Week 6: Assessment of the Abdomen and Gastrointestinal System (Case Study) 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. The Assignment 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. Rubric: ((Please write in APA style with introduction, conclusion, and references included. )) With regard to the SOAP note case study provided, address the following: 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 or 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.--

ANSWER. PAPER DETAILS
Academic Level	College
Subject Area	Nursing
Paper Type	Case Study
Number of Pages	1 Page(s)/275 words
Sources	false
Format	APA
Spacing	Double Spacing

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