ABDOMINAL ASSESSMENT

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.

·

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

Week 6

_

Assignment 1: Lab Assignment: Assessing the Abdomen

CASE

STYDY

A

BDOMINAL

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

t

o

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

100

0mg,

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.

·

The Assignment

–

Instructions

1.

Use the provided template to complete the

assignment

(see

attachment

)

2.

Analyze the subjective portion of the

ca

se

study

(see

above)

. List additional information that

should be included in the documentation.

3.

Analyze the objective portion of t

he 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?

Identif

y

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 refere

nces from current evidence

–

based

literature.

8.

Use APA 7

Week 6 _ Assignment 1: Lab Assignment: 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.



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