Abdomen Diagnosis - Essay Example

Nursing Abdomen Diagnosis data Current Symptoms The patient admits having the feeling of malignant neoplasm in her esophagus and the stomach. This is also experienced in the small intestine, duodenum and rectum. There is the feeling of primary malignancy in the pancreas with unspecified intestinal tract malignant neoplasm. This feeling is also exhibited in the trachea, bronchus and lung. There are secondary malignant neoplasm in the small intestines and lungs. The patient has experiences malignant carcinoid tumors in the appendix, small intestine, and large intestine (Tietz, 2005). Past History The patient reports that she had been well before and had never contracted such an infection. She admits that none of her relatives have portrayed such abdominal disorders before. It has found that she had suffered from abdominal infections three years ago which was treated through medical administration since it was never serious. Family History Some of her family members have had abdominal infections but not a serious one. Her mother used to have frequent abdominal pains which were treated in the local hospital once and for all and since then she has never had it for over five years now. A part from that there has never been an incident except the one she is feeling now. Lifestyle and Health Practices The patient has not been particular with medical examination for a long time. The last time she had a medical examination, she was not diagnosed of any illness or symptoms. She only goes for medical examination when she feels unwell. She used to undergo medical tests twice a month before she started having economic hardships which made her to stop the program for two years now. Her meals are consistent with the nutritionally recommended dietary practices. 2. Musculosketon diagnosis Current symptoms The patient currently is experiencing mild joint pains, swelling and stiffening. Some of these discomforts are mostly experience on the knees, hips, lower vertebra and finger joints. There are variations in pain as the patients’ explanations. The patient cannot bend with ease due to pain in the back bone (Tietz, 2005). Past History The patient admits having gotten some back injury in the early years due to an accident. As a result there was lots of pressure exacted on one knee when moving as one leg was also injured. The patient was given medical treatment at that time which consisted of nonsteroidal anti-inflammatory drugs and analgesics for pain reduction. The patient had gotten a sudden, traumatic derangement injury on the right knee while playing football. Family History None of the family members had been diagnosed with such conditions. The patient attributes the current conditions to the injuries that he obtained in the early years. All of the family members of the same age bracket are showing the symptoms of his condition. Life Style and Health Practices Before the condition began, the patient had been exercising routinely. The patient admits that his meals are calcium proficient and does not attribute the condition to dietary disorders (Tietz, 2005). 3. Neurological Current Symptom The patient who is experiencing an early adulthood admits that he currently experiences a profound disruption in perception which often affects his sense of self, thought and language. This disorder as he explains is often accompanied by psychotic experiences including delusions. As a result, this has led to the disruptions of his studies. Past History The patient had not experienced such a feeling before and as such attributes the feeling to adolescent experiences that he has undergone. He had grown up a normal person with little issues to worry a bout the parents could provide anything he needed. Family History He admits that none in the family that he knows of had suffered from such a condition. There is no history in the family of one who had been of the same conditions that he has been informed of in his inquiries. Life Style and Health Practices The patient tries to keep a healthy lifestyle through routine exercises and proper nutritional adherence. He has adopted a two time medical checkup per month in the local hospital. 4. Mental Status Current Symptom The patient currently is seeing a psychiatrist for a face to face examination. The patient currently is undergoing an administration of standardized testing which is part of the evaluation. These are aimed at ascertaining the patients’ mental health status. The patient admits that he previously he had mental illness diagnosis (McGraw, 2003). Past History The patient had been diagnosed with mental illness. He had undergone psychiatric therapy and recovered well. After sometime the illness resurfaced and now he is to under the same process. In the previous diagnosis it was not clear what the problem was but it was suspected as autism. Family History It was determined that no one in the family of the patient had undergone similar diagnosis. No one in the family had symptoms of mental illness either. The family members have for a long time had stable mental positions that had warranted no need for medical check up. Life Style and Health Practices The patient has been living a simple life style with normal exercises and dietary recommendations from the previous diagnosis. 5. General Status Current Symptoms The patient currently is not under any medication or prescribed diet. The patient is feeling strong and able to perform his duties normally. The patient sleeps normally, breaths normally and has a normal pulse rate. The patient’s eyesight is normal and his appetite is equally normal (McGraw, 2003). Past History The patient had been diagnosed with simple infections such as cold, cough and flue which were all treated. The last time he got an admission in hospital with an infection was in 5 years earlier when he had stomach infection. Family History No one in the entire family had been admitted in the hospital with fatal and long term infections such as cancer. They attend medical observations twice every month and they are examined for various disorders and infections. Life Style and Health Practices The patient is a regular gym attendant and has a medical checkup twice every month. He practices good eating habits by taking small amounts of red meat, sugar and fats and more of cereals and vitamins (McGraw, 2003). References Tietz, N.W. (2005) (ed.), Clinical guide to Laboratory Tests (3rd ed.), pp.452-454. McGraw,Hill (2001), Harrison’s Principles of Internal Medicine (14th ed). Read More