management and supplements including Thiamine, Vitamin B, and Folate. An allergy to Penicillin is noted. Family history is significant for peptic ulcers in the mother and cardiovascular disease in the father. Socially, the patient abstains from smoking but consumes alcohol regularly, which could contribute to gastrointestinal pathology or impact liver function.

Subjective findings suggest a need to evaluate for possible infectious gastroenteritis, peptic ulcer exacerbation, or alcoholic gastritis, given his alcohol history. The absence of travel history reduces suspicion of certain infectious causes, but dietary intake might still be relevant.

Objective

Vital signs include a blood pressure of 170/90 mm Hg, respirations at 16 breaths per minute, and a temperature of 99.9°F, indicating mild fever and potential hypertensive status. The patient weighs 90.9 kg, a decrease from previous weight of 95.5 kg, reflecting possible fluid loss or dehydration.

Physical examination shows an alert but anxious patient with tenderness localized to the upper left quadrant and epigastrium. No rebound tenderness or guarding noted. Abdominal auscultation reveals normal bowel sounds. Inspection reveals no distension, jaundice, or skin abnormalities. Palpation confirms tenderness without rigidity. No hepatomegaly or splenomegaly observed. Laboratory findings are pending but should include liver function tests, complete blood count, and serum electrolytes to evaluate dehydration and hepatic involvement.

Assessment for additional objective signs indicates dehydration from ongoing vomiting and diarrhea, with relative tachycardia and increased blood pressure potentially related to pain or stress response. The absence of jaundice or scleral icterus suggests no overt hepatic failure at this stage. Further diagnostics are warranted to explore etiology, including stool cultures, abdominal ultrasound, and possibly endoscopy.

Objective data point toward gastrointestinal inflammation or infection, dehydration, and possible alcohol-related gastritis or peptic ulcer disease. The patient's vitals and physical findings guide immediate management priorities, including fluid resuscitation and symptom control.

Actual or Potential Risk Factors

1. Potential Gastrointestinal Bleeding: Given the patient's history of alcohol use, family history of peptic ulcers, and recent vomiting with possible bile, there is a risk of gastrointestinal bleeding or ulcer exacerbation. Alcohol increases gastric acid secretion, impairing mucosal defense, thus predisposing to ulcers or bleeding.
2. Dehydration and Electrolyte Imbalance: Repeated vomiting and diarrhea have led to significant fluid and electrolyte loss, as evidenced by weight loss and clinical signs of dehydration. Electrolyte disturbances can influence cardiac rhythm and neurological status, requiring prompt assessment and correction.

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