Problem: Abdominal Assessment Note
• Analyze the subjective portion of the note. List additional information that should be included in the documentation.
• Analyze the objective portion of the note. List additional information that should be included in the documentation.
• Is the assessment supported by the subjective and objective information? Why or why not?
• What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
• 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.
Subjective:
o CC: "My stomach hurts, I have diarrhea and nothing seems to help."
o 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.
o PMH: HTN, Diabetes, hx of GI bleed 4 years ago
o Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs
o Allergies: NKDA
o FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
o Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
Objective:
o VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5'10"; WT 248lbs
o Heart: RRR, no murmurs
o Lungs: CTA, chest wall symmetrical
o Skin: Intact without lesions, no urticaria
o Abd: soft, hyperactive bowel sounds, pos pain in the LLQ
o Diagnostics: None
Assessment:
o Left lower quadrant pain
o Gastroenteritis.
The response should include a reference list. One-inch margins, Using Times New Roman 12 pnt font, double-space and APA style of writing and citations.