Irritable Bowel Case Summary

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N.O. is a 50 year old male with a past medical history of Irritable Bowel Syndrome. He is a very active, full-time employee of Poland Springs, delivering five gallon jugs of water to local communities. Currently, he resides in Brockton with his wife and teenage daughter. He was admitted to the ED on 1/22/17 with acute onset of nausea, vomiting and diarrhea thinking he had food poisoning. During MD assessment, he started complaining of upper abdominal pain that he described as burning with radiation to his back, he believed to be secondary to repetitive vomiting. Orders were placed for labs, EKG, IV fluids, and pain medication. Patient appeared diaphoretic and uncomfortable. Shortly thereafter, patient became unresponsive with no pulse and CPR was initiated. He was in V fib and was defibrillated after which there was a return in his circulation. He received …show more content…
He also had a defect in the left circumflex, which was thought to be due to thrombus. No intervention was performed to that vessel. He was continued on heparin, integrelin, propofol, and levophed drips until he was stable in ICU. He was slowly weaned to room air and remained stable to be transferred to telemetry. He was started on Metoprolol, Aldactone, Coumadin, ASA, Lipitor, and Plavix.
Pt vital sign are stable T- 98.1 orally, P 88 apical, BP 133/63 RA, R 16, O2 95% RA. Pt is A&Ox3, PERRLA, facial movements are strong and symmetrical with moist mucus membranes. Pt has +CSM, skin warm, dry and intact, cap refills <3sec, hand grasps equal. Apical pulse 88 BPM with regular rhythm, LS clear. Pt denies chest pain or discomfort. Denies dysnea or cough. Abdomen soft non tender, + BS, bathroom privileges, +PP, bilateral lower extremities skin warm, dry, and intact with equal strength, denies numbing or tingling in extremities. He reports some
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