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