ABDOMINAL ASSESSMENT

Subjective:

CC: “My stomach has been hurting for the past two days.”

HPI: LZ, 65 y/o AA male, presents to the emergency department with a two days history of intermittent epigastric abdominal pain that radiates into his back. He went to the local Urgent Care where was given PPI’s with no relief. At this time, the patient reports that the pain has been increasing in severity over the past few hours; he vomited after lunch, which led his to go to the ED at this time. He has not experienced fever, diarrhea, or other symptoms associated with his abdominal pain. 

PMH: HTN

Medications: Metoprolol 50mg

Allergies: NKDA

FH: HTN, Gerd,  Hyperlipidemia

Social Hx: ETOH, smoking for 20 years but quit both 2 years ago, divorced for 5 years, 3 children, 2 males, 1 female 

Objective:

  • VS: Temp 98.2; BP 91/60; RR 16; P 76; HT 6’10”; WT 262lbs
  • Heart: RRR, no murmurs
  • Lungs: CTA, chest wall symmetrical
  • Skin: Intact without lesions, no urticaria
  • Abd: abdomen is tender in the epigastric area with guarding but without mass or rebound.
  • Diagnostics: US and CTA

Assessment:

  1. Abdominal Aortic Aneurysm (AAA)
  2. Perforated Ulcer
  3. Pancreatitis

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

THE ASSIGNMENT

  1. 1. Analyze the subjective portion of the note. List additional information that should be included in the documentation.
  2. 2.Analyze the objective portion of the note. List additional information that should be included in the documentation.
  3. 3.Is the assessment supported by the subjective and objective information? Why or why not?
  4. 4.What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
  5. 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. 
  6. 6.Explain your reasoning using at least three different references from current evidence-based literature.
  7.  
  8. please  note 

the case study is an analysis. Please use feedback provided from Week 4/5 SOAP Notes and required/recommended texts to complete the assignment. Note – there is no need to make up any information for the case study. You are to review what is provided and formulate an essay response in terms of what is needed for a SOAP Note with rationale. To be successful, I encourage you to analyze using the SOAP Note Template and my feedback. For example, does the HPI capture all aspects of the mnemonic? Are all allergies indicated?

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ABDOMINAL ASSESSMENT

PLEASE PAY ATTENTION TO THE CASE STUDY

ZERO PLAGIARISM

FIVE REFERENCES

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 course

 

To Prepare

Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.

  • 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.

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