Abdominal Assessment Assignment Discussion Paper

Abdominal Assessment Assignment Discussion Paper

Abdominal Assessment Lab Assignment:

By Day 1 of Week 6

THE ASSIGNMENT
1. Analyze the subjective portion of the note. List additional information that should be included in the documentation.
2. Analyze the objective portion of the note. List additional information that should be included in the documentation.
3. Is the assessment supported by the subjective and objective information? Why or why not?
4. What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
5. Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Abdominal Assessment Explain your reasoning using at least three different references from current evidence-based literature.
Do not use NA or normal.

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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:?

Assessment:

Left lower quadrant pain
Gastroenteritis

Note : you can use the SOAP template I upload to organize the information and continue after that with the assignment.

Abdominal Assessment Assignment Discussion Paper

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