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.