Mr. Simmons is a 42-year-old male who arrived at the jail three weeks ago. In Intake, he reported a history of GERD for which he takes omeprazole and chronic lower back pain for which he takes ibuprofen. Mr. Simmons admits to drinking alcohol every week, but he denies drug use. In intake, his vital signs were 124/72, 76, 16, 98.6°F, 98% O2 sat. He is currently prescribed no medication at your facility, and he has not been seen in medical since intake. Your facility has a commissary that sells, among other things, OTC medications.
He is seen today in Nurse Sick Call as a result of submitting a medical request yesterday stating that he was having abdominal pain and nausea for 24 hours (before the slip submission).
What other subjective information do you need to know as you begin your evaluation of Mr. Simmons?
Where is the pain now? Has it moved?
Pain is now sharp and has “settled in” in his lower left quadrant. Initially, it was more “all over” (diffuse).
What level is his pain? (Pain scale)
Now 6/10 – varies between 2/10 – 8/10
Is it constant or intermittent? If intermittent, can he associate it with any activities?
He thinks it began when he ate something – now pretty much there all the time, although sharper at times. Certain movements, like twisting and bending, make it worse; but the pain is the worst when he has not eaten for a while.
Does anything make it better? Worse?
Eating and having “food” in his belly makes it better; having an empty stomach seems to make it worse.
Has he experienced pain like this before? What about when his GERD flares-up?
He states no, this is different. He gets nauseous with this pain, whereas the pain he felt with his GERD was more like a “bloats, gas pain”.
Has he eaten anything unusual lately? Is anyone else in his unit sick with similar symptoms?
“You mean in addition to the horrible food they give us?” – No, and no one else is sick in the block.
Could he have injured himself somehow?
He has started an exercise program (“might as well right?”), but it made his back pain come back, and so he stopped about a week ago.
What did he do for the back pain?
Took Ibuprofen from the commissary
How much ibuprofen did he take?
800mg 4x a day for a week – “that is the only thing that helps”.
Anything else about the pain/his condition that he thinks is important for you to know?
Not that I can think of.
What objective evaluations will you do?
Vital Signs
132/80, 96, 18, 99.2°F, 98% O2 saturation
Physical Evaluation
Alert, oriented X 4;
Skin warm and dry, color appropriate for ethnicity;
Gait steady, patient bent forward holding abdomen while walking into exam room;
Heart – regular rate, rhythm, with no murmurs, gallops, rubs;
Lungs – clear to auscultation without adventitious sounds;
Abdomen – soft, tender to palpation left upper, right upper, right lower quadrants; firm, tender to palpation with + guarding left lower quadrant.
What will you do next?
RN, LPN
Call provider and give report, and expect that Mr. Simmons will be sent to the emergency department, expect IV insertion and monitoring with vital signs every 5-10 minutes until EMS arrives and assumes care.
APRN
Order send out/Call 911
Order IV access and fluids
Ensure that Mr. Simmons’ condition is monitored until Paramedics arrive with vital signs every 5-10 minutes. Do not re-palpate abdomen unless Mr. Simmons reports new or significantly worsened symptoms.
APRN: Diagnosis
Ruptured peptic ulcer, most likely due to discontinuation of Gerd medication and over-medicating with ibuprofen for his back pain. A history of weekly alcohol use is a contributing factor.
patient education
Treatment Plan – transfer to ED, IV fluids, monitoring
Upon return from hospital, most likely after surgery:
- What is a peptic ulcer?
- How does it occur?
- What medications to avoid.
- Dietary changes that are needed.
- When to notify healthcare staff.
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