NURS6512 Week 6 Assignment 1

NURS6512 Week 6 Assignment 1

ABDOMINAL ASSESSMENT

Subjective: NURS6512 Week 6 Assignment 1

  • 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

NURS6512 Week 6 Assignment 1

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.

  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.

Solution Preview

NURS6512 Week 6 Assignment 1

Analysis of the subjective portion of the note

The subjective information presented by the patient who is 47 years of age is that she has had a challenge of diarrhea and that her stomach hurts. The patient has reported that the condition started three days ago. She as well has reported that she has a past health condition of hypertension and diabetes and that she has a history of HI bleeding that she had 4 years ago. She has reported the medication she uses as well including Lisinopril, amlodipine, metformin, and Lantus.

The necessary additional information includes the characteristics of her pain including whether it is sharp, burning, stabbing, cramping, or aching. She is as well asked what she was doing when the condition started including the kind of diet she has. The client is as well supposed to provide information on the factors that aggravate her pain and whether the pain radiates to any other part of the body. In addition, she should be asked whether she has any trouble urinating and the frequency of her pain and diarrhea….

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