a. Biographical Data: A.G. is a 56 year old Hispanic male who is married with three children. All three children are young adults and living at home. He completed the sophomore year of high school, and works in the fields. Patient can communicate efficiently in English, but more articulate in Spanish. He is insured by Blue Cross. The patient’s primary diagnosis is ascending colon polyp. The operative procedure is DaVinci assisted Laparoscopic right colon resection possible ostomy. Patient was able to answer most of the questions. His wife translated whatever needed more explanation.
Client’s Current Health Status
b. Chief Complaint: Patient stated his chief complaint was that the doctor advised surgical removal of a polyp. “I went to the doctor because of my age {56} for a colonoscopy and the doctor said I had 3 polyps. The doctor got the other two polyps but said he must cut out the polyp or it will rupture in the colon”
c. Presenting Symptoms: No apparent evidence of pain. The onset of his diagnosis began when A.G. was having a diagnostic test done. A.G. went to the doctor on January 23 for a routine colonoscopy and found out during the test that the third polyp was too big, but benign. A.G. states “The location of the polyp was in the right side. It is localized in a small area, a couple of inches of the bowel” A.G. states he feels no pain. Due to the location of the bowel, there are no signs or symptoms that A.G. can detect without the aid of a diagnostic test. A.G. did not have any symptoms associated with the diagnosis with the condition: no alteration in bowel movement, no sensations, or discharges that would alarm the him. No other signs or symptoms were present. The only treatment for this condition is surgery. Due to the location of the polyp, surgery was the only answer. A.G. did not
