Real Due

Name: Cara Jett
Age: 34 years
Provider: R. Mcbride NP
Allergies: NKA
Admit weight: 102 Ibs (46.3kg)
BMI: 17.5
Code status: full code

I just can’t eat. Every time I do, I have horrible pain in my stomach. My family keeps
accusing me of having an eating disorder. It’s not that I don't want to eat. It's that I can’t
without pain and diarrhea!


Nursing Note: Client presents for ongoing stomach pain after eating. Current BMI of
17.5. Last recorded BMI from 3 years ago was 22.2. States pain has been ongoing for
several years, more severe as of late yesterday. Client skipped lunch today. Current
abdominal pain is 2/10. States that she has tried using over-the-counter pain relievers to
help with the abdominal pain, but this has not been successful. Rates 2/10 RLQ
abdominal pain.


Neuro/Cognitive: Alert and oriented x4.

Cardiovascular: Regular heartbeat with S1 and S2 heard. No edema present. Capillary
refill <3 seconds. Bilateral pedal and radial pulses +3.

Respiratory: Lungs clear bilaterally.

Gastrointestinal: Abdomen flat, firm, hyperactive bowel sounds x 4 quadrants. Tender
in RLQ. Denies nausea. Last bowel movement was 1045 today. Loose, brown, mucous
looking – per client. Three loose stools today so far.

Genitourinary: Continent. No pain or burning when urinating

Musculoskeletal: Muscle atrophy present. +5 strengths for all extremities. Tenting
present on arm and collarbone.

Psychosocial: Anxious. Becomes tearful several times during visit. States her family is
accusing her of having an eating disorder.


Nursing Note: Follow-Up Appointment with Gastrointestinal Specialist

Diagnosis: New Crohn’s disease.

Follow-up appointment after colonoscopy and upper GI procedure. Had a CT scan of the
abdomen completed after the procedure. Rates 4/10 abdominal pain. Client is taking
prednisone and metronidazole as prescribed by primary care provider for Crohn's

Date Temp HR RR BP SpO2 O2

4/12 1345 96.8 °F

(36.0 °C)

78 18 102/54 100% RA

5/1 0945 97.2 °F

(36.2 °C)

64 12 94/45 89% RA

5/1 1000 97.2 °F

(36.2 °C)

69 12 104/50 92% RA

5/1 1015 97.2 °F

(36.2 °C)

72 14 110/52 94% RA

5/7 1430 98.6 °F

(37.0 °C)

88 18 138/78 99% RA

Date Diagnostic Test Findings


Upper GI

No abnormal findings.

Small ulcer found in the transverse portion of the large intestine with
evidence of more in the small intestine. Further testing, including an
MRI, is highly suggested.


CT Scan of

Impression: Thickening of the wall of the small intestine present.
Three small abscesses noted by entrance to the colon correlating with
recent gastric studies. No fistula apparent.


Endoscopy Center Nursing Note:

Client has completed an upper GI study and a colonoscopy with no noticeable
complications. Vitals stable. Drowsy but easily woken. Oriented x4.


Endoscopy Center Nursing Note:

Vitals remain stable. Client drank 60mL of clear soda and two bites of graham cracker.
Swallow and gag reflex present. Mild 2/10 throat discomfort present. Driver present and


Endoscopy Center Nursing Note:

Client discharged to home in care of mother, Nancy. Follow-up appointment made.