Assessing the Abdomen

Episodic Note Case STUDY SCENARIO: Subjective: CC: ” My stomach hurts, I have diarrhea and nothing seems to help”
History of past illness (HPI): JR is a 47-year-old white male, who 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 not been as much as 9/10 when it started. He has been able to eat, with some nausea afterward.
Primary Medical History (PMH): HTN, Diabetes, and History of GI bleeding 4 years ago.
Medication: lisinopril 10mg, Amlodipine 5mg, Metformin 1000mg, Lantus 10units at bedtime. Allergies: NKDA. Family history: no history of colon cancer, Father has a history of diabetes type 2, HYpertension, MOTHER: HAS HISTORY HYPERTENSION, Hyperlipidemia, GERD, Social History: Denies tobacco use, occasional alcohol. He is married with three children ( 1 girl, 2 boys).
OBJECTIVE DATA: Vital signs: Temp 99.8, B/P 160/86, RR 16, PULSE 92, HT 5FT 10 inches, WT284LBS, Heart: RRR, no murmurs, LUNGS: CTA, Chest wall symmetrical, Skin intact without lesions, no urticaria, Abdomen: soft, hyperactive bowel sound. POS: pain in left lower quadrant. Diagnostic: Non.
Assessment: Left lower quadrant pain: Diagnosis: Gastroenteritis.
To Prepare: With regard to the Episodic note case study provided,(1) Consider what history would be necessary to collect from the patient in the case study. This is a SCHOLARLY PAPER FORMAT.
(2) 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? (3) Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
The Assignment instructions are: (a) Clearly, accurately, and thoroughly analyze the SUBJECTIVE portion of the note. List additional information that should be included in the documentation.
(b) Clearly, accurately, and thoroughly analyze the OBJECTIVE portion of the note. List additional information that should be included in the documentation.
(c) Is the assessment supported by the OBJECTIVE AND SUBJECTIVE information? Why or Why not?
(d) What diagnostic test should be appropriate for this case, and how would the result be used to make a diagnosis.?
(e) 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.
(F) Please provide a clear and comprehensive purpose statement, introduction, and conclusion that delineate all required criteria.
(g) please answer all parts of the questions critically with no grammar or spelling error in APA writing rules and style. Provide at least four references.

Last Completed Projects