Assessing The Abdomen


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Assessment of the Abdomen and Gastrointestinal System 

ABDOMINAL ASSESSMENT 

case study

Subjective: 

• CC: “My abdomen hurts, I accept diarrhea and annihilation seems to help.” 

• HPI: JR, 47 yo WM, complains of accepting ambiguous belly affliction that started 3 canicule ago. He has not taken any medications because he did not apperceive what to take. He states the affliction is a 5/10 today but has been as abundant as 9/10 back it aboriginal started. He has been able to eat, with some abhorrence afterwards. 

• PMH: HTN, Diabetes, hx of GI drain 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; casual etoh, married, 3 accouchement (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 bank symmetrical 

• Skin: Intact after lesions, no urticaria 

• Abd: soft, hyperactive bowel sounds, pos affliction in the LLQ 

• Diagnostics: None 

Assessment: 

• Left lower division pain 

• Gastroenteritis 

PLAN: This area is not adapted for the assignments in this advance (NURS 6512) but will be adapted for approaching courses. 

  • With attention to the Episodic agenda case abstraction provided:
    • Review this week’s Learning Resources, and accede the insights they accommodate about the case study.
    • Consider what history would be all-important to aggregate from the accommodating in the case study.
    • Consider what concrete exams and analytic tests would be  appropriate to accumulate added advice about the patient’s condition.  How would the after-effects be acclimated to accomplish a diagnosis?
    • Identify at atomic five possible altitude that may be advised in a cogwheel analysis for the patient.

The Assignment

  1. Analyze the abstract allocation of the note. List added advice that should be included in the documentation.
  2. Analyze the cold allocation of the note. List added advice that should be included in the documentation.
  3. Is the appraisal accurate by the abstract and cold information? Why or why not?
  4. What analytic tests would be adapted for this case, and how would the after-effects be acclimated to accomplish a diagnosis?
  5. Would you reject/accept the accepted diagnosis? Why or why not?  Identify three accessible altitude that may be advised as a  differential analysis for this patient. Explain your acumen application at  least three altered references from accepted evidence-based  literature.

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