Assessing the Abdomen

 

CASE STYDY

 

ABDOMINAL ASSESSMENT

Subjective:

· CC: “My stomach hurts, I have diarrhea, and nothing seems to help.”

· HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.

· PMH: HTN, Diabetes, hx of GI bleed 4 years ago

· Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs

· Allergies: NKDA

· FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD

· Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)

Objective:

· VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs

· Heart: RRR, no murmurs

· Lungs: CTA, chest wall symmetrical

· Skin: Intact without lesions, no urticaria

· Abd: soft, hyperactive bowel sounds, pos pain in the LLQ

· Diagnostics: None

Assessment:

· Left lower quadrant pain

· Gastroenteritis

PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

 

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The Assignment – Instructions

 

1. Use the provided template to complete the assignment (see attachment)

2. Analyze the subjective portion of the case study (see above). List additional information that should be included in the documentation.

3. Analyze the objective portion of the note. List additional information that should be included in the documentation.

4. Is the assessment supported by the subjective and objective information? Why or why not?

5. What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?

6. Would you reject/accept the current diagnosis? Why or why not? Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

7. Explain your reasoning using at least five different references from current evidence-based literature.

8. Use APA 7