Health 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


• Gastroenterit

With regard to the Episodic note case study provided:

• Review this week’s Learning Resources, and consider the      insights they provide about the case study.


• Consider what history would be necessary to collect      from the patient in the case study.


• Consider what physical exams and diagnostic tests would      be appropriate to gather more information about the patient’s condition.      How would the results be used to make a diagnosis?


• Identify at least five possible      conditions that may be considered in a differential diagnosis for the      patient.

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